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Mario Guslandi indicates that at based group has some advantages cacy in preventing least two trials have compared COX- ulcer relapses of either celecoxib 2 inhibition with PPI plus traditional the fact that the rate of dyspepsia in 200 mg daily or a combination NSAID with respect to gastrointestinal of naproxen 750 mg daily plus safety.1,2 These two trials provide it decreases compliance, a PPI-based lansoprazole 30 mg daily in a group evidence that both regimens are treatment might possibly be the most of 224 patients with a history of comparable in terms of preventing eff ective strategy.4NSAID-related ulcers. Again, the recurrent ulcer complications. Let us JPHD and MGHvO have no confl ict of interest to two therapeutic regimens proved fi rst highlight the issues at stake here.
declare. FWAV has served on the clinical event Randomised controlled trials by committee of a coxib trial sponsored by Novartis.
recurrent ulcer complications, the their very nature focus on a selective *Joost P H Drenth, only signifi cant diff erence being—not popu lation and strictly defi ne the Martijn G H van Oijen, unexpectedly—a reduction in the occurrence of dyspepsia in patients from these trials are, in sensu stricto,
treated with lansoprazole.
only applicable to populations with Department of Gastroenterology and Hepatology Obviously additional studies are a similar clinical phenotype to that (JPHD, MGHvO) and Department of Cardiology warranted to confi rm the above selected for the study. Both studies (FWAV), HeartLung Centre, Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, fi ndings, but from the available data it Guslandi mentions are from Hong Netherlandsseems that the use of a COX-2 inhibitor Chan FKL, Hung LCT, Suen BY, et al. Celecoxib and the combination of an NSAID high gastrointestinal risk. In the study versus diclofenac and omeprazole in reducing and a PPI represent two distinct but by Chan and colleagues,1 patients were the risk of recurrent ulcer bleeding in patients
with arthritis. N Engl J Med 2002; 347: 2104–10.
randomised after a previous peptic 2 Lai K-C, Chu KM, Hui W-M, et al. Celecoxib quency of ulcer complications in duced ulcer bleed, and in the one by Lai and compared with lansoprazole and naproxen to prevent gastrointestinal ulcer complications. Am J Med 2005; 118: 1271–78.
The choice between the two was also recurrent ulcer incidence. 3 Laine L, Curtis SP, Cryer B, et al. Assessment of regimens seems to rely mainly on So, these patients have a diff erent upper gastrointestinal safety of etoricoxib and diclofenac in patients with osteoarthritis and the cost of therapy, which can vary gastrointestinal risk profi le to those rheumatoid arthritis in the Multinational between countries, and on the included in the MEDAL Program.3 Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomised comparison. Lancet 2007; 369: 465–73.
I declare that I have no confl ict of interest.
Spiegel BM, Farid M, Dulai GS, et al. Comparing rates of dyspepsia with coxibs vs NSAID+PPI: a meta-analysis. Am J Med 2006; 119: 448.e27–36.
S Raff aele Hospital, 20132 Milan, Italy “real-world” situation. Patients were allowed to use aspirin or PPIs during the Taiwan–China health
inhibitors give enough gastrointestinal
protection? Lancet 2007; 369: 439–40.
study period, but this lofty approach partnership is urgently
Chan FKL, Hung LCT, Suen BY, et al. Celecoxib versus diclofenac and omeprazole in reducing cation. Indeed, the MEDAL Program needed for all
the risk of recurrent ulcer bleeding in patients
with arthritis. N Engl J Med 2002; 347: 2104–10.
Lai K-C, Chu KM, Hui W-M, et al. Celecoxib risk of gastrointestinal toxicity to use Your recent coverage of health in compared with lansoprazole and naproxen to PPIs. These patients are likely to be east Asia1,2 is a timely reminder of the prevent gastrointestinal ulcer complications.
Am J Med 2005; 118: 1271–78.
system atically diff erent from those not challenges to health posed by the treated.
political situation in this region, where Authors’ reply
The ideal controlled trial would the opening of markets brings both We concluded that the MEDAL include patients with osteoarthritis opportunities and risks. In the few years Program provides interesting data, and rheumatoid arthritis randomised since China and Taiwan acceded to but falls short of answering the to all possible combinations of COX-2 the World Trade Organization (WTO), question of whether cyclo-oxygenase inhibitors, NSAIDs, PPIs, and aspirin. in 2002, there has been a marked (COX)-2 inhibitors are safer than Serious cardiac or gastrointestinal increase in the number of unsafe proton-pump inhibitors (PPIs) events should be the primary outcome added to standard non-steroidal and dyspepsia might be used as a on the Taiwanese market.3 This is a anti-infl ammatory drugs (NSAIDs) secondary outcome. Although it is new phenomenon: Taiwan has, for in patients with osteoarthritis and diffi cult to foresee the result of such many years, implemented the good Vol 369 April 21, 2007
standard. In late 2006, more than has noted, it is unfortunate that it their prediction was correct, but, at a 10 000 patients were found to have does not place the same emphasis on popu la tion level, regulations must be been prescribed counterfeit antihyper- global health. Taiwan stands ready to uniform ly enforced if they are to be tension drugs. Subsequent checks play its part.
have revealed the presence of many I declare that I have no confl ict of interest.
We declare that we have no confl ict of interest.
more illegally produced medicines in Sheng-Mou Hou Áine Ní Mhaoláin, *Brendan D Kelly,
Minister, Ministry of Health, Taipei, Taiwan Editorial. Public health versus political Department of Adult Psychiatry, University College frontiers. Lancet 2007; 369: 616.
Dublin, Mater Misericordiae University Hospital, Chen Y-MA, Kuo H-SS. HIV-1 in Taiwan. Lancet 2007; 369: 623–25.
Ahmad SR. Safety of recommended doses of paracetamol. Lancet 2007; 369: 462–63.
medications in Asia. International Herald Nourjah P, Ahmad SR, Karwoski C, Willy M. Estimates of acetaminophen (paracetamol)- associated overdoses in the United States. insurance Taiwan profi le. Taipei: Department Pharmacoepidemiol Drug Saf 2006; 15: 398–405.
Hawton K, Townsend E, Deeks J, et al. Eff ects of 2006profi le.pdf (accessed April 2, 2007).
paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. executed prisoners in China. http://www.
BMJ 2001; 322: 1–7.
National Parasuicide Registry Ireland: Annual Report, 2004. Cork: National Suicide Research Foundation, 2005.
Government of Ireland. Statutory instrument take advantage of the trade in organs Legal limits for
No. 540 of 2003: medicinal products (prescription and control of supply) regulations paracetamol sales
potential off ered to micro-organisms Syed Rizwanuddin Ahmad (Feb 10, by travel between China and Taiwan. p 462)1 notes that the US Food and Sluggish sperms
In late 2005, dead birds infected Drug Administration continues to with the infl uenza A H5N1 virus were have concerns about the safety of Shalender Bhasin and colleagues detected in fl ocks being smuggled paracetamol and that paracetamol (Feb 17, p 597)1 mention that from China to Taiwan. The growing overdose causes about 450 deaths in hypothyroidism can cause female volume of tourist and commercial the USA every year.2 There is strong evi- fl ows pose challenges to both Taiwan dence that restricting the availability of para cetamol reduces morbidity and hospital staff told me that he and In May last year, on the eve of the mor tal ity from paracetamol overdose.3 59th World Health Assembly, I travel led In Ireland, there were 7933 recorded infertility. The only abnormality found to Geneva to seek support for Taiwan’s cases of drug overdose in 2004, of had been “sluggish sperms”. Clinically membership of the WHO. I see this as which 31% involved paracetamol.4 essential if Taiwan is to play a full part It is against the law for pharmacies was confi rmed with tests. 3 months in the implementation of the revised in Ireland to sell more than after starting thyroxine his wife International Health Regu lations, 24 paracetamol (500 mg) tablets in a became pregnant.
given the ongoing threat of an avian single transaction.5 In early 2007, we fl u pandemic. My request for a meeting visited 20 pharmacies in Dublin and hypothyroidism might not be a with my counterpart, Gao Qiang, the attempted to purchase amounts of common cause of infertility, but when health minister of China, was not paracetamol in excess of this legal limit: granted, even though I believe that we ten pharmacies allowed us to do so.
can both benefi t from collaboration to In one pharmacy, staff hesitated I declare that I have no confl ict of interest.
The international community wards admitted that they knew they
has recognised the importance of were breaching regulations. Their ex-including China and Taiwan in the plan ation for going through with the Southend Farm, Wotton-under-Edge GL12 7PB, UKglobal economy, by permitting them sale to one of us was “you don’t look 1 Bhasin S, Enzlin P, Coviello A, Basson R. Sexual dysfunction in men and women with endocrine both to join the WTO. As The Lancet like you’ll kill yourself”. In this case, disorders. Lancet 2007; 369: 597–611. Vol 369 April 21, 2007


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