PRECISION Results = Precisely Tailored Arthritis Treatment

By M. Elaine Husni, MD, MPH

The aptly named PRECISION trial results are in, and they’ve challenged many assumptions about the use of nonselective NSAIDs versus selective COX-2 inhibitors. Many osteoarthritis (OA) and rheumatoid arthritis (RA) patients rely on celecoxib, the only COX-2 inhibitor still marketed in the U.S., but we assumed that they faced a greater risk for cardiovascular disease.

PRECISION data tell us that’s not so. I think the randomized controlled trial of 24,081 patients is aptly named because the findings allow rheumatologists to offer more individualized treatment to patients on chronic NSAIDs. PRECISION found celecoxib to be as safe as naproxen and ibuprofen in terms of cardiovascular risk. Full details of the trial are discussed here, but a few key findings from secondary analyses impact how we treat patients with OA and RA.

Key findings: Osteoarthritis

In patients with OA (mean age 63.5 years), celecoxib:

• Carries less CV risk than ibuprofen (HR = 0.84, 95% CI 0.72-0.98, P = 0.03) and similar risk to naproxen
• Has less gastrointestinal risk than ibuprofen (HR = 0.68, 95% CI 0.51-0.91, P = 0.01) and naproxen (HR 0.73 95% CI 0.55-0.98, P=0.04)
• Had fewer renal adverse events than ibuprofen and similar rates with naproxen (HR = 0.58, 95% CI 0.40-0.82, P = 0.003).
• Was similar to both ibuprofen and naproxen in all-cause mortality.

Key findings: Rheumatoid arthritis

For patients with RA (mean age 60.7 years):

• The study found no difference in the rates of major CV and renal adverse events among the three drugs.
• Found a lower but statistically insignificant rate of GI adverse events with celecoxib than with naproxen and ibuprofen.
• Found a doubling of all-cause mortality in patients who used naproxen vs. celecoxib (HR = 0.47, 95% CI = 0.25-0.88, P = 0.02)

Limitations and implications for practice

These subgroup analyses are hypothesis-generating rather than definitive, but I do think we can extrapolate some of these differences to help guide treatment for our arthritis patients. First, it allows us a more tailored approach to treatment for patients who need chronic NSAID therapy. We now have more options given the similar CV risk profiles of these commonly used NSAIDs and can offer a more nuanced approach depending on individual patient factors such as comorbidities.

The PRECISION trial results have challenged the medical community and highlight the need to perform prospective randomized trials to obtain more accurate answers for unmet clinical questions.

Dr. Husni directs both the Arthritis and Musculoskeletal Treatment Center and Cleveland Clinic’s disease-specific biorepositories.