The Association between Cyclo-oxygenase Inhibitor Medications and Clinical Relapse in Inflammatory Bowel Disease: Review of Current Perspectives

Background: Patients with inflammatory bowel disease (IBD) often have associated conditions which may benefit from treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or selective cyclo-oxygenase-2 (COX-2) inhibitors. However, evidence has suggested there may be an association between COX- inhibition and relapse in IBD, which leads to clinicians being reluctant to prescribe these agents.
Aims: The aim of this review is to review the possible biological mechanisms, linking NSAIDs and IBD-relapse and current knowledge on the possible association of NSAIDs and clinical relapse in IBD.
Results: IBD relapse due to NSAID use is most likely due to prostaglandin inhibition via dual COX-inhibition, although the topical effect of NSAIDs on the intestine may also play a role. The evidence for an association between NSAIDs and IBD relapse is contradictory and generally weak, but it is likely a small percentage of patients relapse when taking NSAIDs, but it is not known which patients are at risk. Mixed results have also been obtained from studies examining COX-2 selective agents; although a single randomized controlled-trial showed that celecoxib is safe in ulcerative colitis in the short term.
Conclusions: At present the data are contradictory and most published studies have serious flaws. Overall the association between use of NSAIDs and IBD-relapse seems rather weak, Cyclo-oxygenase inhibitors should not be withheld from stable IBD patients, if clinically indicated and appropriate cautions and monitoring are used. Celecoxib would seem a sensible first choice. Further studies are needed to help identify which patients are at risk of relapse with NSAIDs.