Effect of Mixed Micelle Formulations Including Terpenes on the Transdermal Delivery of Diclofenac

The significant inhibitory action of diclofenac formulated in mixed micelles of lecithin with cholate or deoxycholate was observed on the rat hind paw edema induced by carrageenan. In the primary stage, mixed micelle formulation of deoxycholate was more effective compared with that of cholate. However, in the final term, the inhibitory action was similar in both formulations. In a previous study, the flux of diclofenac was greater in the mixed micelle formulation of deoxycholate compared with that of cholate. It was suggested that the permeation rate of diclofenac through skin was proportional to the pharmacological activity. The hind paw edema was quickly inhibited when cyclic monoterpene such as d-limonene or l-menthol was included in the formulations. All the micelle formulations significantly decreased the value of AUC estimated the hind paw thickness-time profile. This suggests that the micelle formulation of cholate in addition to deoxycholate showed significant anti-inflammatory activity to hind paw edema of rats. Incorporation of d-limonene or l-menthol was more effective on the decrease of AUC. A pharmacological study revealed that micelle formulations were able to reduce the skin irritation of chemicals.

Synthesis, Analgesic, Anti-inflammatory and Antibacterial Activities of Some Novel 2-Methyl-3-substituted Quinazolin-4-(3H)-ones

A series of novel 2-methyl-3-substituted quinazolin-4-(3H)-ones have been synthesized by treating (2-methyl-4-oxo-3H-quinazolin-3-yl)dithiocarbamic acid methyl ester with different amines, the starting material dithiocarbamate was synthesized from anthranilic acid. The compounds synthesized were investigated for analgesic, anti-inflammatory and antibacterial activities. All the test compounds exhibited significant activity, the compounds VA2, VA3 and VA4 shown more potent analgesic activity, and the compounds VA3 and VA4 shown more potent anti-inflammatory activity than the reference compound diclofinac sodium.

Pharmacogenetics of codeine metabolism in an urban population of children and its implications for analgesic reliability

BACKGROUND

Codeine analgesia is wholly or mostly due to its metabolism to morphine by the cytochrome P450 enzyme CYP2D6, which shows significant genetic variation in activity. The aims of this study were to investigate genotype, phenotype and morphine production from codeine in children undergoing adenotonsillectomy, and to compare analgesia from codeine or morphine combined with diclofenac.

METHODS

Ninety-six children received either codeine 1.5 mg kg(-1) or morphine 0.15 mg kg(-1) in a randomized, double-blind design. Genetic analysis was performed and plasma morphine concentrations at 1 h were determined. Postoperative analgesia and side-effects were recorded.

RESULTS

Forty-seven per cent of children had genotypes associated with reduced enzyme activity. Mean (SD) morphine concentrations were significantly lower (P<0.001) after codeine [4.5 (0.3) ng ml(-1)] than after morphine [24.7 (1.5) ng ml(-1)], and morphine and its metabolites were not detected in 36% of children given codeine. There was a significant relationship between phenotype and plasma morphine (P=0.02). More children required rescue analgesia after codeine at both 2 (P<0.05) and 4 h after administration (P<0.01). Fifty-six per cent of children vomited after morphine and 29% after codeine (P<0.01). Neither phenotype nor morphine concentration was correlated with either pain score or the need for rescue analgesia (r=-0.21, 95% confidence interval -0.4, -0.01).

CONCLUSIONS

Reduced ability for codeine metabolism may be more common than previously reported. Plasma morphine concentration 1 h after codeine is very low, and related to phenotype. Codeine analgesia is less reliable than morphine, but was not well correlated with either phenotype or plasma morphine in this study.

Symptomatic intravenous antipyretic therapy: efficacy of metamizol, diclofenac, and propacetamol

Fever is a common symptom in cancer patients. The most frequent causes of fever are infections, malignancy itself, various medications, transfusions, and allergy. Although it is necessary to treat the cause of fever, if possible, symptomatic fever management is also important. Surprisingly, little attention is paid to this topic in the medical literature, despite the fact that it is a very frequent problem. In order to support symptomatic fever therapy, we wanted to study the patients' discomfort accompanying fever and the beneficial effects of the symptomatic fever management. To the best of our knowledge, there is an absence of studies in this area, despite the fever discomfort can be an important reason for the antipyretic treatment, mainly in cancer patients. In this non-randomized open label pilot study, three intravenous antipyretics were tested in five groups of patients: diclofenac (75 mg, brief intravenous [IV] infusion) vs. metamizol (2500 mg or 1000 mg, brief IV infusion) vs. propacetamol (2000 mg or 1000 mg, slow IV injection or brief IV infusion). The study included 254 febrile episodes mainly in hemato-oncological patients with axillary temperature at least 38 degrees C. The main study endpoints were: changes in axillary temperature, improvement in patient comfort, and number and nature of adverse events. To support justification for symptomatic fever management in febrile patients, we asked the first 45 study subjects to fill in a questionnaire concerning their opinions about fever, fever-associated discomfort, and relief upon antipyretic therapy. All study medications had a significant antipyretic effect. However, metamizol at the dose 2500 mg was considered as the most effective, while propacetamol at the dose 1000 mg showed the lowest antipyretic efficacy. Concerning tolerability and adverse events, there were significant differences among the treatment groups. Diclofenac and metamizol (both 2500 mg and 1000 mg) were tolerated at best. All tested antipyretics significantly improved comfort in febrile patients. Overall, 87% of patients declared improvement in their comfort after administration of antipyretics. Based on the results of the present study, the choice of the antipyretic drug should depend on the clinical status of patient, contraindications, and potential adverse events and risks of the selected agent. It is advisable to use proparacetamol at the higher dosage and to administer it as a brief IV infusion in order to avoid injection-related adverse events. The symptomatic antipyretic treatment in febrile cancer patients is supported by patients themselves and has a significant role in the complex supportive care. Discomfort of patients during fever episodes may be greater than previously thought.

Comparison of three analgesics for extracorporeal shock wave lithotripsy

OBJECTIVE

The aim of the study was to compare the clinical efficacy of three different analgesic drugs with respect to their level of sedation, analgesia and quick mobilisation without cardiopulmonary depression, for outpatient extracorporeal shock wave lithotripsy (ESWL) procedure.

MATERIAL AND METHODS

Sixty outpatients undergoing elective ESWL using a third generation lithotriptor were studied. The patients were randomly divided into three groups of twenty patients. All patients received midazolam (2 mg) intravenously five minutes before the procedure. In group F, fentanyl was given (1 microg kg(-1) IV) at the same time with midazolam. In group D, diclofenac sodium was given (1 mg kg(-1), IM) intramuscularly 45 minutes before ESWL. In group T, tramadol was given (1.5 mg kg(-1)) 30 minutes before ESWL. Arterial pressure, heart rate, respiratory rate and oxygen saturation were recorded before the procedure, after sedation, at the first minute, and every ten minutes during the procedure. Pain intensity was identified with a Visual Analogue Scale. The level of sedation was evaluated by using the Observer's Assessment of Alertness/Sedation Scale. All patients were asked to assess their satisfaction with the seven point Verbal Rating Scale before discharge. Side-effects were also recorded during the procedure.

RESULTS

The incidence of nausea and vomiting was higher in fentanyl group compared with the other groups. In patients who received fentanyl, the decrease of oxygen saturation at the first and tenth minute of the procedure was statistically significant (p < 0.05).

CONCLUSIONS

Diclofenac sodium and tramadol were found to be safe and effective analgesics with lower side-effects than fentanyl.

[Diagnosis and treatment of streptococcal myositis]

HISTORY AND CLINICAL FINDINGS

Case 1: Following an influenza a 40-year-old patient was treated by intramuscular injections for backache. 24 hours later he was admitted to a hospital with massive pain in both lower extremities and a markedly reduced general condition. Case 2: Two days after a knee joint arthroscopy a 57-year-old man developed strong pain in the extremity treated by application of diclofenac. On the following day the patient was admitted to a university hospital in a septic state with a swollen, cold and blurry changed extremity.

INVESTIGATIONS

The myoglobin concentration was dramatically increased in both cases (> 15 000 mg/l). CRP values were elevated. The progressive septic state with acute renal failure was verified by elevation of creatinine concentration and decrease of leukocyte values in the second case (from 10/nl to 2,5/nl) shortly after admission.

DIAGNOSIS, TREATMENT AND COURSE

Both the patients died for septic shock. Case 1 died shortly after admission before surgical intervention. The second patient developed rapid progression of the myositis including the trunk despite radical surgical treatment (hip joint exarticulation).

CONCLUSION

In cases of sudden and painful swelling of an extremity of unknown origin or following intramuscular injection streptococcal myositis has to be taken into account. Only an immediate surgical intervention up to amputation of the affected extremity can stop the fatal course.

Dose-dependent pharmacokinetics and disposition of bisphosphonic prodrug of diclofenac based on osteotropic drug delivery system (ODDS)

Rat pharmacokinetics and in vivo disposition of a novel bisphosphonic prodrug of diclofenac (DIC-BP), synthesized with the aim of osteotropic delivery of diclofenac, were determined at whole body, organ and cellular levels in a dose range 0.32-10mg/kg. With an increase in injected dose, total body clearance was decreased while the distribution volume at steady state (V(dss)) was reduced and plasma half-life was prolonged. Over 50% of a dose of DIC-BP was selectively transported into osseous tissues after intravenous injection into rats at doses up to 1mg/kg. As dose increased, the skeletal distribution decreased with hepatic and splenic accumulations increasing. The intrahepatic distribution at 10mg/kg revealed that liver macrophages play a significant role in hepatic uptake of DIC-BP. This is consistent with general arguments that bisphosphonates themselves cannot distribute in soft tissues, but are taken up by the reticuloendothelial system as foreign substances when they form large complexes or aggregate with endogenous metals in plasma. Therefore, to optimize the osteotropic delivery of diclofenac via a bisphosphonic prodrug, the dosage regimen should be such that plasma concentration of DIC-BP is maintained at a level lower than that required for precipitate formation of complexes, similar to the usage of other bisphosphonates.

The effect of glycyrrhizin on the release rate and skin penetration of diclofenac sodium from topical formulations

The influence of glycyrrhizin extracted from Glycyrrhiza glabra var. glandulifera (licorice roots) on the percutaneous absorption of diclofenac sodium from sodium carboxymethylcellulose (NaCMC) gels or oil-in-water (o/w) emulsion was investigated. Skin permeation experiments were carried out using excised abdominal rat skin. The results showed that the efficiency of glycyrrhizin as an enhancer agent is greater in gel formulations than it is in the emulsions. The enhancer with the concentration of 0.1% w/w in gel increased diclofenac sodium flux value to tenfold compared with the control gel.

[Preoperative diclofenac does not reduce pain of laparoscopic cholecystectomy]

OBJECTIVE

To study the safety and efficacy of diclofenac for preemptive analgesia in the first 24 hours after elective laparoscopic cholecystectomy (ELC).

PATIENTS AND METHODS

This prospective, randomized, placebo-controlled, double-blind study enrolled 90 patients of both sexes undergoing ECL. The patients were 17 to 76 years old and weighed between 45 and 100 Kg (ASA I and II). Assignment was to one of the following groups. A control group received diclofenac before and after surgery (DD) as follows: diclofenac 1 mg/Kg i.m. 60 minutes before surgery and a loading dose of 0.35 mg/Kg i.v. after surgery followed by continuous infusion of 1.5 mg/Kg over 24 hours. The study group received diclofenac and placebo (DP) as follows: diclofenac 1 mg/Kg i.m. 60 minutes before surgery and infused saline solution after extubation. A second control group received placebo before surgery and diclofenac afterwards (PD) as follows: a physiological solution was given intramuscularly 60 minutes before the operation and diclofenac was given after extubation as in the DD group. Pain intensity was assessed on a visual analog scale at four times: 1 hour (T1), 6 hours (T2), 12 hours (T3) and 24 hours (T4) after extubation. At those times we also recorded the need for rescue analgesia and side effects. Arterial blood gases and vital signs were recorded 1 hour before surgery (T0) and at T4.

RESULTS

Pain intensity at T1 was 2.67 +/- 0.54, 2.82 +/- 0.63 and 2.88 +/- 0.58 for the DD, DP and PD groups, respectively (p = 0.96). The differences in mean pain between T1 and T2, T3 and T4 were -0.2 +/- 0.66, -0.7 +/- 0.51 and 0.0 +/- 0.72 in the DD group (p = 0.723); -0.9 +/- 0.60, -0.4 +/- 0.57 and -1.3 +/- 0.65 in the DP group (p = 0.578); and -1.0 +/- 0.59, -0.5 +/- 0.77 and -1.0 +/- 0.69 in the PD group (p = 0.816). No significant differences in pain intensity or need for rescue analgesia were observed. Although 22 side effects were observed in group DD, 21 in DP and 21 in PD, none was serious.

CONCLUSIONS

Simple preemptive analgesia with 1 mg/Kg i.m. of diclofenac 60 minutes before induction of anesthesia does not decrease pain intensity or the need for rescue analgesia in the first 24 hours after ELC.

Rapid potentiation of endothelium-dependent vasodilation by estradiol in postmenopausal women is mediated via cyclooxygenase 2

Estrogens influence cardiovascular function through direct and indirect effects and via genomic and nongenomic mechanisms. The pathways underlying the nongenomic mechanisms are not completely understood. Estrogen-induced responses in vascular cells have been shown to influence prostaglandins and cyclooxygenase (COX), a key enzyme in the production of prostaglandins, with two isoforms, COX-1 and COX-2. We investigated the effects of prostaglandins on the acute potentiation by 17beta-estradiol (E) of acetylcholine (ACh)-mediated vasodilation in the cutaneous vasculature. Using a double-blind placebo-controlled design, we assessed skin blood flow in 32 healthy, postmenopausal women by laser Doppler velocimetry with direct current iontophoresis of ACh and sodium nitroprusside before and after 6-wk treatment periods with aspirin (a nonspecific COX-1 and COX-2 inhibitor), diclofenac (predominantly a COX-2 inhibitor, which also inhibits COX-1), celecoxib (a specific COX-2 inhibitor), given at anti-inflammatory doses, or placebo. Blood flux values before iontophoresis of ACh did not differ between the treatment groups or after E administration, excluding a direct cutaneous vasodilator effect of the treatments or of E. Acute E administration enhanced the response to ACh after aspirin, diclofenac, and placebo; however, this effect was completely abolished with celecoxib treatment (P < 0.05). E had no effect on sodium nitroprusside-mediated vasodilation after any of the treatments. We conclude that the COX-2 pathway plays a specific role in the rapid E-induced potentiation of cholinergic vasodilation in postmenopausal women.

Oral controlled release formulation of diclofenac sodium by microencapsulation with ethyl cellulose

The aim of this study was to formulate and evaluate microencapsulated controlled release preparations of diclofenac sodium (DFS) using different proportions of ethyl cellulose (EC) as the retardant material to extend the release. The formulated microcapsules were then compressed into tablets to obtain controlled release oral formulations. Phase separation-coacervation technique was employed to prepare microcapsules of DFS using different proportions of EC in cyclohexane. Physical characteristics of microcapsules and their tablets, in vitro release pattern of the designed microcapsules and their tablets prepared from them were studied using USP dissolution apparatus (USP 2000) type 2 (paddle method) in triple distilled water. The prepared microcapsules were white, free flowing and spherical in shape, with the particle size varying from 49.94-52.72 microm. The duration of DFS release from microcapsules was found to be directly proportional to the proportion of EC and, thus, coat thickness. All tablets were of good quality with respect to appearance, drug content uniformity, hardness, weight variation, friability and thickness uniformity. In vitro release study of the tabletted microcapsules in triple distilled water showed a zero order release kinetics and extended release beyond 24 h. A good correlation was obtained between drug release (t(60)) and proportion of EC in the microcapsules. In the case of tabletted microcapsules, very good correlation could be established between t(60), proportion of EC, weight of the tablets and between release rate constant (K) and proportion of EC. All the formulations were highly stable and possessed reproducible release kinetics across the batches.

[TPD ophthalmic solution (mixture of tropicamide, phenylephrine hydrochloride, and diclofenac sodium) for cataract surgery]

PURPOSE

We made a TPD ophthalmic solution by combining tropicamide solution(Mydrin-P: T), phenylephrine hydrochloride(Neosynesin Kowa: P) and diclofenac sodium(Diclod: D), and evaluated its efficiency in mydriasis during cataract surgery compared to T, P, and D.

SUBJECTS AND METHODS

Twenty-five eyes(19 patients) were given either TPD solution(10 eyes) or T, P, and D solution(15 eyes), and the treatment was given six times before surgery. Pupil diameters were measured before and after surgery.

RESULT

The operation time was 10.0 +/- 5.2(mean +/- standard deviation) minutes in the TPD group, and 9.0 +/- 3.6 minutes in the T, P and D group. The preoperative and postoperative one pupil diameter was 8.65 +/- 0.34 mm and 8.20 +/- 0.35 mm in the TPD group and 8.80 +/- 0.49 mm and 8.37 +/- 0.61 mm in the T, P, and D group, respectively. The rate of miosis was 5.1 +/- 4.2% in the TPD group and 4.8 +/- 5.1% in the T, P, and D group, respectively. There was no statistically significant difference between the two groups.

CONCLUSION

TPD ophthalmic solution maintains the mydriasis as potent by as T, P and D solution.

[Availability of TPD ophthalmic solution (mixture of Mydrin-P solution, Neosynesin Kowa solution, and Diclod solution) in regard to the corneal barrier function--clinical evaluation for vitrectomy in patients with diabetic retinopathy]

PURPOSE

We made TPD ophthalmic solution by combining Tropicamide solution(Mydrin-P: T), Phenylephrine Hydrochloride(Neosynesin Kowa solution: P) and Diclofenac Sodium(Diclod solution: D), and evaluated its efficiency in terms of corneal epithelial damage in patients with diabetic retinopathy.

SUBJECTS AND METHODS

Five patients(10 eyes) who were to undergo vitrectomy were enrolled in this study. They each received T, P, and D 6 times and TPD solution in the same way. Before and after the instillation, superficial punctate keratopathy (SPK) was evaluated and corneal epithelial permeability was determined by anterior fluorophotometry.

RESULTS

After the instillation of T, P, and D, corneal damage increased in all eyes. After the instillation of TPD, three eyes showed only one grade change up in AD(A: area, D: density) classification of SPK. The fluorescein uptake change between pre- and post-instillation was 457.5 +/- 468.8 (mean +/- standard deviation) ng/ml with T, P, and D and 100.5 +/- 235.6 ng/ml with TPD(p < 0.01).

CONCLUSION

TPD solution decreases both corneal epithelium damage and barrier function change of corneal epithelium.

Prospective randomized trial of pre-emptive analgesics following ambulatory inguinal hernia repair: intravenous ketorolac versus diclofenac suppository

BACKGROUND

A pre-emptive non-steroidal anti-inflammatory drug is routinely given to patients undergoing ambulatory inguinal hernia repair. The present prospective randomized trial was undertaken to compare the efficacy of intravenous ketorolac and rectal diclofenac for ambulatory inguinal hernia repairs.

METHODS

Between June 1999 and February 2001, a total of 108 patients who underwent ambulatory inguinal hernia repairs under general anaesthesia were recruited. Patients were randomized to receive either intravenous ketorolac 30 mg immediately prior to induction of general anaesthesia (n = 54) or rectal diclofenac 50 mg after signing consent at the Day Surgery Centre (n = 54).

RESULTS

The demographic features, hernia types, anaesthetic time, dosage of anaesthetic medication and operative details of the two groups were comparable. There was no significant difference in total amount of analgesic consumption and linear analogue pain scores after operation. With regard to recovery variables, the respective times taken to regain ambulation and micturition were similar in both groups.

CONCLUSION

Diclofenac suppository 50 mg and intravenous ketorolac 30 mg provided equivalent postoperative analgesia following ambulatory inguinal hernia repair under general anaesthesia. Diclofenac suppository is an economical alternative to intravenous ketorolac. In the interests of cost containment rectal diclofenac could be considered the non-steroidal anti-inflammatory drug of choice for pre-emptive analgesia.

A case of fatal necrotizing fasciitis after intramuscular administration of diclofenac

Necrotizing fasciitis is a rapidly progressive soft tissue infection that involves subcutaneous fat and spreads along the fascial planes. This disease has a potentially fatal outcome if not recognized in early. Several cases have been reported of a possible association between the use of non-steroidal anti-inflammatory drugs (NSAIDs) and the development or aggravation of necrotizing fasciitis. This association is still a subject of controversy. In this article we present a case of fatal necrotizing fasciitis occurring in association with intramuscular injections of diclofenac in a patient who was admitted for the symptoms of a urinary stone. Our opinion is that the intramuscular injections caused a locally aseptic necrosis, which was secondarily invaded by. Since this incident, our policy is to avoid the use of intramuscular injections of diclofenac and other NSAIDs in cases of potentially infectious diseases.

Design, development, physicochemical, and in vitro and in vivo evaluation of transdermal patches containing diclofenac diethylammonium salt

In this study, matrix-type transdermal patches containing diclofenac diethylamine were prepared using different ratios of polyvinylpyrrolidone (PVP) and ethylcellulose (EC) by solvent evaporation technique. The drug matrix film of PVP and EC was casted on a polyvinylalcohol backing membrane. All the prepared formulations were subjected to physical studies (moisture content, moisture uptake, and flatness), in vitro release studies and in vitro skin permeation studies. In vitro permeation studies were performed across cadaver skin using a modified diffusion cell. Variations in drug release profiles among the formulations studied were observed. Based on a physicochemical and in vitro skin permeation study, formulation PA4 (PVP/EC, 1:2) and PA5 (PVP/EC, 1:5) were chosen for further in vivo experiments. The antiinflammatory effect and a sustaining action of diclofenac diethylamine from the two transdermal patches selected were studied by inducing paw edema in rats with 1% w/v carrageenan solution. When the patches were applied half an hour before the subplantar injection of carrageenan in the hind paw of male Wistar rats, it was observed that formulation PA4 produced 100% inhibition of paw edema in rats 12 h after carrageenan insult, whereas in the case of formulation PA5, 4% mean paw edema was obtained half an hour after the carrageenan injection and the value became 19.23% 12 h after the carrageenan insult. The efficacy of transdermal patches was also compared with the marketed Voveran gel and it was found that PA4 transdermal patches produced a better result as compared with the Voveran gel. Hence, it can be reasonably concluded that diclofenac diethylamine can be formulated into the transdermal matrix type patches to sustain its release characteristics and the polymeric composition (PVP/EC, 1:2) was found to be the best choice for manufacturing transdermal patches of diclofenac diethylamine among the formulations studied.

Effects of various eye drops on corneal wound healing after superficial keratectomy in rabbits

PURPOSE

The effects of various eye drops on corneal wound healing, particularly in the subepithelial haze area, were investigated histologically following superficial keratectomy in rabbits.

METHODS

Mechanical superficial keratectomy was performed in rabbit eyes. Tranilast, betamethasone, hyaluronic acid, and diclofenac eye drops were administered after the procedure. Physiological saline was used as a control. Corneas were excised 1, 2, 3, and 4 weeks after keratectomy, labeled with 3H-thymidine or 3H-proline, and subjected to autoradiography.

RESULTS

In the control and diclofenac groups, corneal haze occurred 3 weeks after keratectomy. Histological examination revealed an accumulation of proliferating keratocytes and active synthesis of collagen in the subepithelial area. In the tranilast and betamethasone groups, formation of corneal haze was reduced compared to the controls. The proliferation of keratocytes and the production of collagen in the corneal stroma were inhibited by these drugs. In the hyaluronic acid group also, corneal haze was decreased. In this group, although the proliferation of keratocytes was activated compared to the controls, abnormal accumulation of keratocytes in the subepithelial area was not detected.

CONCLUSIONS

Tranilast and betamethasone decrease the formation of subepithelial haze by inhibiting keratocyte proliferation and synthesis of extracellular matrix in the corneal stroma. Hyaluronic acid, on the other hand, inhibits subepithelial haze by promoting physiologic wound healing.