Lancet 10 Feb 2007

The cyclo-oxygenase 2 inhibitors came out amidst a fanfare of publicity about their gastrointestinal safety, though from the start, a few discordant notes were sounded by cost/benefit analysts. Then came the discovery of their cardiovascular risks, and hurried comparisons with the entire range of NSAID drugs, all of which were shown to carry risk, apart from aspirin and naproxen. We now know that both diclofenac and etoricoxib are associated with a similar increase in cardiovascular events (about two-fold) – but is the latter any safer in terms of GI bleeding? By nearly a third, say the MEDAL investigators. In defiance of standard pharmacological teaching, this even extends to patients co-prescribed low-dose aspirin.

I have previously stated my intention of searching the Institutes of Religion by John Calvin to find the place where he warns the Elect against the excessive prescribing of antibiotics. The great majority of modern sermons on the subject come from Calvinist countries – see the sermon from Scotland on p. 442 or indeed listen to one from the Netherlands on the Lancet website. As an obdurate sinner, cut off from Grace and doomed to Perdition in this as in so many other respects, I can’t say that I am too impressed with this simple study which shows that giving macrolide antibiotics to healthy volunteers increases their resident throat population of macrolide-resistant streptococci. This is what you’d expect. I am more intrigued by the fact that most streptococci remain fully penicillin-sensitive after 60 years of “over-use