Effects of diclofenac on the pharmacokinetics of celastrol in rats and its transport

CONTEXT

Diclofenac and celastrol are always used together for the treatment of rheumatoid arthritis; the herb-drug interaction potential between diclofenac and celastrol is still unknown.

OBJECTIVE

This study investigates the effects of diclofenac on the pharmacokinetics of celastrol in rats.

MATERIALS AND METHODS

Twelve male Sprague-Dawley rats were divided into two groups and received celastrol (1 mg/kg) or both celastrol (1 mg/kg) and diclofenac (10 mg/kg) by oral gavage, and blood samples were collected via the oculi chorioideae vein and determined using the LC-MS method developed in this study. Additionally, the effects of diclofenac on the transport of celastrol were investigated using a Caco-2 cell transwell model.

RESULTS

Diclofenac could significantly (p < 0.05) decrease the C_max (from 66.93 ± 10.28 to 41.25 ± 8.06 ng/mL) and AUC_0-t (from 765.84 ± 163.61 to 451.33 ± 110.88 μg × h/L) of celastrol in rats. The efflux ratio of celastrol increased significantly (p < 0.05) from 3.12 to 4.55 with the treatment of diclofenac.

DISCUSSION AND CONCLUSION

These results indicated that diclofenac could decrease the system exposure of celastrol in rats when they are co-administered, and these effects might be exerted via decreasing its absorption in intestine.

Heterocycles 48. Synthesis, Characterization and Biological Evaluation of Imidazo[2,1-b][1,3,4]Thiadiazole Derivatives as Anti-Inflammatory Agents

Non-steroidal anti-inflammatory drugs (NSAIDs) are an important pharmacological class of drugs used for the treatment of inflammatory diseases. They are also characterized by severe side effects, such as gastrointestinal damage, increased cardiovascular risk and renal function abnormalities. In order to synthesize new anti-inflammatory and analgesic compounds with a safer profile of side effects, a series of 2,6-diaryl-imidazo[2,1-b][1,3,4]thiadiazole derivatives 5a⁻l were synthesized and evaluated in vivo for their anti-inflammatory and analgesic activities in carrageenan-induced rat paw edema. Among all compounds, 5c showed better anti-inflammatory activity compared to diclofenac, the standard drug, and compounds 5g, 5i, 5j presented a comparable antinociceptive activity to diclofenac. None of the compounds showed ulcerogenic activity. Molecular docking studies were carried out to investigate the theoretical bond interactions between the compounds and target, the cyclooxygenases (COX-1/COX-2). The compound 5c exhibited a higher inhibition of COX-2 compared to diclofenac.

Diclofenac use and cardiovascular risks: series of nationwide cohort studies

OBJECTIVE

To examine the cardiovascular risks of diclofenac initiation compared with initiation of other traditional non-steroidal anti-inflammatory drugs, initiation of paracetamol, and no initiation.

DESIGN

Series of 252 nationwide cohort studies, each mimicking the strict design criteria of a clinical trial (emulated trial design).

SETTING

Danish, nationwide, population based health registries (1996-2016).

PARTICIPANTS

Individuals eligible for inclusion were all adults without malignancy; schizophrenia; dementia; or cardiovascular, kidney, liver, or ulcer diseases (that is, with low baseline risk). The study included 1 370 832 diclofenac initiators, 3 878 454 ibuprofen initiators, 291 490 naproxen initiators, 764 781 healthcare seeking paracetamol initiators matched by propensity score, and 1 303 209 healthcare seeking non-initiators also matched by propensity score.

MAIN OUTCOME MEASURES

Cox proportional hazards regression was used to compute the intention to treat hazard ratio (as a measure of the incidence rate ratio) of major adverse cardiovascular events within 30 days of initiation.

RESULTS

The adverse event rate among diclofenac initiators increased by 50% compared with non-initiators (incidence rate ratio 1.5, 95% confidence interval 1.4 to 1.7), 20% compared with paracetamol or ibuprofen initiators (both 1.2, 1.1 to 1.3), and 30% compared with naproxen initiators (1.3, 1.1 to 1.5). The event rate for diclofenac initiators increased for each component of the combined endpoint (1.2 (1.1 to 1.4) for atrial fibrillation/flutter, 1.6 (1.3 to 2.0) for ischaemic stroke, 1.7 (1.4 to 2.0) for heart failure, 1.9 (1.6 to 2.2) for myocardial infarction, and 1.7 (1.4 to 2.1) for cardiac death) as well as for low doses of diclofenac, compared with non-initiators. Although the relative risk of major adverse cardiovascular events was highest in individuals with low or moderate baseline risk (that is, diabetes mellitus), the absolute risk was highest in individuals with high baseline risk (that is, previous myocardial infarction or heart failure). Diclofenac initiation also increased the risk of upper gastrointestinal bleeding at 30 days, by approximately 4.5-fold compared with no initiation, 2.5-fold compared with initiation of ibuprofen or paracetamol, and to a similar extent as naproxen initiation.

CONCLUSIONS

Diclofenac poses a cardiovascular health risk compared with non-use, paracetamol use, and use of other traditional non-steroidal anti-inflammatory drugs.

Single-dose intravenous diclofenac for acute postoperative pain in adults

BACKGROUND

Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, reduces the incidence and severity of opioid-induced adverse events (AEs).

OBJECTIVES

To assess the analgesic efficacy and adverse effects of single-dose intravenous diclofenac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults.

SEARCH METHODS

We searched the following databases without language restrictions: the Cochrane Central Register of Controlled Trials (Cochrane Register of Studies Online), MEDLINE, and Embase on 22 May 2018. We checked clinical trials registers and reference lists of retrieved articles for additional studies.

SELECTION CRITERIA

We included randomized trials that compared a single postoperative dose of intravenous diclofenac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for review inclusion, assessed risk of bias, and extracted data.Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period.Our secondary outcomes were time to, and number of participants using rescue medication; withdrawals due to lack of efficacy, AEs, and for any cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related AEs. We performed a post hoc analysis of opioid-related AEs, to enable indirect comparisons with other analyses of postoperative analgesics.For subgroup analysis, we planned to analyze different doses and formulations of parenteral diclofenac separately.We assessed the overall quality of the evidence for each outcome using GRADE and created two 'Summary of findings' tables.

MAIN RESULTS

We included eight studies, involving 1756 participants undergoing various surgeries (dental, mixed minor, abdominal, and orthopedic), with 20 to 175 participants receiving intravenous diclofenac in each study. Mean study population ages ranged from 24.5 years to 54.5 years. Intravenous diclofenac doses varied among and within studies, ranging from 3.75 mg to 75 mg. Five studies assessed newer formulations of parenteral diclofenac that could be administered as an undiluted intravenous bolus. Most studies had an unclear risk of bias for several domains and a high risk of bias due to small sample size. The overall quality of evidence for each outcome was generally low for reasons including unclear risk of bias in studies, imprecision, and low event numbers.Primary outcomeThree studies (277 participants) produced a number needed to treat for an additional beneficial outcome (NNTB) for at least 50% of maximum pain relief versus placebo of 2.4 (95% confidence interval (CI) 1.9 to 3.1) over four hours (low-quality evidence). Four studies (436 participants) produced an NNTB of 3.8 versus placebo (95% CI 2.9 to 5.9) over six hours (low-quality evidence). No studies provided data for the comparison of intravenous diclofenac with another NSAID over four hours. At six hours there was no difference between intravenous diclofenac and another NSAID (low-quality evidence).Secondary outcomesFor secondary efficacy outcomes, intravenous diclofenac was generally superior to placebo and similar to other NSAIDs.For time to rescue medication, comparison of intravenous diclofenac versus placebo demonstrated a median of 226 minutes for diclofenac versus 80 minutes for placebo (5 studies, 542 participants, low-quality evidence). There were insufficient data for pooled analysis for comparisons of diclofenac with another NSAID (very low-quality evidence).For the number of participants using rescue medication, two studies (235 participants) compared diclofenac with placebo. The number needed to treat to prevent one additional harmful event (NNTp) (here, the need for rescue medication) compared with placebo was 3.0 (2.2 to 4.5, low-quality evidence). The comparison of diclofenac with another NSAID included only one study (98 participants). The NNTp was 4.5 (2.5 to 33) for ketorolac versus diclofenac (very low-quality evidence).The numbers of participants withdrawing were generally low and inconsistently reported (very low-quality evidence). Participant withdrawals were: 6% (8/140) diclofenac versus 5% (7/128) placebo, and 9% (8/87) diclofenac versus 7% (6/82) another NSAID for lack of efficacy; 2% (4/211) diclofenac versus 0% (0/198) placebo, and 3% (4/138) diclofenac versus 2% (2/129) another NSAID due to AEs; and 11% (21/191) diclofenac versus 17% (30/179) placebo, and 18% (21/118) diclofenac versus 15% (17/111) another NSAID for any cause.Overall adverse event rates were similar between intravenous diclofenac and placebo (71% in both groups, 2 studies, 296 participants) and between intravenous diclofenac and another NSAID (55% and 58%, respectively, 2 studies, 265 participants) (low-quality evidence for both comparisons). Serious and specific AEs were rare, preventing meta-analysis.There were sufficient data for a dose-effect analysis for our primary outcome for only one alternative dose, 18.75 mg. Analysis of the highest dose employed in each study demonstrated a relative benefit compared with placebo of 1.9 (1.4 to 2.4), whereas for the group receiving 18.75 mg, the relative benefit versus placebo was 1.6 (1.2 to 2.1, 2 studies). Compared to another NSAID, the high-dose analysis demonstrated a relative benefit of 0.9 (0.8 to 1.1), for the group receiving 18.75 mg, the relative benefit was 0.78 (0.65 to 0.93). For direct comparison of high dose versus 18.75 mg, the proportion of participants with at least 50% pain relief was 66% (90/137) for the high-dose arm versus 57% (77/135) in the low-dose arm. There were insufficient data for subgroup meta-analysis of different diclofenac formulations.

AUTHORS' CONCLUSIONS

The amount and quality of evidence for the use of intravenous diclofenac as a treatment for postoperative pain is low. The available evidence indicates that postoperative intravenous diclofenac administration offers good pain relief for the majority of patients, but further research may impact this estimate. Adverse events appear to occur at a similar rate to other NSAIDs. Insufficient information is available to assess whether intravenous diclofenac has a different rate of bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was insufficient information to evaluate the efficacy and safety of newer versus traditional formulations of intravenous diclofenac. There was a lack of studies in major and cardiovascular surgeries and in elderly populations, which may be at increased risk for adverse events.

The Effectiveness of the Rectal Administration of Low-dose Diclofenac for the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis

Objective A 50-100-mg rectal dose of nonsteroidal anti-inflammatory drugs (NSAIDs; diclofenac or indomethacin) has been shown to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, this is higher than the recommended 25-mg dose that is commonly administered to Japanese patients. The objective of this study was to evaluate the safety and efficacy of 25-mg rectal dose of diclofenac in preventing PEP. Methods Between January 2016 and March 2017, a total of 147 patients underwent ERCP with or without the rectal administration of diclofenac (25 mg) 20 min before the procedure. A retrospective analysis was conducted to evaluate the efficacy and safety of this dose in preventing PEP. Results Thirteen patients (8.8%) developed PEP: 3 patients (4.1%) in the diclofenac group and 10 (13.7%) in the control group (p=0.0460). After ERCP, there were no cases of gastrointestinal hemorrhage, ulceration, acute renal failure, or death. A multivariate logistic regression analysis revealed that the non-administration of rectal diclofenac was a risk factor for PEP (odds ratio=3.530; 95% confidence interval=1.017-16.35; p=0.0468). Conclusions A 25-mg rectal dose of diclofenac might prevent PEP.

Clinical therapeutic effect and safety of celecoxib in treating knee osteoarthritis

The clinical therapeutic effect and safety of celecoxib in treating knee osteoarthritis were observed. 180 patients who have been confirmed with knee osteoarthritis in our hospital were selected as research objects. They were randomly divided into research group and control group, each containing 90 patients. The control group was given with diclofenac sodium therapy, while the research group was subjected to celecoxib therapy. The total therapeutic response rates between the two groups were observed and compared. The total therapeutic response rate of research groups was relatively higher, P<0.05. There was no significant difference in pain score, erythrocyte sedimentation rate (ESR), quality of life score (QLS) between two groups before treatment, P>0.05. However, these indexes of research group were superior then the control group after treatment，P<0.05. In addition, the rate of adverse reaction of research group was also lower than that of control group, P<0.05. Using celecoxib to treat knee osteoarthritis can significantly improve the total therapeutic rate and reduce the rate of adverse effect.

Topical Diclofenac Sodium Compared with Prednisolone Acetate after Phacoemulsification-Lens Implant Surgery

Purpose.

This study was performed to compare the efficacy, safety and tolerability of diclofenac sodium 0.1 % ophthalmic solution with that of prednisolone acetate 1.0% ophthalmic suspension for treatment of inflammation following phacoemulsification and posterior chamber lens implantation.

Methods.

One hundred and sixteen patients (diclofenac 57, prednisolone 59) with visually disabling cataract were enrolled in this prospective, randomised, double-masked, parallel group study in two centres. Post-operative patient assessments at day 1, 5–8 and 12–16 included visual acuity, slit-lamp examination, applanation tonometry and subjective evaluation of local tolerance.

Results.

There was no statistically significant difference between the diclofenac and prednisolone groups in the sum of the grades of anterior chamber flare and cells or the degree of conjunctival hyperaemia at any study visit. The overall assessment of local tolerance was similar for both the study medications. There were two (3.4%) possibly drug-related adverse events in the prednisolone group but neither was severe.

Conclusions.

Diclofenac sodium 0.01% ophthalmic solution was as effective, safe and well tolerated overall as prednisolone acetate 1.0% ophthalmic suspension.

Fixed-Dose Combination of 0.1% Diclofenac plus 0.3% Tobramycin Ophthalmic Solution for Inflammation after Cataract Surgery: A Randomized, Comparative, Active Treatment-Controlled Trial

Purpose

To assess the efficacy, tolerance, and ocular tolerability of a fixed-dose combination of 0.1% diclofenac plus 0.3% tobramycin ophthalmic solution compared with 0.1% diclofenac (Voltaren®) and 0.3% tobramycin (Tobrex®) in patients undergoing cataract extraction by either nuclear expression (extracapsular) or ultrasound-assisted aspiration (phacoemulsification) with intraocular lens implantation.

Methods

Eighty-eight patients undergoing cataract extraction with intraocular lens implantation participated in a randomized, parallel, observer-masked trial, in which the clinical usefulness of a fixed-dose combination of 0.1% diclofenac plus 0.3% tobramycin ophthalmic solution, two eyedrops every 6 hours (n=44) was compared with Voltaren® and Tobrex®, one drop of each every 6 hours (n=44) in a 22-day course. Efficacy was assessed from changes of the sum of anterior chamber cell count plus flare, conjunctival hyperemia and edema, and ciliary congestion, by means of slit lamp biomicroscopy on days 1, 7, 14, and 21. Tolerance and ocular tolerability were assessed by recording intraocular pressure (IOP), side effects, and the patient's and investigator's opinions.

Results

Anterior chamber cell count plus flare showed no differences in the two treatment groups at any evaluation point. The study treatment was associated with a significantly higher score for conjuncitval edema on day 1 (p=0.015), conjuncitval hyperemia on day 14 (p=0.009) and anterior chamber cell count on day 21 (p=0.04), but these differences had no clinical relevance. No side effects related to the study treatment were recorded.

Conclusions

Efficacy, tolerance, and ocular tolerability of a fixed-dose combination of 0.1% diclofenac plus 0.3% tobramycin ophthalmic solution were comparable to Voltaren® plus Tobrex® for the control of anterior chamber inflammation after cataract surgery, with the advantage that both active principles are supplied in a single container.

Comparison of the Efficacy and Safety of two Formulations of Diclofenac Sodium 0.1 % Eyedrops in Controlling Postoperative Inflammation after Cataract Surgery

PURPOSE

To compare the efficacy and safety of diclofenac sodium 0.1% eyedrops packaged in an Abak multidose container without preservative (Dicloabak) with the reference product, sodium merthiolate-preserved diclofenac sodium 0.1% eyedrops, in controlling postoperative inflammation after cataract surgery.

METHODS

The multicenter, controlled, randomized, single-masked study included 194 patients (Dicloabak 96, preserved diclofenac 98) scheduled to have cataract surgery by phacoemulsification with foldable intraocular lens. All were evaluated preoperatively and postoperatively after 1, 7, and 28 days. Postoperative inflammation was measured by the total score of anterior chamber cells and flare. Ocular plin, conjunctival hyperemia and ciliary flush were also assessed. Postoperative patient assessments also included visual acuity, objective tolerance by slit-lamp, fluorescein test, and subjective evaluation of local tolerance.

RESULTS

There was no statistically significant difference between the groups in the total score of flare and cells or the degree of conjunctival hyperemia and ciliary flush at any study visit. Dicloabak was demonstrated to be not inferior to preserved diclofenac at all assessment times. The overall assessment of local tolerance was similar for both study medications.

CONCLUSIONS

Preservative suppression did not alter diclofenac efficacy. Results support the good safety profile of both formulations when dosed three times daily for 4 weeks in absence of concomitant use of drugs potentially toxic for cornea. Preservative-free formulations like Dicloabak should be preferred to generic diclofenac formulations including other ingredients and may improve the safety profile of this topical nonsteroid anti-inflammatory drug.

Elective Division of Ilioinguinal Nerve in Inguinal Hernioplasty: Remedy for the Morbid Postoperative Inguinal Pain

OBJECTIVE

To compare the postoperative pain in inguinal hernioplasty, by preserving versus wide elective division of ilioinguinal nerve.

STUDY DESIGN

Randomized controlled trial.

PLACE AND DURATION OF STUDY

Surgical Department, Civil Hospital, Karachi, from January till August 2015.

METHODOLOGY

All patients of either gender above 15 years of age, undergoing mesh repair for unilateral, reducible inguinal hernia, were included. Patients with recurrent inguinal hernia, bilateral inguinal hernia, and those who will require emergency hernia surgeries like irreducible, obstructed, and strangulated hernia, were excluded. They were randomly assigned 42 into inguinal nerve preservation group (group A) and 42 in division (group B). Postoperative pain was assessed at first day, at discharge and after one month using visual analogue scale.

RESULTS

There were a total of 84 patients. Group Apatients had median (IQR) pain scores of 5 (1) and 3 (2) as compared to group B pain scores of 4 (2) and 2 (1) at 24 hours of surgery and at discharge, respectively (p <0.05). Median (IQR) postoperative pain score one month after inguinal hernioplasty was 2.5 (1) in group A, while 0.5 (1) in group B (p <0.05). Asignificant decline in the pain scores were observed in group B from the first day of surgery till one month afterwards (p <0.05).

CONCLUSION

Wide resection of ilioinguinal nerve has a lower frequency of postoperative pain in comparison to the ilioinguinal nerve preservation, in inguinal hernioplasty.

Corticosteroid transdermal delivery significantly improves arthritis pain and functional disability

Arthritis is characterized by pain and functional limitation affecting the patients' quality of life. We performed a clinical study to investigate the efficacy of a betamethasone valerate medicated plaster (Betesil) in improving pain and functional disability in patients with arthritis and osteoarthritis. We enrolled 104 patients affected by osteoarthritis (n = 40) or arthritis (n = 64) in different joints. Patients received diclofenac sodium cream (2 g, four times a day) or a 2.25-mg dose of Betesil applied to the painful joint every night before bedtime for 10 days. Pain and functional disability were assessed, by the Visual Analogue Scale (VAS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores. Redness was assessed by clinical inspection, and edema by the "fovea sign" method. C-reactive protein (CRP) was also measured; CRP can be used to cost-effectively monitor the pharmacological treatment efficacy and is increased during the acute-phase response, returning to physiological values after tissue recovery and functional restoration. All measurements were at baseline and at 10-day follow-up. At 10-day follow-up, a greater improvement in VAS and WOMAC pain and WOMAC stiffness and functional limitation scores from baseline was observed in patients treated with Betesil compared with diclofenac (all p < 0.01). At 10-day follow-up, improvement in redness, edema, and CRP levels from baseline was also greater in patients treated with Betesil compared with diclofenac (all p < 0.01). This study demonstrates the safety and efficacy of transdermal delivery of betamethasone valerate in patients affected by arthritis and osteoarthritis.

Efficacy of dexmedetomidine for pain management in knee arthroscopy: A systematic review and meta-analysis

BACKGROUND

Dexmedetomidine showed some potential in pain control in patients undergoing knee arthroscopy. We conducted a systematic review and meta-analysis to explore the efficacy of dexmedetomidine in patients undergoing knee arthroscopy.

METHODS

We searched the randomized controlled trials (RCTs) assessing the effect of dexmedetomidine on knee arthroscopy in PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases. The primary outcome was pain scores. Meta-analysis was performed using the random-effect model.

RESULTS

Five RCTs were included. Overall, compared with control intervention in patients with knee arthroscopy, dexmedetomidine intervention could significantly reduce the pain scores [Std. mean difference = -0.84; 95% confidence interval (95% CI) = -1.24 to -0.44; P < .0001] and postoperative diclofenac sodium consumption (Std. mean difference = -1.76; 95% CI = -3.32 to -0.21; P = .03), improve duration of analgesic effect (Std. mean difference = 1.78; 95% CI = 0.56-3.00; P = .004), but showed no influence on hypotension [risk ratio (RR) = 0.93; 95% CI = 0.14-5.92; P = .94], bradycardia (RR = 4.93; 95% CI = 0.91-26.58; P = .06), nausea, and vomiting (RR = 1.96; 95% CI = 0.31-12.58; P = .48).

CONCLUSION

Dexmedetomidine intervention was able to significantly reduce the pain scores and postoperative diclofenac sodium consumption, and improve duration of analgesic effect in patients undergoing knee arthroscopy, but had no influence on hypotension, bradycardia, nausea, and vomiting.

Intramuscular Diclofenac Vs Periprostatic Lidocaine Injection For Controlling Pain Undergoing Transrectal Ultrasound Guided Prostatic Biopsy

BACKGROUND

Transrectal ultrasound (TRUS) technique for getting prostatic tissue for histopathology is now the standard procedure for malignant lesions of the prostate and imperative diagnostic investigation of patients with clinical specks of prostatic neoplasia. During TRUS guided biopsy, pain control has been important issue therefore, highly potent analgesia before this procedure should be considered on high priority according to current census. Therefore, we compared intramuscular diclofenac injection with sensory blockade of injection lidocaine to abolish pain undergoing prostatic biopsy with TRUS technique.

METHODS

Total 200 patients were selected for this study having raised PSA values and suspicious nodule on Digital Rectal Examination. These patients were segregated into two groups by randomization. Group "A" received intramuscular diclofenac and group "B" were infiltrated with lidocaine injection for sensory blockade.

RESULTS

Patients in group A was having mean age of 64.5±5.8 years while for group B patients was 65.6±4.9 years (p=0.16). Both groups have statistically insignificant difference in their mean PSA values (p=0.24) and mean prostatic volume (p=0.22). The mean pain scores on visual analogue scale in groups A was 3.5±0.8 and in group B it was 2.4±0.8 (p<0.001). 60% group A patients reported with mild or no pain compared to 90% in group B. (p<0.001)..

CONCLUSIONS

Local blockade with lidocaine injection has better pain control as compared to patients experienced pain with intramuscular diclofenac used for prostatic biopsy through TRUS technique..

Conjunctival Goblet Cell Density Following Cataract Surgery With Diclofenac Versus Diclofenac and Rebamipide: A Randomized Trial

PURPOSE

To determine the effects of topical diclofenac or betamethasone with concomitant application of topical rebamipide on the conjunctival goblet cell density in eyes after cataract surgery.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Eighty patients who were scheduled for cataract surgery.

METHODS

Patients were randomized into 4 groups according to the postoperative topical drugs to be given; Group A, diclofenac alone; Group B, diclofenac and rebamipide; Group C, betamethasone alone; and Group D, betamethasone and rebamipide. Impression cytology was performed before and at 1 month after the surgery, and the mean density of goblet cells was determined.

RESULTS

The mean (± SD) density of goblet cells before the surgery in Group A was 257.0 ± 188.7 cells/mm², and it decreased significantly to 86.5 ± 76.7 cells/mm² at 1 month after the surgery (P = .002). In Group B, the goblet cell density was not statistically different between before (238.5 ± 116.6 cells/mm²) and at 1 month after the surgery (211.3 ± 184.4 cells/mm², P = .55). In Groups C and D, the mean density of goblet cells was decreased at 1 month after the surgery, but the decreases were not significant (P = .11 and P = .52, respectively).

CONCLUSION

After cataract surgery with postoperative topical diclofenac, the conjunctival goblet cell density was significantly reduced, and this reduction was blocked by the concomitant use of topical rebamipide. These results suggest that the concomitant use of topical rebamipide with nonsteroidal anti-inflammatory drugs is beneficial, especially in cases with postoperative dry eyes.

Skin penetration and tissue permeation after topical administration of diclofenac

OBJECTIVE

Topical delivery of drugs is an alternative to oral administration, often with similar efficacy but potentially a more favorable tolerability profile. However, topical formulations need to be able to penetrate the skin and permeate to the target areas in quantities sufficient to exert a therapeutic effect. Many factors can affect this process, including the physicochemical properties of the drug, the formulation used, and the site and mode of application. It is believed that measurement of drug concentrations at the sites of action may be an indicator of their likely efficacy. This review addresses these issues, with reference to topically administered diclofenac in osteoarthritis.

METHODS

Articles relevant to this review were identified after a systematic search of Medline and Embase, using the key words "diclofenac", "topical administration" and "osteoarthritis" in the search strategy.

RESULTS

The sparse data available indicate that topical diclofenac can penetrate and permeate to deeper tissues, with a lower plasma to tissue ratio than oral diclofenac. The tissue diclofenac levels after topical delivery are sustained over time (at least several hours). However, there is not enough data to establish how diclofenac levels in the joint compare with IC₅₀ levels (50% of the maximum inhibition of prostaglandin synthesis) established following oral administration.

CONCLUSIONS

After topical application, diclofenac can penetrate the skin and permeate to deeper tissues, where it reaches a concentration that appears to be sufficient to exert a therapeutic effect. More robust methods are required for in vivo characterization to better estimate the clinical efficacy of topically applied drugs.

Topical bioavailability of diclofenac from locally-acting, dermatological formulations

Assessment of the bioavailability of topically applied drugs designed to act within or beneath the skin is a challenging objective. A number of different, but potentially complementary, techniques are under evaluation. The objective of this work was to evaluate in vitro skin penetration and stratum corneum tape-stripping in vivo as tools with which to measure topical diclofenac bioavailability from three approved and commercialized products (two gels and one solution). Drug uptake into, and its subsequent clearance from, the stratum corneum of human volunteers was used to estimate the input rate of diclofenac into the viable skin layers. This flux was compared to that measured across excised porcine skin in conventional diffusion cells. Both techniques clearly demonstrated (a) the superiority in terms of drug delivery from the solution, and (b) that the two gels performed similarly. There was qualitative and, importantly, quantitative agreement between the in vitro and in vivo measurements of drug flux into and beyond the viable skin. Evidence is therefore presented to support an in vivo - in vitro correlation between methods to assess topical drug bioavailability. The potential value of the stratum corneum tape-stripping technique to quantify drug delivery into (epi)dermal and subcutaneous tissue beneath the barrier is demonstrated.

Diclofenac Does Not Reduce the Risk of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis in Low-Risk Units

BACKGROUND

Nonsteroidal anti-inflammatory drugs have an inhibitory role in pathogenesis of pancreatitis. Guidelines from the European Society of Gastrointestinal Endoscopy recommend routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP for all patients without contraindications.

AIMS

Our aim was to evaluate the effect of diclofenac in preventing post-ERCP pancreatitis (PEP) in a high-volume, low-PEP-risk ERCP unit.

METHODS

The rate and severity of PEP were compared in groups of 1000 historical controls prior to the routine use of diclofenac and in 1000 patients receiving 100 mg diclofenac before ERCP.

RESULTS

PEP occurred in 56 (2.8%) of the 2000 patients, and the rate of the pancreatitis was 2.8% in control group and 2.8% in diclofenac group (p = 1.000). The PEP rate among the native papilla patients was 3.9% in control group and 3.6% in diclofenac group (p = 0.803). In subgroup analysis of patients with a high risk of PEP, diclofenac neither prevented PEP nor made its course milder.

CONCLUSIONS

In an unselected patient population in a center with a low incidence of PEP, diclofenac seems to have no beneficial effect.

Analgesic efficacy and safety of transdermal and oral diclofenac in postoperative pain management following dental implant placement

The aim of this study was to compare the efficacy and safety of transdermal and oral routes of diclofenac for postoperative pain management in patients undergoing dental implant placement. Twenty systemically healthy, partially edentulous patients who required dental implants bilaterally in the mandibular first molar region were included. While the patient was under local anesthesia, an implant was placed in the mandibular first molar region of one quadrant. After a minimum of 4 weeks, an implant was placed in the contralateral quadrant under local anesthesia. Patients were prescribed 50 mg of oral diclofenac, taken twice daily for 3 days, following implant placement on the first side and a 100-mg diclofenac transdermal patch, placed once daily for 3 days, after surgery on the contralateral side. Postoperative pain was documented using the Numeric Rating Scale, Verbal Rating Scale, and Pain Relief Scale. Demographic, intraoperative, and postoperative characteristics were comparable in all the patients. The data obtained with the 3 subjective scales were analyzed by the Mann-Whitney test. No statistically significant differences in scores were discerned between the oral and transdermal routes of diclofenac delivery. None of the patients developed any adverse effects when using the transdermal patch, whereas 3 patients reported gastric irritation and a mild burning sensation when taking oral diclofenac. Thus, while the efficacy of transdermal and oral diclofenac for postoperative pain management was similar, the safety of the transdermal diclofenac patches was evidently superior. Further research with larger patient samples is necessary, but delivery of diclofenac through a transdermal route is a promising approach to the management of postoperative pain.

Functionalized Lipid-Polymer Hybrid Nanoparticles Mediated Codelivery of Methotrexate and Aceclofenac: A Synergistic Effect in Breast Cancer with Improved Pharmacokinetics Attributes

The present study was aimed to coencapsulate methotrexate (MTX) and aceclofenac (ACL) in fucose anchored lipid-polymer hybrid nanoparticles (Fu-LPHNPs) to achieve target specific and controlled delivery for developing therapeutic interventions against breast cancer. The effective combination therapy requires coadministration of drugs to achieve synergistic effect on tumor with minimum adverse effects. Present study investigates the potential of codelivery of MTX and ACL through LPHNPs in MCF-7 and triple negative breast cancer cells (MDA-MB-231). We obtained LPHNPs in the nanosize range (<150 nm) with better particle size distribution (<0.3). The entrapment and loading efficiency of MTX and ACL was calculated as 85-90% and 10-12%, respectively. The coumarin-6 LPHNP formulations showed rapid internalization within 2 h incubation with MCF-7 and MDA-MB-231 cells. With 8-10 times, greater bioavailability of drug-loaded LPHNPs than free MTX and ACL was obtained. Also, antitumor efficacy of MTX- and ACL-loaded LPHNPs was determined on DMBA-induced experimental breast cancer mouse model. This model showed better control over tumor growth with MTX- and ACL-loaded LPHNPs than the combination of MTX and ACL or MTX alone. ACL-loaded LPHNPs showed prophylactic and anticancer activity in DMBA-induced mouse model at higher dose (10 mg/kg). ACL-LPHNPs confer synergistic anticancer effect when administered in combination with MTX. In conclusion, ACL enhances the therapeutic and anticancer efficacy of MTX, when coencapsulated into fucose-anchored LPHNPs, as confirmed by cell viability and serum angiogenesis (IL-6, TNF-α, IL-1β, COX2, and MMP1) at both transcript and proteome level.

Topical non-steroidal anti-inflammatory drugs for analgesia in traumatic corneal abrasions

BACKGROUND

Traumatic corneal abrasions are relatively common and there is a lack of consensus about analgesia in their management. It is therefore important to document the clinical efficacy and safety profile of topical ophthalmic non-steroidal anti-inflammatory drugs (NSAIDs) in the management of traumatic corneal abrasions.

OBJECTIVES

To identify and evaluate all randomised controlled trials (RCTs) comparing the use of topical NSAIDs with placebo or any alternative analgesic interventions in adults with traumatic corneal abrasions (including corneal abrasions arising from foreign body removal), to reduce pain, and its effects on healing time.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 2), MEDLINE Ovid (1946 to 30 March 2017), Embase Ovid (1947 to 30 March 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 30 March 2017), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/); searched 30 March 2017, ZETOC (1993 to 30 March 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 30 March 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 30 March 2017 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 30 March 2017. We did not use any date or language restrictions in the electronic searches for trials.We checked the reference lists of identified trials to search for further potentially relevant studies.

SELECTION CRITERIA

RCTs comparing topical NSAIDs to placebo or any alternative analgesic interventions in adults with traumatic corneal abrasions.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and assessed risks of bias in the included studies. We rated the certainty of the evidence using GRADE.

MAIN RESULTS

We included nine studies that met the inclusion criteria, reporting data on 637 participants.The studies took place in the UK, USA, Israel, Italy, France and Portugal. These studies compared five types of topical NSAIDs (0.1% indomethacin, 0.03% flurbiprofen, 0.5% ketorolac, 1% indomethacin, 0.1% diclofenac) to control (consisting of standard care and in four studies used placebo eye drops). Overall, the studies were at an unclear or high risk of bias (particularly selection and reporting bias). None of the included studies reported the primary outcome measures of this review, namely participant-reported pain intensity reduction of 30% or more or 50% or more at 24 hours. Four trials, that included data on 481 participants receiving NSAIDs or control (placebo/standard care), reported on the use of 'rescue' analgesia at 24 hours as a proxy measure of pain control. Topical NSAIDs were associated with a reduction in the need for oral analgesia compared with control (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.34 to 0.61; low-certainty evidence). Approximately 4 out of 10 people in the control group used rescue analgesia at 24 hours. No data were available on the use of analgesia at 48 or 72 hours.One trial (28 participants) reported on the proportion of abrasions healed after 24 and 48 hours. These outcomes were similar in both arms of the trial. (at 24 hours RR 1.00 (0.81 to 1.23); at 48 hours RR 1.00 (0.88 to 1.14); low-certainty evidence). In the control group nine out of 10 abrasions were healed within 24 hours and all were healed by 48 hours. Complications of corneal abrasions were reported in 6 studies (609 participants) and were infrequently reported (4 complications, 1 in NSAID groups (recurrent corneal erosion) and 3 in control groups (2 recurrent corneal erosions and 1 corneal abscess), very low-certainty evidence). Possible drug-related adverse events (AEs) were reported in two trials (163 participants), with the number of adverse events low (4 AEs, 3 in NSAID group, including discomfort/photophobia on instillation, conjunctival hyperaemia and urticaria, and 1 in the control group, corneal abscess) very low-certainty evidence.

AUTHORS' CONCLUSIONS

The findings of the included studies do not provide strong evidence to support the use of topical NSAIDs in traumatic corneal abrasions. This is important, since NSAIDs are associated with a higher cost compared to oral analgesics. None of the trials addressed our primary outcome measure of participant-reported pain intensity reduction of 30% or more or 50% or more at 24 hours.

Randomised controlled trial evaluating the short-term analgesic effect of topical diclofenac on chronic Achilles tendon pain: a pilot study

OBJECTIVES

To determine if a topically applied non-steroidal anti-inflammatory drug (diclofenac) can provide short-term pain relief for chronic Achilles tendinopathy (CAT), in order to inform the development of a new rehabilitation protocol.

DESIGN AND SETTING

Pilot double-blind, cross-over randomised controlled trial providing participants with tertiary care. The study was conducted at a single research centre in Vancouver, BC.

PARTICIPANTS

Sixteen adults with unilateral CAT and three adults with bilateral CAT participated.

INTERVENTIONS

Participants received two successive treatments (10% diclofenac gel or placebo gel) in random order over a 3-day period. There was a 1-week washout period between the treatments. Allocation was by simple randomisation, and the participants as well as the assessing/treating researcher were blinded to treatment allocation.

OUTCOME MEASURES

The primary outcome measure was pain level (0-10) during tendon loading (hopping). Secondary outcome measures included pain at rest, pressure pain threshold of the Achilles tendon and symptom improvement.

RESULTS

Nineteen adults participated in the study, and all were included in the analysis. Diclofenac gel significantly reduced the average pain during tendon loading (p<0.001) and at rest (p=0.031). The average baseline hopping pain was 4.8/10 (95% CI 3.92 to 5.68) and was reduced to 3.1/10 (2.35-3.85) by diclofenac. Pain at rest was decreased and pressure pain threshold increased with diclofenac treatment, but not with placebo gel. There were no observed or reported side effects of either treatment.

CONCLUSIONS

In this small, short-term study, diclofenac was able to improve symptoms and reduce pain during tendon loading in participants with CAT, whereas placebo gel was not. A future study of diclofenac as a supplement to rehabilitation, with longer follow-up and powered to detect a difference between diclofenac and placebo, is indicated.

TRIAL REGISTRATION

ISRCTN60151284, http://www.isrctn.com/ISRCTN60151284 ETHICS: UBC Clinical Research Ethics Board approval was obtained for this research. The certificate number of the ethics certificate of approval to conduct research is H15-00999.

Efficacy and Safety Profile of Diclofenac/Cyclodextrin and Progesterone/Cyclodextrin Formulations: A Review of the Literature Data

Background

According to health technology assessment, patients deserve the best medicine. The development of drugs associated with solubility enhancers, such as cyclodextrins, represents a measure taken in order to improve the management of patients. Different drugs, such as estradiol, testosterone, dexamethasone, opioids, non-steroidal anti-inflammatories (NSAIDs; i.e. diclofenac), and progesterone are associated with cyclodextrins. Products containing the association of diclofenac/cyclodextrins are available for subcutaneous, intramuscular, and intravenous administration in doses that range from 25 to 75 mg. Medicinal products containing the association of progesterone/cyclodextrins are indicated for intramuscular and subcutaneous injection at a dose equal to 25 mg.

Objectives and Methods

The effects of cyclodextrins have been discussed in the solubility profile and permeability through biological membranes of drug molecules. A literature search was performed in order to give an overview of the pharmacokinetic characteristics, and efficacy and safety profiles of diclofenac/hydroxypropyl-β-cyclodextrin (HPβCD) and progesterone/HPβCD associations.

Results

The results of more than 20 clinical studies were reviewed. It was suggested that the new diclofenac/HPβCD formulation gives a rapid and effective response to acute pain and, furthermore, has pharmacokinetic and efficacy/safety profiles comparable to other medicinal products not containing cyclodextrins. One of the principal aspects of these new diclofenac formulations is that in lowering the dose (lower than 50 mg) the drugs could be more tolerable, especially in patients with comorbid conditions. Moreover, results of studies investigating the characteristics of progesterone and cyclodextrins showed that the new formulation (progesterone/HPβCD 25 mg solution) has the same bioavailability as other products containing progesterone. It is more rapidly absorbed and allows the achievement of peak plasma concentrations in a shorter time. Finally, the new formulation of progesterone was shown to be safe and not inferior to other products already on the market, with the exception of progesterone administered vaginally.

Conclusions

As shown by the results of clinical studies presented in this review, the newly approved medicines containing cyclodextrins have been found to be as effective and as well-tolerated as other medicinal products that do not contain cyclodextrins. Moreover, the newly approved lower dose of diclofenac associated with cyclodextrins is consistent with the European Medicines Agency recommendations reported in the revision of the Assessment Report for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Cardiovascular Risk. Finally, the use of cyclodextrins led to significant increases in solubility and bioavailability of drugs, such as diclofenac and progesterone, and improvement in the efficacy and safety of these drugs.

Efficacy and Safety of Different Aceclofenac Treatments for Chronic Lower Back Pain: Prospective, Randomized, Single Center, Open-Label Clinical Trials

PURPOSE

Nonsteroidal anti-inflammatory drugs are a mainstay for medical treatment of chronic lower back pain (CLBP). Increased dose intervals for medication have been associated with increased patient adherence to prescriptions. The purpose of this clinical trial was to compare the efficacy and safety of a once daily dose of aceclofenac controlled release (CR) and a twice daily dose of aceclofenac for CLBP management.

MATERIALS AND METHODS

A prospective, randomized, single center, open-label clinical trial was performed to compare the efficacy and safety of aceclofenac CR (200 mg once daily) to aceclofenac dose (100 mg twice daily). Fifty patients in each group were enrolled for the study. The primary end point was Visual Analogue Scale (VAS) change at baseline to that at 2 weeks after medication and safety profiles. Also, change in quality of life measured by EuroQoL 5D (EQ-5D) and Oswestry Disability Index (ODI) functional score for the lumbar spine were also assessed.

RESULTS

Within groups at pre- and post-treatment, there were significant VAS reductions for aceclofenac CR and aceclofenac (p=0.028). EQ-5D increased significantly in both groups (p=0.037). ODI scores decreased significantly in both groups (p=0.012). However, there were no significant differences between aceclofenac CR and aceclofenac at pre- and post-treatment. Patients with aceclofenac CR showed significant increases in heartburn and indigestion and adverse gastrointestinal effects, compared to aceclofenac.

CONCLUSION

In patients with CLBP, aceclofenac CR and aceclofenac demonstrated significant symptomatic pain relief, improvement in quality of life and functional scores. Aceclofenac CR slightly increased gastrointestinal adverse effects, such as heartburn and indigestion.

Poly(N-methacryloyl glycine)/nanocellulose composites as pH-sensitive systems for controlled release of diclofenac

The present study reports the development of non-cytotoxic and pH-sensitive nanostructured membranes consisting of a polymer with amino acid pending moieties and bacterial nanocellulose (BC). The nanocomposites were prepared through a simple methodology under green reaction conditions. The obtained materials display good thermal stability (up to 200°C), viscoelastic (storage modulus>700MPa) and mechanical (Young's modulus=3.5-4.9GPa) properties, together with high water uptake capacity. The results of the in vitro MTT assay showed that the nanocomposites are non-cytotoxic to HaCaT cells for 72h. The in vitro release profile of diclofenac sodium salt (DCF) from the nanocomposites into simulated body fluids at different pH values demonstrates the pH-responsive behaviour of these materials. Besides, DCF is mainly retained in the nanocomposites at pH 2.1 and released at pH 7.4, revealing their potential for the controlled release of DCF in dermal as well as in oral drug delivery applications.