Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis

Trends in Peptic Ulcer Disease and the Identification of Helicobacter Pylori as a Causative Organism: Population-based Estimates from the US Nationwide Inpatient Sample

Background:

Peptic ulcer disease can lead to serious complications including massive hemorrhage or bowel perforation. The modern treatment of peptic ulcer disease has transitioned from the control of gastric acid secretion to include antibiotic therapy in light of the identification of Helicobacter pylori as a causative infectious organism. We sought to determine trends related to this discovery by using a national database.

Materials and Methods:

Patient discharges with peptic ulcer disease and associated sequelae were queried from the Nationwide Inpatient Sample, 1993 to 2007, under the auspices of a data user agreement. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. Standard error was calculated using SUDAAN software (Research Triangle International, NC, USA).

Results:

Decreases in the incidences of gastrointestinal perforation, gastrointestinal hemorrhage, and surgical procedures most specific to peptic ulcer disease were statistically significant over the study period [range of P value (two tailed) = 0.000 – 0.00353; significant at P < 0.001 to < 0.01]. The incidence of H. pylori rose dramatically, peaking at an estimated 97,823 cases in 1998 [SE = 3155; 95% CI = 6,184]. Since that time it has decreased and then stabilized.

Conclusions:

The identification of H. pylori as the causative agent in the majority of peptic ulcer disease has revolutionized the understanding and management of the disease. Medical conditions and surgical procedures associated with end-stage peptic ulcer disease have significantly decreased according to analysis of selected index categories. Resident physician education objectives may need to be modified in light of these trends.

Review Criteria:

We reviewed patients with peptic ulcer disease. The database used was the Nationwide Inpatient Sample, 1993 to 2007.

Message for the Clinic:

Medical therapy has resulted in decreased morbidity from H. pylori infection as it is the causative agent in the majority of peptic ulcer disease. Aggressive screening and treatment of this infection will lead to further reduction in morbidity.

Stability of diclofenac sodium oral suspensions packaged in amber polyvinyl chloride bottles

BACKGROUND

Prescribing of diclofenac for children usually involves a dose different from commercially available strengths. This drug is available only as tablets, which can be divided only so many times before the dose obtained becomes inaccurate. In addition, children may have difficulty swallowing tablets. For these reasons, a compounding formula for a liquid dosage form is essential to ensure effective delivery of the drug to pediatric patients.

OBJECTIVES

To develop a compounding formula for diclofenac sodium and to determine the extended physical and chemical stability of this compound when stored in amber polyvinyl chloride (PVC) prescription bottles under refrigeration and at room temperature.

METHODS

A suspension of diclofenac sodium (10 mg/mL) was prepared from commercially available diclofenac sodium tablets, with Ora-Blend as the suspending and flavouring agent. The suspension was packaged in 60-mL amber PVC prescription bottles and stored at either room temperature (23°C) or under refrigeration (5°C). Samples were collected on days 0, 7, 14, 21, 27, 56, and 93. Chemical stability was determined using a validated stability-indicating high-performance liquid chromatography method. At each sampling time, the suspensions were checked for changes in appearance (i.e., colour, layering, caking, ease of resuspension), odour, and pH.

RESULTS

The diclofenac sodium suspensions were very stable, retaining at least 99.5% of the original concentration for up to 93 days, regardless of storage temperature. There were no apparent changes in the physical appearance of the suspensions, nor were there any substantial changes in odour or pH.

CONCLUSIONS

Suspensions of diclofenac sodium (10 mg/mL) were quantitatively stable but difficult to prepare because of the enteric coating of the tablets. Therefore, it is recommended that diclofenac powder be used for the preparation of suspensions. For pediatric use, palatability is a consideration, and a masking agent should be added before administration. An expiry date of up to 93 days is suggested.

Efficacy and safety of Ibuprofen arginine in the treatment of primary dysmenorrhoea

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of ibuprofen arginate in the treatment of patients with primary dysmenorrhoea in normal clinical practice.

STUDY DESIGN

In this open trial, patients received an initial oral dose of ibuprofen arginine 600mg at the onset of pain, followed by the same dose every 6 hours, if necessary, with a maximum daily dose of 2400mg. The study assessed the evolution of pain intensity, rapidity of action, need for supplementary analgesics, decrease in working or school hours lost, and safety and tolerability of ibuprofen arginine treatment. Each patient was evaluated prior to inclusion in the study and after one and three cycles.

RESULTS

From the 1093 recruited patients, 854 women were evaluable for safety and tolerability, and 838 for efficacy. Significant improvement in pain relief was observed 15 minutes after treatment compared with baseline values (p < 0.001). At 15 and 30 minutes the percentage of patients reporting a marked decrease in pain intensity was 82.2% and 97.6%, respectively. Additionally, a significant reduction in absenteeism from work or school (from a mean of 4.6-0.8 hours per cycle) was observed (p < 0.001). Thirty-eight patients presented with adverse events in the trial period, but only 26 subjects (3% of 854) in the adverse events cohort reported having a possible adverse event, with gastrointestinal complaints being the most frequent.

CONCLUSION

Ibuprofen arginine appears to be effective, fast, safe and well tolerated in the treatment of patients with primary dysmenorrhoea.

NSAIDs: take with food or after fasting?

OBJECTIVE

Published and regulatory advice is to take NSAIDs with fluids and/or food irrespective whether NSAIDs are taken over the counter or long-term. The basis for this recommendation is not clear and we sought to establish the reasons for it through a search of published literature and personal files.

RESULTS

Results from experimental animals show that fasting increases the gastric side effects of NSAIDs while food increases small bowel damage, but this has not been tested in humans. The possible effects of food in modifying the gastric damage caused by NSAIDs are complex, as food quantity and composition modify the responses substantially. Food usually delays peak levels of NSAIDs (and hence onset of action) without affecting total bioavailability. This may not be important when a steady state is achieved, but rapid onset of action is highly relevant for over-the-counter use of NSAIDs. The safety of over-the-counter use of ibuprofen and naproxen appears to be excellent and comparable with paracetamol.

CONCLUSION

The rapid onset of action of NSAIDs is most important during over-the-counter use, in which case it may be more appropriate to take the drugs on a fasting stomach.

Endoscopic evaluation of the gastro-duodenal tolerance of short-term analgesic treatment with 25 mg diclofenac-K liquid capsules

BACKGROUND

Diclofenac-potassium (diclofenac--K) 25 mg liquid capsule is absorbed more quickly than the tablet formulation. It offers potential for rapid pain relief, but may alter gastro-duodenal tolerability.

AIM

To evaluate the gastro-duodenal tolerance of diclofenac-K 25 mg liquid capsules vs. diclofenac-K 12.5 mg tablets, acetylsalicylic acid (ASA) 500 mg tablets and ibuprofen 200 mg liquid capsules.

METHODS

In an endoscopist-blinded, randomised, parallel-group study, volunteers received 15 doses of diclofenac-K 25 mg liquid capsules (n = 36), diclofenac-K 2 × 12.5 mg tablets (n = 36), ibuprofen 2 × 200 mg liquid capsules (n = 24) or ASA 2 × 500 mg tablets (n = 36) over 5 days. The primary outcome was the incidence of erosive gastro-duodenal lesions at Day 6. Secondary outcomes included modified Lanza score and change in gastric mucosal prostaglandin synthesis.

RESULTS

The lowest incidence of erosive gastro-duodenal lesions was with diclofenac-K liquid capsules (53%), compared to 61% with diclofenac-K tablets (P = 0.52), 75% with ibuprofen (P = 0.08) and 94% with ASA (P = 0.001). Results were similar for the Lanza scores, although diclofenac-K liquid capsules were significantly superior to ibuprofen liquid capsules (P = 0.04). Diclofenac-K liquid capsules inhibited prostaglandin synthesis by 52% compared to 64% for diclofenac-K tablets (P = 0.10), 50% for ibuprofen (P = 0.85) and 79% for ASA (P = 0.002). With respect to safety, adverse events were most frequent in the ASA group, predominantly gastrointestinal events.

CONCLUSIONS

Mucosal injury with diclofenac-K liquid 25 mg liquid capsules was similar to diclofenac-K 25 mg tablets, significantly lower than ASA 1 g tablets and showed some superiority over ibuprofen 400 mg liquid capsules (EudraCT Number 2009-011278-14).

Non-steroidal anti-inflammatory drugs for the treatment of pain and immobility-associated osteoarthritis: consensus guidance for primary care

Background

Osteoarthritis is a common presentation in primary care, and non-selective non-steroidal anti-inflammatory drugs (sometimes also referred to as traditional NSAIDs or tNSAIDs) and selective cyclo-oxygenase 2 inhibitors (COX-2 inhibitors) are commonly used to treat it. The UK's National Institute for Health and Clinical Excellence (NICE) recommends taking patient risk factors into account when selecting a tNSAID or a COX-2 inhibitor, but GPs have lacked practical guidance on assessing patient risk.

Methods

A multi-disciplinary group that included primary care professionals (PCPs) developed an evidence-based consensus statement with an accompanying flowchart that aimed at providing concise and specific guidance on NSAID use in osteoarthritis treatment. An open invitation to meet and discuss the issue was made to relevant healthcare professionals in South Yorkshire. A round table meeting was held that used a modified nominal group technique, aimed at generating opinions and ideas from all stakeholders in the consensus process. A draft developed from this meeting went through successive revisions until a consensus was achieved.

Results

Four statements on the use of tNSAIDs and COX-2 inhibitors (and an attached category of evidence) were agreed: 1) tNSAIDs are effective drugs in relieving pain and immobility associated with osteoarthritis. COX-2 inhibitors are equally effective; 2) tNSAIDs and COX-2 inhibitors vary in their potential gastrointestinal, liver, and cardio-renal toxicity. This risk varies between individual treatments within both groups and is increased with dose and duration of treatment; 3) COX-2 inhibitors are associated with a significantly lower gastrointestinal toxicity compared to tNSAIDs. Co-prescribing of aspirin reduces this advantage; 4) PPIs should always be considered with a tNSAID and with a COX-2 inhibitor in higher GI risk patients. An accompanying flowchart to guide management was also agreed.

Conclusions

Individual patient risk is an important factor in choice of treatment for patients with osteoarthritis and the consensus statement developed offers practical guidance for GPs and others in primary care. Where there are clinical uncertainties, guidance developed and agreed by local clinicians has a role to play in improving patient management.

Insights into the effects of diclofenac and other non-steroidal anti-inflammatory agents on ion channels

OBJECTIVES

Diclofenac and other non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of inflammation and pain. Most effects of NSAIDs are attributed to the inhibition of cyclooxygenases (COX). However, many NSAIDs may have other effects not related to COX, including the modulation of various ion channels. The clinical implications of the effects on channels are not fully understood. This review outlines the effects of NSAIDs, with special attention to diclofenac, on ion channels and highlights the possible underlying mechanisms.

KEY FINDINGS

NSAIDs have effects on channels such as inhibition, activation or changes in expression patterns. The channels affected include voltage-gated Na(+) , Ca(2+) , or K(+) channels, ligand-gated K(+) channels, transient receptor potential and other cation channels as well as chloride channels in several types of cells. The mechanisms of drug actions not related to COX inhibition may involve drug-channel interactions, interference with the generation of second messengers, changes in channel expression, or synergistic/antagonist interactions with other channel modulators.

SUMMARY

The effects on ion channels may account for novel therapeutic actions of NSAIDs or for adverse effects. Among the NSAIDs, diclofenac may serve as a template for developing new channel modulators and as a tool for investigating the actions of other drugs.

Nitric oxide donor and non steroidal anti inflammatory drugs as a therapy for muscular dystrophies: evidence from a safety study with pilot efficacy measures in adult dystrophic patients

This open-label, single centre pilot study was designed to evaluate safety and tolerability of the combination of the drugs isosorbide dinitrate, a nitric oxide donor, and ibuprofen, a non steroid anti-inflammatory drug, in a cohort of adult dystrophic patients (Duchenne, Becker and Limb-Girdle Muscular Dystrophy). Seventy-one patients were recruited: 35, treated with the drug combination for 12 months, and 36 untreated. Safety and adverse events were assessed by reported signs and symptoms, physical examinations, blood tests, cardiac and respiratory function tests. Exploratory outcomes measure, such as the motor function measure scale, were also applied. Good safety and tolerability profiles of the long-term co-administration of the drugs were demonstrated. Few and transient side effects (i.e. headache and low blood pressure) were reported. Additionally, exploratory outcomes measures were feasible in all the disease population studied and evidenced a trend towards amelioration that reached statistical significance in one dimension of the MFM scale. Systemic administration of ibuprofen and isosorbide dinitrate provides an adequate safety margin for clinical studies aimed at assessing efficacy.

Rofecoxib and clinically significant upper and lower gastrointestinal events revisited based on documents from recent litigation

INTRODUCTION

On the basis of published data, it is widely believed and cited that rofecoxib use is associated with approximately a 50% reduction in significant gastrointestinal (GI) complications such as bleeding.

METHODS

Data made available as part of litigation, including the Vioxx Gastrointestinal Outcomes Research trial and an Alzheimer's study, allow a reassessment of the reported benefits of rofecoxib in terms of a significant reduction in complicated GI events and in lower GI bleeding.

RESULTS

During the review process of the Vioxx Gastrointestinal Outcomes Research study, it was suggested that rofecoxib might have little benefit, with regard to GI toxicity, for patients with rheumatoid arthritis not treated with corticosteroids. Reanalysis of the original Merck data set showed 9 complicated confirmed events in the rofecoxib group compared with 10 in the naproxen group among corticosteroid nonusers and 7 versus 27 among corticosteroid users so that the difference between rofecoxib and naproxen in the occurrence of confirmed complicated perforations, ulcers or bleeds seemed to be entirely because of the effects within corticosteroid users. The claim that serious lower GI events were 54% lower with the use of the selective cyclooxygenase-2 inhibitor rofecoxib was stated to be based on an assessment blinded to treatment allocation. In fact, the choice did not represent the original blinded analysis that showed a nonsignificant difference, but rather was based on an assessment after treatment allocation was disclosed.

CONCLUSION

Examination and reanalysis of unpublished data regarding rofecoxib has failed to confirm a safety advantage of rofecoxib over traditional nonsteroidal anti-inflammatory drugs in terms of complicated upper or lower GI events.

Impact of a health safety warning and prior authorisation on the use of piroxicam: a time-series study

BACKGROUND

The aim of this study was to assess the quantitative changes in systemic use of piroxicam after the issue of a health safety warning about its risks and the subsequent implementation of prior authorisation.

METHODS

We determined the number of monthly daily defined doses/1000 inhabitants/day (DHDs) of piroxicam in the period 2005-2008 in a health area in Spain. The data were analysed graphically, and the impact of the safety warning and introduction of prior authorisation were estimated by using segmented regression analysis.

RESULTS

The graph showed that the number of DHDs of piroxicam was stable both before and after the health safety warning but registered a very marked decrease after implementation of prior authorisation, after which DHDs of piroxicam remained stable at a 98% inferior level compared with previous to prior authorisation. Segmented regression analysis showed no statistically significant immediate jump in piroxicam utilisation after the safety warning nor a change in the slope afterwards, but it did show a significant immediate jump after prior authorisation.

CONCLUSION

Population exposure to systemic piroxicam remained unaffected by a previous health safety warning but declined sharply after the introduction of prior authorisation.

Short-term acetylsalicylic acid (aspirin) use for pain, fever, or colds - gastrointestinal adverse effects: a meta-analysis of randomized clinical trials

Background and Aim: Acetylsalicylic acid (ASA [aspirin]) is a commonly used over-the-counter drug for the treatment of pain, fever, or colds, but data on the safety of this use are very limited. The aim of this study was to provide data on the safety of this treatment pattern, which is of interest to clinicians, regulators, and the public.

Methods: A meta-analysis of individual patient data from 67 studies sponsored by Bayer HealthCare was completed. The primary endpoints were patient-reported gastrointestinal (GI) adverse events (AEs); the secondary endpoints were the incidence of patient-reported non-GI AEs. Event incidence and odds ratios (ORs) based on Cochran-Mantel-Haenszel estimates are reported. In total, 6181 patients were treated with ASA, 3515 with placebo, 1145 with acetaminophen (paracetamol), and 754 with ibuprofen. Exposure to ASA was short term (82.5% of patients had a single dose).

Results: GI AEs were more frequent with ASA (9.9%) than with placebo (9.0%) [OR 1.3; 95% CI 1.1, 1.5]. Dyspeptic symptoms were infrequent (4.6% in placebo subjects). The ORs for ASA were 1.3 (95% CI 1.1, 1.6) versus placebo; 1.55 (95% CI 0.7, 3.3) versus ibuprofen; and 1.04 (95% CI 0.8, 1.4) versus acetaminophen. There were very few serious GI AEs (one ASA case; three placebo cases). No differences were found for non-GI AEs and no cases of cerebral hemorrhage were reported.

Conclusion: Short-term, mostly single-dose exposure to ASA for the treatment of pain, fever, or colds was associated with a small but significant increase in the risk of dyspepsia relative to placebo.No serious GI complications were reported.

Over-the-counter ibuprofen and risk of gastrointestinal bleeding complications: a systematic literature review

BACKGROUND

Exposure to over-the-counter (OTC) ibuprofen and other OTC non-steroidal anti-inflammatory drugs (NSAIDs) is substantial. Although the literature on gastrointestinal (GI) safety of NSAID therapy is extensive, the risk profiles of OTC and prescription dosing are seldom separated, and few studies provide risks specific to OTC ibuprofen.

OBJECTIVE

To conduct a literature review to evaluate the risk of GI bleeding events related to OTC ibuprofen use.

METHODS

Published clinical trials, observational studies, and meta-analyses of OTC ibuprofen use, defined as up to 1200 mg/day or stated as 'over the counter,' reporting endpoints of incidence rates and proportions of GI bleeding events (e.g., GI bleeding-related hospitalizations and deaths) were identified via MEDLINE through 2010. Data from these studies were summarized.

RESULTS

Twenty studies (nine observational, ten clinical trials, one meta-analysis) reporting incidence rates and proportions of a GI bleeding-related event associated with OTC or OTC-specific doses of ibuprofen were included. The frequency of a GI-related hospitalization was <0.2% for patients on OTC-comparable doses. Incidence rates among those using OTC-comparable doses ranged from 0 to 3.19 per 1000 patient-years. The incidence of a GI bleeding-related event increased with age and the use of concomitant medications, and there was a general, though not always statistically significant, ibuprofen dose-response relationship. The relative risk of any GI bleeding-related event ranged from 1.1 to 2.4 for users of OTC-specific doses of ibuprofen compared to non-users.

CONCLUSIONS

Studies reported low incidence of GI bleeding events with use of OTC ibuprofen. Few published studies that specifically investigated OTC ibuprofen use were identified. Varying methodologies and definitions of exposure and outcomes prevented direct comparison of many results. Only studies that used the methods herein described were identified. Further research evaluating the risk of GI bleeding events in patients taking OTC-specific ibuprofen use may be useful.

Optimal management of Barrett's esophagus: pharmacologic, endoscopic, and surgical interventions

Esophageal adenocarcinoma and its precursor, Barrett’s esophagus, are rapidly rising in incidence. This review serves to highlight the role of pharmacologic, endoscopic, and surgical intervention in the management of Barrett’s esophagus, which requires acid suppression and endoscopic assessment. Treatment with a proton pump inhibitor may decrease acid exposure and delay the progression to dysplasia. Patients who require aspirin for cardioprotection or other indications may also benefit in terms of a protective effect against the development of esophageal cancer. However, without other indications, aspirin is not indicated solely to prevent cancer. A careful endoscopic examination should include assessment of any visible lesions in a Barrett’s segment. An expert gastrointestinal pathologist should confirm neoplasia in the setting of Barrett’s esophagus. For those patients with high-grade dysplasia or intramucosal carcinoma, careful consideration of endoscopic therapy or surgical therapy must be given. All visible lesions in the setting of dysplasia should be targeted with focal endoscopic mucosal resection for both accurate histopathologic diagnosis and treatment. The remainder of the Barrett’s epithelium should be eradicated to address all synchronous and metachronous lesions. This may be done by tissue acquiring or nontissue acquiring means. Radiofrequency ablation has a positive benefit-risk profile for flat Barrett’s esophagus. At this time, endoscopic therapy is not indicated for nondysplastic Barrett’s esophagus. Esophagectomy is still reserved for selected cases with evidence of lymph node metastasis, unsuccessful endoscopic therapy, or with high-risk features of high-grade dysplasia or intramucosal carcinoma.

Gastrointestinal and Cardiovascular Risk of Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) confer a gastrointestinal (GI) side effect profile and concerns regarding adverse cardiovascular effects have emerged associated with considerable morbidity and mortality. NSAIDs are highly effective in treating pain and inflammation, but it is well recognized that these agents are associated with substantial gastrointestinal toxicity. Cyclo-oxygenase-2 inhibitors may also reduce the risk for gastrointestinal events, although they may increase cardiovascular adverse events. The selection of an appropriate analgesic or anti-inflammatory agent with or without gastroprotective therapy should be individualized.

Current evidence on the safety profile of NSAIDs for the treatment of PDA

Patent ductus arteriosus (PDA) complicates the clinical course of preterm infants. Nonsteroidal anti-inflammatory drugs, especially Indomethacin and Ibuprofen, have been widely used for both prevention and treatment of PDA. Short-term efficacy of Indomethacin or Ibuprofen is equivalent, while Ibuprofen results show a higher safety profile. Ibuprofen is associated with fewer clinical gastrointestinal and renal side effects with respect to Indomethacin even if subclinical potential effects are reported. When administered as prophylaxis, Ibuprofen has no effects on prevention of intraventricular haemorrhage unlike Indomethacin. Considering the potential adverse effects of both these drugs, a careful monitoring during and after the treatment period is highly recommended.

Cardiovascular risk with non-steroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies

BACKGROUND

Randomised trials have highlighted the cardiovascular risks of non-steroidal anti-inflammatory drugs (NSAIDs) in high doses and sometimes atypical settings. Here, we provide estimates of the comparative risks with individual NSAIDs at typical doses in community settings.

METHODS AND FINDINGS

We performed a systematic review of community-based controlled observational studies. We conducted comprehensive literature searches, extracted adjusted relative risk (RR) estimates, and pooled the estimates for major cardiovascular events associated with use of individual NSAIDs, in different doses, and in populations with low and high background risks of cardiovascular events. We also compared individual drugs in pair-wise (within study) analyses, generating ratios of RRs (RRRs). Thirty case-control studies included 184,946 cardiovascular events, and 21 cohort studies described outcomes in >2.7 million exposed individuals. Of the extensively studied drugs (ten or more studies), the highest overall risks were seen with rofecoxib, 1.45 (95% CI 1.33, 1.59), and diclofenac, 1.40 (1.27, 1.55), and the lowest with ibuprofen, 1.18 (1.11, 1.25), and naproxen, 1.09 (1.02, 1.16). In a sub-set of studies, risk was elevated with low doses of rofecoxib, 1.37 (1.20, 1.57), celecoxib, 1.26 (1.09, 1.47), and diclofenac, 1.22 (1.12, 1.33), and rose in each case with higher doses. Ibuprofen risk was seen only with higher doses. Naproxen was risk-neutral at all doses. Of the less studied drugs etoricoxib, 2.05 (1.45, 2.88), etodolac, 1.55 (1.28, 1.87), and indomethacin, 1.30 (1.19, 1.41), had the highest risks. In pair-wise comparisons, etoricoxib had a higher RR than ibuprofen, RRR = 1.68 (99% CI 1.14, 2.49), and naproxen, RRR = 1.75 (1.16, 2.64); etodolac was not significantly different from naproxen and ibuprofen. Naproxen had a significantly lower risk than ibuprofen, RRR = 0.92 (0.87, 0.99). RR estimates were constant with different background risks for cardiovascular disease and rose early in the course of treatment.

CONCLUSIONS

This review suggests that among widely used NSAIDs, naproxen and low-dose ibuprofen are least likely to increase cardiovascular risk. Diclofenac in doses available without prescription elevates risk. The data for etoricoxib were sparse, but in pair-wise comparisons this drug had a significantly higher RR than naproxen or ibuprofen. Indomethacin is an older, rather toxic drug, and the evidence on cardiovascular risk casts doubt on its continued clinical use. Please see later in the article for the Editors' Summary.

Low back pain (acute)

INTRODUCTION

Low back pain affects about 70% of people in resource-rich countries at some point in their lives. Acute low back pain can be self-limiting; however, 1 year after an initial episode, as many as 33% of people still have moderate-intensity pain and 15% have severe pain. Acute low back pain has a high recurrence rate; 75% of those with a first episode have a recurrence. Although acute episodes may resolve completely, they may increase in severity and duration over time.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments for acute low back pain? What are the effects of local injections for acute low back pain? What are the effects of non-drug treatments for acute low back pain? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics (paracetamol, opioids), back exercises, back schools, bed rest, behavioural therapy, electromyographic biofeedback, epidural corticosteroid injections, lumbar supports, massage, multidisciplinary treatment programmes, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulation, temperature treatments (short-wave diathermy, ultrasound, ice, heat), traction, and transcutaneous electrical nerve stimulation (TENS).

Assessment of nonsteroidal anti-inflammatory drug-induced hepatotoxicity

INTRODUCTION

Liver toxicity related to NSAIDs is of outstanding importance because of the wide use of these drugs. NSAIDs are responsible for roughly 10% of the total of cases of drug-induced hepatotoxicity. The assessment of NSAID-induced hepatotoxicity, presently based on clinical and analytical biomarkers, is critical for early diagnosis and immediate withdrawal of the causing drug.

AREAS COVERED

The review presents an overview of current knowledge of the assessments of NSAID-induced hepatotoxicity with emphasis on the causative drugs, the NSAID-specific mechanisms involved, and a summary of genetic and non-genetic risk factors. Additionally, the authors discuss genetic factors which show NSAID-specific risk, namely CYP2C, UGT2B7, GSTM1 and GSTT1, as well as HLA alleles. The paper includes a list of the NSAID 'usual suspects' that cause hepatotoxicity based on the integrated information of drug-induced hepatotoxicity databases.

EXPERT OPINION

The ultimate goal of this research is pre-prescription testing. Unfortunately, genetic testing, alone, is not sufficient to predict NSAID-induced hepatotoxicity. The development of genetic biomarkers capable of identifying at-risk individuals will not be complete until we develop the ability to fully characterize patients' phenomes and the phenome-genome interaction in patients with NSAID-induced hepatotoxicity. Additionally, a characterization of the metabolic profile of the causative drug in patients with NSAID-induced hepatotoxicity would add crucial information which is presently disregarded in most studies. The full development of robust biomarkers will require the combination of several disciplines including causal statistics, phenomics, genomics, transcriptomics and metabonomics.

Safety profile of topical diclofenac: a meta-analysis of blinded, randomized, controlled trials in musculoskeletal conditions

BACKGROUND

Topical non-steroidal anti-inflammatory drugs (NSAIDs) are clinically proven for the management of musculoskeletal conditions. It is important that prescribers and patients are aware of the safety profile of topical NSAIDs.

OBJECTIVES

To evaluate the risk of adverse events (AEs) associated with topical diclofenac for the treatment of acute and chronic musculoskeletal conditions.

DESIGN

Systematic review and meta-analysis of blinded, randomized, placebo-, vehicle- or active-controlled trials.

RESULTS

The risk of any type of AE experienced with topical diclofenac was slightly higher compared with placebo/vehicle (RR 1.11), but was more than 50% lower than the risk observed with active topical comparators (RR 0.53). Absolute risk values indicated differences in the risk of AEs depending on the diclofenac formulation used; in particular, lower rates of local skin reactions were observed with diclofenac patches (e.g. 2.5% in placebo/vehicle-controlled studies) and gels (4.2%) compared with diclofenac solutions containing dimethylsulfoxide (34.2%). Dry skin/crusting and rash were the most common local skin reactions reported (9.0% and 3.0% of patients, respectively, in placebo/vehicle-controlled studies), which were usually mild-to-moderate and self-resolving. The discontinuation rate due to local skin reactions with topical diclofenac (1.9%) was low and comparable with non-active comparators (0.7%), and the tolerability of topical diclofenac treatment was rated as 'good' to 'excellent' by >90% physicians and patients.

CONCLUSIONS

Topical diclofenac appears to be generally well tolerated for cutaneous use in acute and chronic musculoskeletal conditions.

Efficacy of ibuprofen versus lornoxicam after third molar surgery: a randomized, double-blind, crossover pilot study

PURPOSE

The aim of this study is to compare the analgesic efficacy and tolerability of a pre-emptive/post-surgery 4-day regimen of oral ibuprofen 400 mg with that of lornoxicam 8 mg.

METHODS

Sixteen patients received ibuprofen or lornoxicam, respectively, before and after surgery of impacted third molars in two separate appointments, in a double-blind, randomized, and crossover design. The postoperative analgesic and rescue medication consumption was recorded and pain scores were evaluated with a visual analogue scale at 2, 6, 24, 48, and 72 h, postoperatively.

RESULTS

No statistically significant differences were found between ibuprofen 400 mg and lornoxicam 8 mg with respect to study medication (p = 0.34) or rescue analgesic consumption (p = 0.5) (SUMstudy and SUMrescue). Ibuprofen: SUMstudy median 7.5 interquartile range IQR (4.25-8), 95% CI (4.6-7.7); SUMrescue median and IQR 0, 95% CI (-0.6-4.6). Lornoxicam: SUMstudy median 7 IQR (3.75-9), 95% CI (7.7-4.9); SUMrescue median and IQR 0, 95% CI (-0.7-2.7). The area under the pain intensity curve (AUC(2-72) PI) over the 4 days of investigation did not reveal significant differences between the two medications (p = 0.32). AUC(2-72) PI ibuprofen: median 1,509.7 IQR (712.36-2,444.65); 95% CI (1,078.7-2,156.5). AUC(2-72) PI lornoxicam: median 1,166.9 IQR (783.4-2,221.2), 95% CI (1,032-2,130.6). Moreover, patient satisfaction and incidence of adverse events did not reveal any significant differences between treatment groups.

CONCLUSION

Ibuprofen 400 mg and lornoxicam 8 mg were rated as equal and effective pain treatment medication after wisdom tooth surgery. In comparison, neither of the drugs provided clinical advantages nor did side effects occur more frequently after one of the analgesics.

Patient awareness of the adverse effects of aspirin and non-aspirin non-steroidal anti-inflammatory drugs

Objective

To determine the extent to which patients reported having been informed about the adverse effects of aspirin and non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs)

Method

Questionnaire survey of 26 patients who had suffered an acute gastrointestinal bleed while taking aspirin, and 100 patients who had suffered an acute gastrointestinal bleed while taking a non-aspirin NSAID

Setting

Admissions to three United Kingdom hospitals. Patients were identified from endoscopy clinic records

Key findings

Five (19 per cent) of the aspirin-treated patients and 45 (45 per cent) of the non-aspirin NSAID-treated patients remembered having been informed of potential adverse effects, an odds ratio of 3.4 (95 per cent confidence interval 1.2–9.8, P&lt;0.05). Five (19 per cent) of the aspirin-treated patients recalled having been advised what to do should adverse symptoms develop, whereas 44 (44 per cent) of the non-aspirin NSAID-treated patients did so, an odds ratio of 3.3 (95 per cent CI 1.2–9.5, P&lt;0.05). Three (12 per cent) of aspirin-treated patients reported having been given an information leaflet, whereas 29 (29 per cent) of non-aspirin NSAID-treated patients did so, an odds ratio of 3.1 (95 per cent CI 0.9–11.2, P=0.08)

Conclusion

Our results suggest that aspirin-treated patients are less informed about their drug than are patients taking non-aspirin NSAIDs, in spite of the risk of gastrointestinal bleeding with which aspirin is associated

Prescription Drug Use and Seniors

L'augmentation des dépenses de médicaments a placé les aîné(e)s sous les feux de la réforme de santé puisqu'ils en sont les plus grands consommateurs. On pourrait apporter des modifications substantielles à la consommation de médicaments presents, ce qui rehausserait les bienfaits des traitements et en minimiserait les effets négatifs, surtout chez les aîné(e)s. On documente ici un bon nombre de problèmes, notamment la surconsommation et la sous-consommation des médicaments, les erreurs d'ordonnances, la conformité au traitement et les médicaments inutilement coûteux. On a démontré l'efficacité de certaines éléments à l'égard de certains aspects du problème; qu'on cite simplement les politiques reliées au système de soins de santé, les interventions de certains médecins et de pharmaciens d'hôpitaux, les aides à la prise de dècisions et à la conformité aux traitements. Il faut mettre en place l'intégration des principales politiques et des interventions en une solution globale visant une meilleure utilisation des médicaments. Elle pourrait se composer des éléments suivants: (1) la révision des politiques de relations entre l'industrie pharmacologique et le secteur de la santé; (2) l'établissement de règlements d'expérimentation des médicaments chez les aînés avant leur approbation; (3) un institut du consommateur servant de ressource centrale objective aux demandes de renseignements des patients et de système d'appui aux décisions; (4) des systèmes intégrés d'information clinique à l'appui des systèmes de gestion des ordonnances et de la fourniture des médicaments et de la gestion des médicaments et des maladies à l'intention des pharmaciens et des médecins de premier recours; (5) une réforme de la formation médicale et de l'octroi des permis.

Identification of NSAID users at risk for gastrointestinal complications: a systematic review of current guidelines and consensus agreements

NSAIDs are among the most often used drugs worldwide. Numerous NSAID users are at risk for developing gastrointestinal complications. The purpose of this review was to identify and stratify risk factors for gastrointestinal complications in NSAID users documented in guidelines and consensus agreements, and to collect recommendations regarding over-the-counter (OTC) NSAID use. To facilitate this, a PubMed search from 1 January 1999 until 1 March 2009 was performed, resulting in the inclusion of nine English-language guidelines in our analysis. Risk factors were defined as 'definite' if mentioned in all guidelines; otherwise they were defined as 'controversial' risk factors. 'Definite' risk factors were a history of (complicated) peptic ulcer disease, older age (cut-off range 60-75 years), concomitant anticoagulant or corticosteroid use and multiple NSAID use, including low-dose aspirin (acetylsalicylic acid). 'Controversial' risk factors were high-dose NSAID use, concomitant clopidogrel or selective serotonin reuptake inhibitor use, a history of gastrointestinal symptoms, rheumatoid arthritis disability and cardiovascular disease. Infection with Helicobacter pylori was identified as an additive risk factor. Risk factors in OTC NSAID users were difficult to identify in the current literature. Risk factors were not all uniformly present in analysed guidelines and consensus agreements. We identified a history of (complicated) peptic ulcer disease, older age, concomitant anticoagulant or corticosteroid use and multiple NSAID use, including low-dose aspirin, as definite gastrointestinal risk factors in NSAID users.

NSAIDs

INTRODUCTION

NSAIDs are widely used. Almost 10% of people in The Netherlands used a non-aspirin NSAID in 1987, and the overall use was 11 defined daily doses per 1000 population a day. In Australia in 1994, overall use was 35 defined daily doses per 1000 population a day, with 36% of the people receiving NSAIDs for osteoarthritis, 42% for sprain and strain or low back pain, and 4% for rheumatoid arthritis; 35% of the people receiving NSAIDs were aged over 60 years.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: Are there any important differences between oral NSAIDs? What are the effects of topical NSAIDs; and of co-treatments to reduce the risk of gastrointestinal adverse effects of oral NSAIDs? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 36 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the benefits and harms of the following interventions: differences in efficacy among different oral NSAIDs, between oral and topical NSAIDs, and between oral NSAIDs and alternative analgesics; dose-response relationship of oral NSAIDs; and H(2) blockers, misoprostol, or proton pump inhibitors to mitigate gastrointestinal adverse effects of oral NSAIDs.

Variability among nonsteroidal antiinflammatory drugs in risk of upper gastrointestinal bleeding

OBJECTIVE

Traditional nonsteroidal antiinflammatory drugs (NSAIDs) increase the risk of upper gastrointestinal (GI) bleeding/perforation, but the magnitude of this effect for coxibs in the general population and the degree of variability between individual NSAIDs is still under debate. This study was undertaken to assess the risk of upper GI bleeding/perforation among users of individual NSAIDs and to analyze the correlation between this risk and the degree of inhibition of whole blood cyclooxygenase 1 (COX-1) and COX-2 in vitro.

METHODS

We conducted a systematic review of observational studies on NSAIDs and upper GI bleeding/perforation published between 2000 and 2008. We calculated pooled relative risk (RR) estimates of upper GI bleeding/perforation for individual NSAIDs. Additionally, we verified whether the degree of inhibition of whole blood COX-1 and COX-2 in vitro by average circulating concentrations predicted the RR of upper GI bleeding/perforation.

RESULTS

The RR of upper GI bleeding/perforation was 4.50 (95% confidence interval [95% CI] 3.82-5.31) for traditional NSAIDs and 1.88 (95% CI 0.96-3.71) for coxibs. RRs lower than that for NSAIDs overall were observed for ibuprofen (2.69 [95% CI 2.17-3.33]), rofecoxib (2.12 [95% CI 1.59-2.84]), aceclofenac (1.44 [95% CI 0.65-3.2]), and celecoxib (1.42 [95% CI 0.85-2.37]), while higher RRs were observed for ketorolac (14.54 [95% CI 5.87-36.04]) and piroxicam (9.94 [95% CI 5.99-16.50). Estimated RRs were 5.63 (95% CI 3.83-8.28) for naproxen, 5.57 (95% CI 3.94-7.87) for ketoprofen, 5.40 (95% CI 4.16-7.00) for indomethacin, 4.15 (95% CI 2.59-6.64) for meloxicam, and 3.98 (95% CI 3.36-4.72) for diclofenac. The degree of inhibition of whole blood COX-1 did not significantly correlate with RR of upper GI bleeding/perforation associated with individual NSAIDs (r(2) = 0.34, P = 0.058), but a profound and coincident inhibition (>80%) of both COX isozymes was associated with higher risk. NSAIDs with a long plasma half-life and with a slow-release formulation were associated with a greater risk than NSAIDs with a short half-life.

CONCLUSION

The results of our analysis demonstrate that risk of upper GI bleeding/perforation varies between individual NSAIDs at the doses commonly used in the general population. Drugs that have a long half-life or slow-release formulation and/or are associated with profound and coincident inhibition of both COX isozymes are associated with a greater risk of upper GI bleeding/perforation.

NSAIDs and Acute Pancreatitis: A Systematic Review

The resulting pain is the main symptom of acute pancreatitis and it should be alleviated as soon as possible. NSAIDs are the first line therapy for pain and they are generally administered to acute pancreatitis patients upon admission to the hospital. In addition, these drugs have also been used to prevent post-endoscopic cholangiopancreatography (ERCP) acute pancreatitis. On the other hand, there are several reports indicating that NSAIDs may be the actual cause of acute pancreatitis. We carried out a literature search on PubMed/MEDLINE; all full text papers published in from January 1966 to November 2009 on the use of NSAIDs in acute pancreatitis were collected; the literature search was also supplemented by a review of the bibliographies of the papers evaluated. Thus, in this article, we will systematically review the current literature in order to better illustrate the role of NSAIDs in acute pancreatitis, in particular: i) NSAIDs as a cause of acute pancreatitis; ii) their use to prevent post-retrograde ERCP pancreatitis and iii) their efficacy for pain relief in the acute illness of the pancreas.

Hospitalizations for gastrointestinal and cardiovascular events in the CADEUS cohort of traditional or Coxib NSAID users

AIMS

To assess hospital admission rates for gastrointestinal (GI) or cardiovascular (CV) events in real-life use of nonsteroidal anti-inflammatory drugs (NSAIDs).

METHODS

CADEUS is a real-life population-based cohort study of 23 535 coxib (celecoxib or rofecoxib) and 22 919 traditional NSAID (tNSAID) users. Each hospitalization reported between index day (NSAID delivery) and questionnaire submission (median = 75 days) was explored using hospital discharge summaries. An expert committee validated blindly serious GI and CV events according to predefined criteria.

RESULTS

Coxib users were older and had more GI history than tNSAID users. There were 21 hospitalizations for GI events, 12 in the coxib cohort and nine in the tNSAID cohort (respectively one and three upper GI haemorrhages and no ulcer perforations). Rates of GI events were 0.39 per 1000 patients [95% confidence interval (CI) 0.18, 0.75] for tNSAID users and 0.51 per 1000 patients (95% CI 0.26, 0.89) for coxib users. There were 21 hospitalizations for CV events, 13 in the coxib cohort and eight in the tNSAID cohort. None was fatal. Rates of CV events were, respectively, 0.59 (95% CI 0.24, 1.22), 0.51 (95% CI 0.19, 1.11) and 0.35 (95% CI 0.15, 0.69) per 1000 patients for celecoxib, rofecoxib and tNSAIDs. GI or CV event rates were not different between products even for patients >60 years old.

CONCLUSIONS

Hospitalization rates for GI bleeding were 10-20 times lower than expected from published randomized clinical trials, probably because of differences in drug usage and concomitant gastroprotection. CV event rates conformed to those expected from general population data. These results emphasize the necessity of developing population healthcare databases to explore such low event rates.

Response of community pharmacists to the presentation of back pain: a simulated patient study

Objective

To assess the response of community pharmacists to the presentation of back pain.

Method

The researcher posed as a customer to obtain medication for back pain for her grandfather, and the consultations were recorded in a pretested data collection form.

Setting

The study was conducted in 100 randomly selected community pharmacies located within the Klang Valley in Malaysia. This includes Kuala Lumpur, the capital city of Malaysia and its surrounding suburban areas.

Key findings

In 85% of the consultations, pharmacists asked at least one question before recommending a treatment. The patient's medical history was the most frequently asked question by the pharmacists (60%). In general, a median of only five counselling elements were addressed by the pharmacists out of 13 recommended. The most common element of counselling addressed was the route of administration (98%), followed by the frequency and dose to be taken (92% and 88%, respectively). None of the pharmacists asked the ‘customer’ whether she required any further information. The number of counselling elements addressed was significantly associated with the age of the pharmacist, duration of consultation and the types of medication recommended (P &lt; 0.05). Most of the pharmacists (88%) recommended at least an oral non-steroidal anti-inflammatory drug or a selective cyclooxygenase-2 inhibitor for the treatment of acute back pain. Diclofenac was the most commonly recommended medication for back pain (55% of consultations), followed by meloxicam (15%). The cost of treatment for back pain ranged from RM2.00 to RM38.00 with a median of RM10.00.

Conclusion

This study demonstrates that the extent of information gathering and counselling varied among community pharmacists in Malaysia and that in general, this appeared to be suboptimal. Professional bodies such as the Malaysian Pharmaceutical Society should create awareness among pharmacists regarding their responsibility to counsel patients or their caregivers.

Influence of cyclooxygenase inhibitors on the function of the prostaglandin transporter organic anion-transporting polypeptide 2A1 expressed in human gastroduodenal mucosa

The human organic anion-transporting polypeptide 2A1 (OATP2A1) is a prostaglandin transporter expressed in several tissues and plays an important role for local distribution of prostaglandins, which contribute to the integrity of gastric mucosa. Blockade of prostaglandin pathways by cyclooxygenase (COX) inhibitors has been associated with serious side effects such as gastrointestinal ulceration and bleeding. However, little is known regarding OATP2A1 expression in the upper gastrointestinal tract and the potential impact of cyclooxygenase inhibitors on OATP2A1 function. We first investigated the expression of OATP2A1 mRNA and protein in human gastroduodenal mucosa using human biopsy specimens obtained from antrum, corpus, and duodenum. The results indicate that OATP2A1 is expressed in the neck region and deep pyloric glands of antrum and in parietal cells of gastric corpus. Second, we examined various COX inhibitors for their effects on OATP2A1 transporter activity. Using HEK293 cells expressing OATP2A1, we found that diclofenac and lumiracoxib are potent inhibitors of OATP2A1-mediated transport of prostaglandin (PG) E(2) with IC(50) values of 6.2 +/- 1.2 and 3.1 +/- 1.2 microM. In contrast, indomethacin, ketoprofen, and naproxen led to significant stimulation of OATP2A1-mediated PGE(2) transport by 162.7 +/- 13.9, 77.2 +/- 3.6, and 32.3 +/- 4.9%, respectively. Taken together, our results suggest that various clinically used COX inhibitors have differential impact on the function of the prostaglandin transporter OATP2A1 in human stomach and that these effects may contribute to differences in the gastrointestinal side effects of COX inhibitors.

Drug-related damage of the ageing gastrointestinal tract

Drug use increases with age and the elderly is at increased risk of adverse drug reactions. Gastrointestinal adverse effects are one of the most often reported. Serious event are mostly caused by NSAIDs and/or aspirin which are the most widely prescribed medications in the world. NSAIDs and/or aspirin use are associated with complications from both the upper and the lower gastrointestinal tract. The risk of these complications depends on presence of risk factors, and age is the most frequent and relevant one. At-risk patients should be on prevention strategies including the use of the lowest effective dose, co-therapy with a gastroprotective agents or use of a COX-2 selective agent. Treatment of Helicobacter pylori infection is beneficial in patients starting therapy with these agents, especially in the presence of ulcer history. The best strategy to prevent lower GI complications has yet to be defined.

Gastrointestinal-Related Complications in a Long-Term Care Population Taking NSAIDs Versus COX-2 Inhibitor Therapy

OBJECTIVES

To determine the following in a long-term care population taking traditional nonsteroidal anti-inflammatory drug (NSAID) or cyclo-oxygenase-2 (COX-2) inhibitor therapy: (1) incidence of gastrointestinal (GI) adverse events and GI-related hospitalizations, (2) prevalence of GI-protective medication use, and (3) prevalence of GI risk factors as defined by Indiana Medicaid prior-authorization criteria.

DESIGN

Longitudinal cross-sectional study.

SETTING

Long-term care facilities in Indiana.

PATIENTS

Residents in long-term care and assisted-living facilities were included if they were receiving either traditional NSAID or COX-2 inhibitor therapy.

MAIN OUTCOME MEASURES

The number of residents experiencing GI intolerance or complications or GI-related hospitalizations associated with NSAID or COX-2 inhibitor use.

RESULTS

Over this 14-month evaluation period, 1,198 long-term care and assisted living residents were identified as receiving NSAID or COX-2 inhibitor therapy. Celecoxib was the most frequently prescribed medication used in this population. Age >70 years and concomitant aspirin use were the most frequently noted risk factors for GI disease. Significantly fewer GI complications were observed in COX-2 recipients (4.0%) compared with NSAID users (8.4%) (P = 0.002). GI-related hospitalizations occurred significantly less with COX-2 use (2.0%) compared with traditional NSAID use (4.5%) (P = 0.014). A relatively low incidence of GI-related events also was associated with ibuprofen use.

CONCLUSION

Individuals residing in assisted living or long-term care settings had lower rates of GI complications and hospitalizations related to COX-2 inhibitors compared with traditional NSAIDs.