Can I add Vioxx (rofecoxib) to a patient's treatment plan if they have costochondritis, asthma, and their pain is not relieved by analgesia?

No, You Cannot Add Rofecoxib (Vioxx) - It Has Been Withdrawn From the Market

Rofecoxib (Vioxx) was permanently withdrawn from the market in 2004 due to increased cardiovascular risks, including myocardial infarction and stroke, and is no longer available for prescription. 1

Critical Drug Availability Issue

• Rofecoxib is not an option because it has been removed from sale worldwide following the APPROVe study, which demonstrated increased serious thromboembolic events after 18 months of use. 1
• The drug showed a relative risk increase for myocardial infarction compared to placebo and posed unacceptable cardiovascular mortality risks. 1

Asthma-Specific Considerations for COX-2 Inhibitors

While rofecoxib is unavailable, understanding COX-2 inhibitor safety in asthma is relevant for alternative options:

• Highly selective COX-2 inhibitors were generally safe in aspirin-sensitive asthma in clinical studies, with rofecoxib showing no cross-reactivity in patients with aspirin-exacerbated respiratory disease. 2, 3, 4
• Studies demonstrated that rofecoxib (25-50 mg) was well-tolerated in 100% of aspirin-sensitive asthmatic patients without inducing bronchospasm or respiratory reactions. 3, 4
• The mechanism relates to COX-1 inhibition causing asthma exacerbations, while selective COX-2 inhibitors spare COX-1 activity. 5

Alternative Analgesic Options for Costochondritis with Asthma

Stepped-Care Approach for Pain Management

First-line options (before NSAIDs):

• Acetaminophen (paracetamol) in doses <1000 mg is generally safe in aspirin-sensitive asthma. 5
• Tramadol or small doses of narcotics if acetaminophen is insufficient. 1

Second-line options:

• Nonselective NSAIDs like naproxen can be considered if initial therapy fails, though aspirin-sensitive asthma poses significant risk and requires individual assessment. 1
• Use the lowest effective dose for the shortest duration with careful monitoring. 1

COX-2 selective inhibitors (if needed):

• Celecoxib remains available and shows excellent tolerability in aspirin-sensitive asthma, though cardiovascular risks must be considered. 5
• Use only when acetaminophen, tramadol, and nonselective NSAIDs provide inadequate relief. 1
• Always prescribe with proton pump inhibitor if combined with aspirin, use lowest dose, and monitor blood pressure and renal function regularly. 6

Critical Safety Warnings

• All NSAIDs with COX-2 selectivity carry cardiovascular risks that appear proportional to their degree of COX-2 selectivity, with amplified risk in patients with established cardiovascular disease. 1
• The cardiovascular risk appears to be a class effect across all COX-2 inhibitors (rofecoxib, valdecoxib, celecoxib). 1, 7
• Aspirin-sensitive asthma remains a relative contraindication for all NSAIDs and requires individual risk-benefit assessment, though selective COX-2 inhibitors have superior respiratory safety profiles. 1, 8