Medication Summary

The literature supports the use of NSAIDs in FAP syndrome, with regression of polyps already present. It has been demonstrated that COX-2 is up-regulated 2-50 times in most (85-90%) adenocarcinomas.^[28]The role for NSAIDs (including the newer COX-2 inhibitors) in nonfamilial adenomatous lesions is unclear. For sporadic polyps, NSAID use has not been proven to cause regression in already developed polyps, although evidence suggests a decreased incidence of polyps in persons already taking NSAIDs. Therefore, a potential role exists for NSAIDs as primary prophylaxis.

In patients who have had a history of colon cancer, patients undergoing therapy with aspirin at 81 mg or 325 mg daily have fewer polyps than those on placebo. In patients with a history of a colonic polyp, low-dose aspirin (81 mg) may have some benefit in decreased adenoma recurrence.^{[29, 30]}

Studies with celecoxib have shown some regression in polyps in those patients with FAP. However, the routine use of COX-2 inhibitors for this indication may not be reasonable, especially in consideration of the recent documentation on cardiovascular toxicity/contraindications.

Class Summary

Mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions, also may exist.

Sulindac (Clinoril)

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Sulfoxide NSAID that is metabolized to the anti-inflammatory sulfide metabolite and a sulfone metabolite. Sulfide metabolite is now known to have apoptotic activity on colonic epithelial cells and is presumed to be responsible for regression of adenomatous polyps. Primary route of excretion is via urine as both sulindac and its sulfone metabolite.

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Media Gallery

Villous Adenoma. Endoscopic view of a sessile polyp, which histology studies revealed to be a villous adenoma. Courtesy of H. Chaun, MD.
Villous Adenoma. Endoscopic view of a sessile polyp histologically determined to be a villous adenoma. Courtesy of R. Enns, MD.
Villous Adenoma. Endoscopic view of injection of saline into the base of a sessile polyp histologically determined to be a villous adenoma. This enables an easier polypectomy. Courtesy of R. Enns, MD.
Villous Adenoma. Polypectomy with a snare around a sessile polyp base (villous adenoma) injected with saline. Courtesy of R. Enns, MD.
Villous Adenoma. Histology of villous adenoma. Fingerlike projections stretching from the surface of a polyp downward with minimal branching. Courtesy of D. Owen, MD.
Villous Adenoma. Histology of villous adenoma. Low-grade dysplasia with loss of mucin, prominent nucleoli, and hyperchromatic and elongated cells. Courtesy of D. Owen, MD.
Villous Adenoma. Fecal occult blood testing. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University).