Moxibustion versus diclofenac sodium gel for the treatment of knee osteoarthritis: a study protocol for a double-blinded, double-placebo, randomised controlled trial

INTRODUCTION

Knee osteoarthritis is a common form of arthritis in elderly patients that is characterised by pain and functional limitation. Moxibustion has been employed to relieve chronic pain as an alternative therapy for knee osteoarthritis. However, the evidence of its efficacy is equivocal due to the low methodological quality in most clinical studies. Therefore, we are performing a double-blinded, double-placebo, randomised controlled trial to evaluate the efficacy of moxibustion in participants with knee osteoarthritis.

METHODS AND ANALYSIS

This is a multicentre, double-blinded, double-placebo, randomised controlled clinical trial. 144 eligible participants with knee osteoarthritis will be randomly assigned to two different groups in a 1:1 ratio. Participants in the moxibustion group will undergo active moxibustion plus placebo gel, whereas participants in the control group will receive diclofenac sodium gel plus placebo moxibustion. Each participant will receive 12 sessions of active/placebo moxibustion at three acupoints (ST35, ST36 and EX-LE4) as well as 2 months of follow-up. Diclofenac sodium gel or placebo gel at a dose of 4 g per knee will be applied three times per day for 4 weeks. The primary outcome measure will be the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score change at the end of the intervention period from baseline. The secondary outcome measures include changes of other subscales (pain, stiffness and function) of WOMAC, visual analogue scale and patient globalassessment. The safety of moxibustion and diclofenac sodium gel will be assessed at every visit.

ETHICS AND DISSEMINATION

This trial has been approved by the Sichuan Regional Ethics Review Committee (permission number: 2015KL-014). The results of this study are expected to provide clinical evidence on the efficacy of moxibustion for pain relief and physical function improvement in patients with knee osteoarthritis. The findings will be submitted for publication in peer-reviewed medical journals and presented at relevant academic conferences.

TRIAL REGISTRATION NUMBER

NCT02769572.

Efficacy of an eye drop mixture for pupillary dilatation: A randomized comparative study

PURPOSE

Pupillary dilatation with three types of eye drops is used regularly in the clinic; however, a mixture of these drops in a single bottle may be more beneficial in reducing workloads and resources. This study compared the efficacy in pupillary dilatation between two protocols of dilating drop instillation.

METHODS

This prospective, randomized, comparative study included 30 eligible Thai patients. The patients randomly received preoperative pupillary dilatations by either the conventional protocol (1% tropicamide (T), 10% phenylephrine (P) and 0.1% diclofenac (D) in three separate bottles) or the fixed combination (TPD) protocol which had the three types of eye drops mixed in a single bottle in a ratio of 4:3:3. The chi-square test and independent t-test were used to analyze the data.

RESULTS

The conventional protocol group and TPD protocol group each had 15 patients. Sixty minutes after the initial instillation, all patients in the TPD protocol and 13 patients (86.7%) in conventional protocol achieved at least 6mm in the shortest diameter. The mydriatic rate between protocols showed no difference. In patients who received the TPD protocol, the systemic effects on the mean arterial blood pressure and pulse rate decreased over time.

CONCLUSION

The mixture of tropicamide, phenylephrine and diclofenac had a comparable efficacy for a pupillary dilatation to the conventional dilating drops in separate bottles. The systemic complications on blood pressure and arterial pulse of the TPD mixture were less than the conventional protocol.

TRIAL REGISTRATION

TCTR20130325001.

Central nervous system toxicity of mefenamic acid overdose compared with other NSAIDs: an analysis of cases reported to the United Kingdom National Poisons Information Service

AIMS

Case reports and small case series suggest increased central nervous system (CNS) toxicity, especially convulsions, after overdose of mefenamic acid, compared with other nonsteroidal anti-inflammatory drugs (NSAIDs), although comparative epidemiological studies have not been conducted. The current study compared rates of CNS toxicity after overdose between mefenamic acid, ibuprofen, diclofenac and naproxen, as reported in telephone enquiries to the UK National Poisons Information Service (NPIS).

METHODS

NPIS telephone enquiries related to the four NSAIDs, received between January 2007 and December 2013, were analysed, comparing the frequency of reported CNS toxicity (convulsions, altered conscious level, agitation or aggression, confusion or disorientation) using multivariable logistic regression.

RESULTS

Of 22 937 patient-specific telephone enquiries, 10 398 did not involve co-ingestion of other substances (mefenamic acid 461, ibuprofen 8090, diclofenac 1300, naproxen 547). Patients taking mefenamic acid were younger and more commonly female than those using other NSAIDs. Those ingesting mefenamic acid were more likely to experience CNS toxicity than those ingesting the other NSAIDs combined [adjusted odds ratio (OR) 7.77, 95% confidence interval (CI) 5.68, 10.62], especially convulsions (adjusted OR 81.5, 95% CI 27.8, 238.8). Predictors of CNS toxicity included reported dose and age, but not gender.

CONCLUSIONS

Mefenamic acid overdose is associated with a much larger and dose-related risk of CNS toxicity, especially convulsions, compared with overdose of other NSAIDs. The benefit-risk profile of mefenamic acid should now be re-evaluated in light of effective and less toxic alternatives.

Quality by Design (QbD)-enabled development of aceclofenac loaded-nano structured lipid carriers (NLCs): An improved dermatokinetic profile for inflammatory disorder(s)

Present study was designed to prepare and characterize aceclofenac loaded nanostructured lipid carriers (NLCs) employing Quality by Design (QbD)-oriented approach. The NLCs were evaluated for their transdermal penetration potential and stability. Aceclofenac loaded nanostructured lipid carriers (NLCs) were prepared & characterized, by employing Quality by Design (QbD)-oriented approach and further evaluated for transdermal penetration potential and stability. Different lipids and surfactants were chosen to prepare NLCs using microemulsion method as critical material attributes (CMAs). A 3³ factorial design was used for optimization of NLCs, and evaluating them for different critical quality attributes (CQAs), viz. particle size, polydispersity index (PDI), zeta potential, in vitro drug release, entrapment efficiency. The effect of CMAs such as lipids, oil: lipid ratio and concentration of surfactants on CQAs viz. drug entrapment efficiency and particle size were systematically evaluated to optimize NLCs. The optimized NLCs were further incorporated into carbopol gel and characterized for texture and rheology profile followed by in vitro and in vivo evaluations. The optimized ACE-NLCs were found to be spherical, nanometric in size with higher drug loading and entrapment efficiency. Results of the in vitro drug release study showed that the developed formulation followed Korsmeyer-Peppas model showing Fickian diffusion. The release was biphasic i.e., initial burst release followed by sustained drug release upto 48h. The optimized NLCs-based gel formulation showed superior texture, rheological profile and showed better cell uptake efficiency on hyperkeratinocytic cells (HaCaT cell lines) with higher ex vivo skin permeability efficiency vis-à-vis marketed formulation. In conclusion, dermatokinetic modeling and pharmacodynamic study using carrageenan induced edema mice suggests that aceclofenac loaded NLCs hydrogel may provide a better delivery alternative to target various skin layers.

Alkylglycerol Derivatives, a New Class of Skin Penetration Modulators

The absorption modulating activity of two alkylglycerol derivatives (batyl and chimyl alcohol) on skin barrier properties was evaluated. Biophysical tests such as transepidermal water loss (TEWL) and attenuated total reflectance–Fourier transform infrared (ATR-FTIR) spectroscopy, as well as in vitro skin permeation studies, were performed in order to determine the effect of these compounds as chemical absorption modulators. Four drugs were used as models: three NSAIDS (diclofenac, naproxen, and piroxicam) and glycyrrhizic acid. The results showed that treatment of the skin with alkylglycerols caused (i) a reduction on the amount of drug permeated; (ii) a reduction in TEWL; and (iii) changes in the ATR-FTIR peaks of stratum corneum lipids, indicative of a more ordered structure. All of these findings confirm that alkyl glycerols have an absorption retarding effect on the drugs tested. Such effects are expected to give rise to important applications in the pharmaceutical and cosmetic sectors, in cases where it is desirable for the drug to remain in the superficial layers of the skin to achieve a local effect.

Sex differences and effects of oestrogen in rat gastric mucosal defence

AIM

To evaluate sex differences and the effects of oestrogen administration in rat gastric mucosal defence.

METHODS

Sex differences in gastric mucus thickness and accumulation rate, absolute gastric mucosal blood flow using microspheres, the integrity of the gastric mucosal epithelium in response to a chemical irritant and the effects of oestrogen administration on relative gastric mucosal blood flow in an acute setting was assessed in an in vivo rat experimental model. Subsequently, sex differences in the distribution of oestrogen receptors and calcitonin gene related peptide in the gastric mucosa of animals exposed to oestrogen in the above experiments was evaluated using immunohistochemistry.

RESULTS

The absolute blood flow in the GI-tract was generally higher in males, but only significantly different in the corpus part of the stomach (1.12 ± 0.12 mL/min•g in males and 0.51 ± 0.03 mL/min•g in females) (P = 0.002). After removal of the loosely adherent mucus layer the thickness of the firmly adherent mucus layer in males and females was 79 ± 1 µm and 80 ± 3 µm respectively. After 60 min the mucus thickness increased to 113 ± 3 µm in males and 121 ± 3 µm in females with no statistically significant difference seen between the sexes. Following oestrogen administration (0.1 followed by 1 µg/kg•min), mean blood flow in the gastric mucosa decreased by 31% [68 ± 13 perfusion units (PFU)] in males which was significantly different compared to baseline (P = 0.02). In females however, mean blood flow remained largely unchanged with a 4% (5 ± 33 PFU) reduction. The permeability of the gastric mucosa increased to a higher level in females than in males (P = 0.01) after taurocholate challenge. However, the calculated mean clearance increase did not significantly differ between the sexes [0.1 ± 0.04 to 1.1 ± 0.1 mL/min•100 g in males and 0.4 ± 0.3 to 2.1 ± 0.3 mL/min•100 g in females (P = 0.065)]. There were no significant differences between 17β-Estradiol treated males (mean ratio of positive staining ± SEM) (0.06 ± 0.07) and females (0.11 ± 0.11) in the staining of ERα (P = 0.24). Also, there were no significant differences between 17β-Estradiol treated males (0.18 ± 0.21) and females (0.06 ± 0.12) in the staining of ERβ (P = 0.11). Finally, there were no significant differences between 17β-Estradiol treated males (0.04 ± 0.05) and females (0.11 ± 0.10) in the staining of CGRP (P = 0.14).

CONCLUSION

Gastric mucosal blood flow is higher in male than in female rats and is reduced in male rats by oestrogen administration.

Efficacy of an Ayurvedic Formulation for Mild-to-moderate Osteoarthritis: A Phase 3, Randomized Controlled Study

Context • Current treatment options offer only symptomatic pain relief for patients with osteoarthritis (OA). Thus, a need exists for effective treatment of the disability-causing disease. The proprietary polyherbal formulation, Nartana, has been used for several years for OA. Objective • The study intended to compare the benefits of the herbal formulation with those of routinely used nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with mild-to-moderate OA. Design • The research team designed a phase 3, double-blind, double-dummy, randomized controlled study. Setting • The study was conducted at 2 hospital sites in Pune, India. Participants • The participants were 80 outpatients with OA at the hospitals. Intervention • The participants were randomly assigned to receive either the intervention (herbal formulation) or the active control (diclofenac) for 12 wk. The herbal formulation group received 450 mg of Nartana capsule and diclofenac-matching placebo. Treatment was given 2 ×/d for first 15 d and then 1 ×/d until the end of the study. The control group received 50 mg of diclofenac tablet 2 ×/d for first 15 d and then 100 mg of diclofenac tablet 1 ×/d and a Nartana-matching placebo until end of the study. Outcome Measures • To measure efficacy, the study used the modified Center for Rheumatic Diseases Pune version of the Western Ontario and McMaster Universities OA index (WOMAC) and the Health Assessment Questionnaire (HAQ). The study also measured overall perceived pain relief. The primary outcome measure was the change in the combined WOMAC score from baseline to postintervention (12 wk). Safety and other efficacy measures were the secondary end points. Results • The herbal formulation and diclofenac groups matched well at baseline for demographic profile, disease status, and WOMAC scores. The combined WOMAC scores were significantly reduced from baseline to postintervention for both groups (P < .01). The earliest significant reduction was seen at week 4 (P < .01) and persisted at subsequent visits (P < .01). Similar changes were also seen in the WOMAC subscales-pain, stiffness, and physical function or difficulty in performing routine activities-and HAQ scores. Similar changes were also seen in the WOMAC subscales-pain, stiffness, and physical function or difficulty in performing routine activities-and HAQ scores. Improvement was also observed with perceived pain relief. Overall, the efficacy of the herbal formulation was not inferior to the diclofenac. Related adverse events were generally mild to moderate in nature and were resolved with or without symptomatic treatment. Conclusions • For patients with mild-to-moderate OA, Nartana significantly reduced joint pain, stiffness, and physical function; improved quality of life; and provided pain relief. The herbal formulation's efficacy was not inferior to routinely prescribed diclofenac. The drug should be explored further in large long-term comparative studies as an alternative to NSAIDs.

Intravitreal Diclofenac in the Treatment of Macular Edema Due to Branch Retinal Vein Occlusion

BACKGROUND AND OBJECTIVE

To evaluate the effect of a single dose of intravitreal diclofenac on macular edema (ME) due to branch retinal vein occlusion (BRVO).

PATIENTS AND METHODS

In this prospective, interventional case series, 15 eyes with BRVO and ME with central macular thickness (CMT) greater than 250 µm on spectral-domain optical coherence tomography (SD-OCT) were enrolled. All patients were given 0.05 mg/0.1 mL of intravitreal diclofenac under aseptic conditions and followed up for 3 months with respect to best-corrected visual acuity (BCVA), intraocular pressure (IOP), fundus fluorescein angiography, and CMT measured on OCT.

RESULTS

The mean visual acuity improved from 0.115 ± 0.03 preoperatively to 0.356 ± 0.29 at 3 months (P = .002). Mean line improvement was 2.2 ± 1.6. Mean preoperative CMT decreased from 453.2 µm ± 55.3 µm to 340.47 µm ± 101 µm at 3 months postoperatively (P = .001). The mean preoperative IOP was 16.4 mm Hg ± 1.59 mm Hg, whereas the mean postoperative IOP was 16.6 mm Hg ± 1.58 mm Hg (P = .08). None of the 12 phakic eyes showed evidence of cataract progression.

CONCLUSION

Intravitreal diclofenac is safe and effective in improving BCVA and decreasing CMT in patients with BRVO and ME.

Comparison of Morphine Suppository and Diclofenac Suppository for Pain Management After Elective Caesarean Section

This study investigated efficacy and side effects of Morphine suppository for pain management after the first elective caesarean delivery in comparison to Diclofenac suppository. One hundred women aged 18-40 with term pregnancies undergoing elective caesarean section for the first time participated in this prospective project. Exclusion criteria included drug sensitivity, fetal malformations or defects, and complications during the cesarean operation. After same spinal anesthesia and same surgical techniques and in the recovery room patients consecutively received 100 mg diclofenac suppository or 10 mg morphine suppository. The pain severity was rated by "Numerical Rating Scale." There was not the difference between two groups in terms of basal information. Pain score was significantly different between two groups in the first 12 hours (5.66 ±1.36 in morphine group and 3.63±0.96 in diclofenac group) but not in the second 12 hour period. Considering pain scores every two hours in first 12 hours and every 4 hours in second 12 hours, morphine group had higher scores in comparison to diclofenac group. Also, the morphine group required pethidine injection sooner than the other group. The time giving first pethidine injection was 3.28±2.16 hours after operation in morphine group and 5.24±4.07 hours after operation (P<0.05). This study demonstrated that diclofenac suppository in comparison to morphine suppository decreased subjective pain scores in the first twenty-four hours after elective caesarean section which reached statistical significance in the first twelve hours. Although in diclofenac group, pethidine injection was prescribed significantly later.

Cost-effectiveness of Low-dose Submicron Diclofenac Compared With Generic Diclofenac

PURPOSE

NSAIDs are commonly prescribed for the treatment of pain and inflammation. Despite the effectiveness of NSAIDs, concerns exist regarding their tolerability. Worldwide health authorities, including the European Medicines Agency, Health Canada, and the US Food and Drug Administration, have advised that NSAIDs be prescribed at the lowest effective dosage and for the shortest duration. Effective lowering of NSAID dosage without compromising pain relief has been demonstrated in randomized, controlled trials of the recently approved NSAID lower-dose submicron diclofenac. Building on previously published work from an independently published systematic review and meta-analysis, a linear dose-toxicity relationship between diclofenac dose and serious gastrointestinal (GI) events was recently demonstrated, indicating that reductions in adverse events (AEs) may be seen even with modest dose reductions in many patients. The objective of the present study was to estimate the potential reduction in risk for NSAID dose-related AEs, corresponding savings in health care costs, and the incremental cost-effectiveness of submicron diclofenac compared with generic diclofenac in the United States.

METHODS

Our decision-analytic cost-effectiveness model considered a subset of potential AEs that may be avoided by lowering NSAID dosage. To estimate the expected reductions in upper GI bleeding/perforation and major cardiovascular events with submicron diclofenac, our model used prediction equations estimated by meta-regressions using data from systematic literature reviews. Utilities, lifetime costs, and health outcomes associated with AEs were estimated using data from the literature. The face validity of the model structure and inputs was confirmed by clinical experts in the United States. Results were evaluated in 1-way and probabilistic sensitivity analyses.

FINDINGS

The model predicted that submicron diclofenac versus generic diclofenac could reduce the occurrence of modeled GI events (by 18.0%), cardiovascular events (by 6.9%), and acute renal failure (by 18.8%), leading to a 9.8% reduction in costs of treating AEs. Submicron diclofenac was predicted to be cost-saving, with results relatively insensitive to parameter uncertainty.

IMPLICATIONS

Submicron diclofenac has the potential to provide clinical and economic value to patients using NSAIDs in the United States. Further investigation regarding the potential effects of submicron diclofenac on the risks for additional NSAID dose-related toxicities should be explored.

Therapeutic effects of low-frequency phonophoresis with a Chinese herbal medicine versus sodium diclofenac for treatment of knee osteoarthritis: a double-blind, randomized, placebo-controlled clinical trial

OBJECTIVE

To evaluate the therapeutic effects of low-frequency phonophoresis with a Chinese herbal medicine (CHM) compared with sodium diclofenac (SD) for knee osteoarthritis (KOA).

METHODS

In this double-blind, randomized, placebo-controlled trial, 100 KOA patients were assigned randomly to a placebo group, a CHM group, or SD group. Low-frequency phonophoresis was used to improve the efficiency of drug delivery. Pain at rest [using a visual analog scale (VAS)], pain on movement (VAS), and range of motion (degrees) in the three groups were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMACAI) scores. Safety assessments comprised emergency adverse events, as well as laboratory tests of blood biochemistry, creatinine, blood urea nitrogen, alanine aminotransferase and aspartate aminotransferase.

RESULTS

Significant improvements were found after treatment in all outcome measures except stiffness and range of motion in patients in the CHMP group and SDP group (P < 0.05). No significant differences in all outcome measures were found between the CHMP group and SDP group.

CONCLUSION

CHMP and SDP can show good therapeutic effects for KOA in terms of relieving pain and improving physical function.

Glycerosomes: Use of hydrogenated soy phosphatidylcholine mixture and its effect on vesicle features and diclofenac skin penetration

In this work, diclofenac was encapsulated, as sodium salt, in glycerosomes containing 10, 20 or 30% of glycerol in the water phase with the aim to ameliorate its topical efficacy. Taking into account previous findings, glycerosome formulation was modified, in terms of economic suitability, using a cheap and commercially available mixture of hydrogenated soy phosphatidylcholine (P90H). P90H glycerosomes were spherical and multilamellar; photon correlation spectroscopy showed that obtained vesicles were ∼131nm, slightly larger and more polydispersed than those made with dipalmitoylphosphatidylcholine (DPPC) but, surprisingly, they were able to ameliorate the local delivery of diclofenac, which was improved with respect to previous findings, in particular using glycerosomes containing high amount of glycerol (20 and 30%). Finally, this drug delivery system showed a high in vitro biocompatibility toward human keratinocytes.

Preoperative anxiety may increase postcesarean delivery pain and analgesic consumption

BACKGROUND

The aim of this study was to reveal the relationship between high level of prenatal anxiety and postoperative pain and/or analgesic consumption in women undergoing elective cesarean delivery under spinal anesthesia.

METHODS

Eighty women, aged between 18-45 years with minimum 37 week- gestation and received spinal anesthesia during elective cesarean delivery, were included into this observational cohort study. Prenatal anxiety was measured with state anxiety inventory, trait anxiety inventory and somatosensory amplification scale. Visual Analogue Scale (VAS) was used to quantify postoperative pain. Amount of analgesic consumed was recorded at 6th, 12th and 18th postoperative hours.

RESULTS

State Anxiety Score was above the threshold level (>45) in 18 women (22.5%). No difference was found between women with and without high state anxiety scores except for significantly higher BMI values in high-score group (P=0.07). In multivariate analysis, high BMI at pregnancy (OR: 1.2, 95% CI; 1.0-1.5, P=0.02) and high State Anxiety Score (OR: 1.1, 95% CI; 1.0-1.2, P=0.01) emerged as independent predictors of higher mean pain scores (VAS >4 cm) within 18 hours after cesarean delivery. Also, high State Anxiety Score was found to be independently associated with higher pethidine consumption after cesarean delivery (OR: 1.1, 95% CI; 1.0-1.2, P=0.006).

CONCLUSIONS

State anxiety has a negative effect on postcesarean pain whereas trait anxiety does not seem to produce such effect. The effect seems to be more profound in overweight women. Detection of anxiety level before elective cesarean delivery and therapeutic approach to pregnant women may be useful for postoperative pain control.

Pharmacokinetic and bioequivalence studies of immediate release diclofenac potassium tablets (50mg) in healthy volunteers

This study was conducted with the aim to determine the pharmacokinetic and bioequivalence of diclofenac potassium 50 mg test (F4) tablet formulation with reference product (Caflam). Present study was single dose, randomized, two phase cross over design, conducted in 12 healthy Pakistani volunteers and planned in accordance with FDA guidelines. In this study a simple, selective, sensitive and reproducible HPLC procedure was developed and validated for the estimation of diclofenac potassium in plasma. The process was validated in the range of 50 - 0.05 µg.mL-1 and used in bioequivalence trial of two products. Multiple blood samples were collected at various time points (0.5, 1, 2, 3, 4, 5, 6, 8, 10, 12 and 14 hr after treating volunteers with test (F4) and marketed reference brand. Plasma separation and deproteination were carried out with acetonitrile; samples (20µL) were injected using the validated HPLC method. Various pharmacokinetic parameters (compartmental and noncompartmental) were estimated using KineticaTM 4.4.1 (Thermo Electron Corp. USA). Bioequivalence among the products was established by calculating the 90% CI with log and non log transformed data for Cmaxcalc, Tmaxcalc, AUC0-∞, AUCtot and AUClast using two way ANOVA and Schirmann's Two one sided t- test. No significant difference was found between log and non-log data. The 90% confidence interval values using log transformed data for AUC0-∞ (0.997-1.024), AUCtot (1.004-1.031), AUClast (0.997 -1.024), Cmaxcalc (0.994-1.007) and Tmaxcalc (0.996-1.013) for the trial and reference products were found within the FDA acceptable limits of 0.8-1.25. Results were further verified by the Schirmann's one-sided t test. Results showed the bioequivalence of test and reference formulations. Both the products were well tolerated.

Efficacy of Combined Ultrasound-and-Microbubbles-Mediated Diclofenac Gel Delivery to Enhance Transdermal Permeation in Adjuvant-Induced Rheumatoid Arthritis in the Rat

A previous study that investigated the effect of ultrasound (US) on the transdermal permeation of the non-steroidal anti-inflammatory drug diclofenac found that therapeutic US can increase circulation in an inflamed joint and decrease arthritic pain. Transdermal drug delivery has recently been demonstrated by US combined with microbubbles (MB) contrast agent (henceforth referred to as "US-MB"). The present study evaluated the efficacy of US-MB-mediated diclofenac delivery for treating adjuvant-induced rheumatoid arthritis (RA) in rats. RA was induced by injecting 100 μL of complete Freund's adjuvant into the ankle joint of male Sprague-Dawley rats (250-300 g) that were randomly divided into five treatment groups: (i) carbopol gel alone (the control [group C]), (ii) diclofenac-carbopol gel (group D), (iii) US plus carbopol gel (group U), (iv) US plus diclofenac-carbopol gel (group DU) and (v) US-MB plus diclofenac-carbopol gel (group DUB). The ankle width was measured over 10 d using high-frequency (40-MHz) US B-mode and color Doppler-mode imaging, covering the period before and after treatment. Longitudinal US images of the induced RA showed synovitis and neovascularity. Only a small amount of neovascularity was observed after treatment. The recovery rate on day 10 was significantly higher in group DUB (97.7% ± 2.7%, mean ± standard deviation [SD]) than in groups C (1.0% ± 2.7%), D (37.5% ± 4.6%), U (75.5% ± 4.2%) and DU (87.3% ± 5.2%) (p < 0.05). The results obtained indicate that combining US and MB can increase the skin permeability and thereby enhance the delivery of diclofenac sodium gel and thereby inhibit inflammation of the tissues surrounding the arthritic ankle. Color Doppler-mode imaging revealed that US-MB treatment induced a rapid reduction in synovial neoangiogenesis in the arthritic area.

Diclofenac rectal suppository: an effective modality for perineal pain

OBJECTIVE

To determine the frequency of perineal pain after childbirth after a single dose of diclofenac rectal suppository.

METHODS

This cross-sectional study was conducted at Shaikh Zayed Women Hospital, Larkana, Pakistan, from April to September 2014, and comprised patients who were admitted to the labour room for normal vaginal delivery. A single dose of rectal diclofenac suppository of 100mg was given to the patients delivered vaginally or by second-stage emergency Caesarean section. Post-partum pain was noted after 12 and 24 hours of the administration of analgesia. SPSS 16 was used for data analysis.

RESULTS

Of the 169 subjects, 63(37.28%) were aged 20 years or less, 85(50.3%) between 21 and 30 years, and 21(12.43%) between 31 and 40 years. Frequency of perineal pain was predominantly mild in 95(56%) patients, moderate in 60(35.5%) and severe in 14(8.28%).

CONCLUSIONS

The use of non-steroidal anti-inflammatory rectal suppositories was found to be a simple and highly effective modality of reducing the perineal pain.

Expression of Endoglin and Vascular Endothelial Growth Factor as Prognostic Markers in Experimental Colorectal Cancer

BACKGROUND/AIM

Endoglin (CD105) is a receptor for the transforming growth factor-beta 1 (TGFβ1) with crucial role in vascular development and angiogenesis. Additionally, vascular endothelial growth factor (VEGF) overexpression has been associated with advanced stage and poor survival for several cancer types. These molecules have been shown to be useful markers for identifying proliferating endothelium involved in tumor angiogenesis, especially in patients with cancer at risk of developing metastases. The aim of this study was to evaluate the relationship between VEGF and endoglin expression in an experimental model of colorectal cancer, as well as to investigate the effect of cyclooxygenase-2 (COX2) inhibitors on tumor development incidence.

MATERIALS AND METHODS

Colon cancer was induced with 1,2-dimethylhydrazine dihydrochloride (DMH). Celecoxib and diclofenac treatment was started simultaneously with DMH induction. Endoglin protein expression was performed using western blot analysis. VEGF plasma concentrations were measured by enzyme-linked immunosorbent assay.

RESULTS

In histopathological evaluations, no pathological change was observed in control rats, while adenocarcinoma (62.5%), dysplasia (31.25%) and inflammation (6.25%) were detected in the group given DMH. In treatment groups, a marked decrease was observed in adenocarcinoma rate. Expression of endoglin protein was significantly elevated in the DMH group compared to controls (p<0.001). No statistically significant difference was noted between treatment groups and DMH group regarding endoglin expression but a decrease was detected in the celecoxib-treated groups.

CONCLUSION

It was confirmed by histopathology and western blotting that COX2 inhibitors, particularly celecoxib, decrease the rate of disease and slow-down progression of existing CRC. These data show that endoglin expression may have an important role in tumor angiogenesis and predict of tumor invasion.

Long-Acting Diclofenac Ester Prodrugs for Joint Injection: Kinetics, Mechanism of Degradation, and In Vitro Release From Prodrug Suspension

A prodrug approach for local and sustained diclofenac action after injection into joints based on ester prodrugs having a pH-dependent solubility is presented. Inherent ester prodrug properties influencing the duration of action include their pH-dependent solubility and charge state, as well as susceptibility to undergo esterase facilitated hydrolysis. In this study, physicochemical properties and pH rate profiles of 3 diclofenac ester prodrugs differing with respect to the spacer carbon chain length between the drug and the imidazole-based promoiety were determined and a rate equation for prodrug degradation in aqueous solution in the pH range 1-10 was derived. In the pH range 6-10, the prodrugs were subject to parallel degradation to yield diclofenac and an indolinone derivative. The prodrug degradation was found to be about 6-fold faster in 80% (vol/vol) human plasma as compared to 80% (vol/vol) human synovial fluid with 2-(1-methyl-1H-imidazol-2-yl)ethyl 2-(2-(2,6 dichlorophenyl)amino)phenylacetate being the poorest substrate toward enzymatic cleavage. The conversion and release of parent diclofenac from prodrug suspensions in vitro were studied using the rotating dialysis model. The results suggest that it is possible to alter and control dissolution and reconversion behavior of the diclofenac prodrugs, thus making the prodrug approach feasible for local and sustained diclofenac action after joint injection.

Diclofenac Epolamine is Effective in The Treatment of Acute Migraine Attacks. A Randomized, Crossover, Double Blind, Placebo-Controlled, Clinical Study

Hydrosoluble diclofenac epolamine (DHEP) represents an interesting approach to acute migraine attacks, where gastrointestinal motility and drug absorption are often reduced. Its efficacy was investigated in a randomized, crossover, double-blind trial on 155 patients who treated four consecutive mild-to-moderate migraine attacks, either with DHEP (65-mg sachet) or placebo. If pain was not relieved within 1 h, a second dose was given. The total number of treated attacks was 481. A pain-free condition was achieved within 2h in 45.8% and 25.1% of attacks treated, respectively, with DHEP or placebo ( P < 0.0001), with a therapeutic gain of 20.7%. Time to attack resolution, light and noise sensitivity and impact on working ability were significantly reduced by DHEP compared with placebo. Moreover, significantly fewer patients required a second drug dose or a rescue medication when treated with DHEP than with placebo. No adverse reaction was recorded. In conclusion, DHEP was effective and safe for pain relief in patients with an acute mild-to-moderate migraine attack.

The diameter response of retinal arterioles in diabetic maculopathy is reduced during hypoxia and is unaffected by the inhibition of cyclo-oxygenase and nitric oxide synthesis

PURPOSE

Diabetic retinopathy is accompanied with changes in the diameter regulation and oxygenation of retinal vessels. Previous studies have shown that in normal persons and in diabetic patients without retinopathy hypoxia-induced vasodilatation is mediated by cyclo-oxygenase (COX) products and nitric oxide (NO). The purpose of the present study was to study whether these effects can be reproduced in patients with diabetic maculopathy.

METHODS

Eighteen patients with diabetic maculopathy aged 29-57 years were examined using the Dynamic Vessel Analyzer. The resting diameter and the diameter changes of retinal arterioles during isometric exercise and flicker stimulation were studied before and during breathing a hypoxic gas mixture. The examinations were also performed before and during intravenous infusion of the NOS inhibitor L-NMMA, and were repeated on a second day after topical administration of the COX-inhibitor diclofenac.

RESULTS

The diameter of retinal arterioles showed no significant change during hypoxia or L-NMMA infusion, or after topical application of diclofenac (p > 0.25 for all comparisons). The resting diameter of the venules was significantly increased during hypoxia (p = 0.003) and decreased during L-NMMA infusion (p < 0.0001). The diameter of retinal venules during isometric exercise increased significantly during hypoxia (p = 0.01). Flicker stimulation induced significant dilatation of the venules, which was significantly reduced during hypoxia and increased during L-NMMA infusion (p < 0.0001 for all comparisons).

CONCLUSION

Hypoxia-induced dilatation of retinal arterioles is severely reduced in patients with diabetic maculopathy. Future intervention studies aimed at normalizing the diameter regulation of retinal arterioles in diabetic patients should preferentially be conducted in the early stages of the disease where the potential for changing the vessel diameter is preserved. ClinicalTrials.gov identifier: NCT01689090.

Topical treatment of actinic keratosis with 3.0% diclofenac in 2.5% hyaluronan gel: review of the literature about the cumulative evidence of its efficacy and safety

BACKGROUND

Topical 3% diclofenac in 2.5% hyaluronic acid (HA) gel is a nonsteroidal anti-inflammatory drug approved for the treatment of actinic keratosis (AK). It has been shown to be a safe and effective for treatment of AK on both skin and mucosal lip.

EVIDENCE ACQUISITION

A PubMed search was carried out from 1997 to 2015 using key words in multiple combinations.

EVIDENCE SYNTHESIS

Different studies from the literature shown the efficacy and safety of HA in both immunocompetent and immunosuppressed patients, with important impact on preventing field cancerization. In different clinical trials, the product was effective in significantly reducing lesions when applied for 60 or 90 days.

CONCLUSIONS

Despite the effectiveness of the treatment with topical 3% diclofenac in 2.5% HA, the patients who achieve the complete clinical response should be adequately educated to continue their photoprotection in order to minimize recurrence of AK.