Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies

Acute Kidney Injury in the Age of Enhanced Recovery Protocols

BACKGROUND

Acute kidney injury is a prevalent complication after abdominal surgery. With increasing adoption of enhanced recovery protocols, concern exists for concomitant increase in acute kidney injury.

OBJECTIVE

This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors.

DESIGN

This was a retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

All of the patients undergoing elective colorectal surgery between 2010 and 2016, excluding patients with stage 5 chronic kidney disease, were included.

MAIN OUTCOME MEASURES

Patients before and after enhanced recovery implementation were compared, with rate of acute kidney injury as the primary outcome. Acute kidney injury was defined as a rise in serum creatinine ≥1.5 times baseline within 30 days of surgery. Multivariable logistic regression identified risk factors for acute kidney injury.

RESULTS

A total of 900 cases were identified, including 461 before and 439 after enhanced recovery; 114 cases were complicated by acute kidney injury, including 11.93% of patients before and 13.44% after implementation of enhanced recovery (p = 0.50). Five patients required hemodialysis, with 2 cases after protocol implementation. Multivariable logistic regression identified hypertension, functional status, ureteral stents, nonsteroidal anti-inflammatory drugs, operative time >200 minutes, and increased intravenous fluid administration on postoperative day 1 as predictors of acute kidney injury. Laparoscopic surgery decreased the risk of acute kidney injury. The enhanced recovery protocol was not independently associated with acute kidney injury.

LIMITATIONS

The study was limited by its retrospective and nonrandomized before-and-after design.

CONCLUSIONS

No difference in rates of acute kidney injury was detected before and after implementation of a colorectal enhanced recovery protocol. Independent predictors of acute kidney injury were identified and could be used to alter the protocol in high-risk patients. Future study is needed to determine whether protocol modifications will further decrease rates of acute kidney injury in this population. See Video Abstract at http://links.lww.com/DCR/A568.

The Association Between Proton Pump Inhibitor Use With Acute Kidney Injury and Chronic Kidney Disease

Proton pump inhibitors (PPIs) are among the most commonly prescribed medicines and are the mainstay of treatment for gastroesophageal reflux disease. Recently, there has been an increase in the use of these medicines for unclear and inappropriate indications. Although generally well tolerated and considered to be safe, several observational studies have linked PPI use with a variety of conditions such as pneumonia, Clostridium difficile infection, fractures, hypomagnesemia, and dementia. The well-established association between PPIs and acute interstitial nephritis has raised questions about whether they may also cause acute kidney injury and chronic kidney disease. Observational studies have evaluated these possible associations. This paper reviews the currently available literature about these associations and considers their possible underlying pathophysiological mechanisms. The level of evidence-linking PPI use with acute kidney injury and chronic kidney disease is weak and does not establish causality. More research is required to explore these possible associations further. The PPIs should be used in the lowest effective dose and inappropriate use should be avoided.

Diclofenac in the treatment of pain in patients with rheumatic diseases

Diclofenac, a phenylacetic acid derivative, is a drug demonstrating high efficacy after oral administration in the treatment of pain and physical disability in rheumatic diseases. In view of the adverse effects associated with using diclofenac, it is necessary to consider all known drug safety information before the drug is selected for therapy and the dosage regimen is set for individual patients. Selecting an oral dosage form with specific properties determined by excipients is a method to improve the availability of the drug substance and, at the same time, minimize adverse drug reactions. An alternative to tablet or capsule dosage forms is diclofenac application to the skin. The proven efficacy of this method is further improved through the use of transdermal penetration enhancers and vehicle ingredients which provide dosage forms with specific physical properties.

Pharmacotherapy for chronic non-specific low back pain: current and future options

INTRODUCTION

Low back pain is associated with a large burden-of-illness. It is responsible for the most years lived with disability as compared with any other medical condition. A comprehensive overview of the evidence on pharmacological treatment options for chronic low back pain is lacking. This review evaluates the evidence for the benefits and risks of currently available pharmacological treatments for chronic low back pain.

AREAS COVERED

The authors focus on the recent (Cochrane) systematic reviews and meta-analyses of randomized clinical trials covering paracetamol (acetaminophen), NSAIDs, muscle relaxants, antidepressants, anticonvulsants, opioids, and other (new) drugs.

EXPERT OPINION

The overall impression of the efficacy of pharmacological treatments for patients with chronic low back pain is rather sobering. The effects on pain reduction and improvement of function are commonly small to moderate and short lasting when compared to placebo. At the same time, the various types of drugs are not without side-effects. This holds especially true for serious side-effects associated with (prolonged) use of strong opioids. Future studies on patients with chronic back pain should aim to identify subgroups of patients with good response to specific pharmacological treatment to facilitate personalized care.

Targeted eco-pharmacovigilance for ketoprofen in the environment: Need, strategy and challenge

Implementing "targeted" eco-pharmacovigilance(EPV) which focuses on individual or specific pharmaceuticals on a prioritised basis is a feasible, economical and customized approach to reduce the environmental concentrations and risks of pharmaceuticals. Non-steroidal anti-inflammatory drugs(NSAIDs) remaining in environment are a kind of priority hazard substances, due to a notable case that diclofenac residues caused the loss of more than 99% of vultures across the Indian sub-continent. Ketoprofen, as another widely used NSAID with comparable or even higher global consumption than diclofenac, in the environment has been shown to present a potential risk to non-target terrestrial and aquatic species. Based on the review of 85 articles reporting the analyses of ketoprofen residues in environment since 2010, we found that this NSAID frequently present in various environmental compartments around the world. Therefore, it is urgent to implement EPV targeting ketoprofen pollution. Here, we provide some recommendations for implementing the targeted EPV for ketoprofen, including: Closely monitoring ketoprofen in the natural environment; Reducing the residues of ketoprofen through source control; Encouraging urine source separation and treatment; Limiting the application of veterinary ketoprofen; Designing and constituting a framework system of targeted EPV. But some challenges, such as ambiguity in the accountability of the main bodies responsible for continued monitoring of ketoprofen residues, the lack of optimized urine source separation scenarios and procedure, the need for detailed design and application schemes of the framework system of targeted EPV, etc. should be addressed.

Probing the Antiallergic and Anti-inflammatory Activity of Biflavonoids and Dihydroflavonols from Dietes bicolor

Dietes bicolor (Iridaceae) is an ornamental plant used by African local healers to treat diarrhea and dysentery. A new dihydroflavonol, (2R,3R)-3,5,7-trihydroxy-8-methoxyflavanone (1); two known dihydroflavonols, trans-3-hydroxy-5-methoxy-6,7-methylenedioxyflavanone (2) and trans-3-hydroxy-5,7-dimethoxyflavanone (3); the known isoflavone orobol 7,3'-di-O-methyl ether (4); the known biflavones lanaroflavone (5), robustaflavone (6), and amentoflavone (7); and β-sitosterol (8) were isolated from the CH₂Cl₂ fraction of D. bicolor leaves. The extract showed potent activity in antiallergic and anti-inflammatory assays. The structures of the isolates were identified by spectroscopic and spectrometric methods. Compounds 6 and 7 (400 μM) exhibited antiallergic activity by inhibiting antigen-induced β-hexosaminidase release at 45.7% and 46.3%, respectively. Moreover, 6 and 7 exerted anti-inflammatory activity as demonstrated by the inhibition of superoxide anion generation with an IC₅₀ value of 1.0 μM as well as the inhibition of elastase release with IC₅₀ values of 0.45 and 0.75 μM, respectively. The anti-inflammatory activity was further explained by the virtual docking of the isolated compounds to the binding sites in the human neutrophil elastase (HNE) crystal structure using Discovery Studio 2.5. It was concluded that the biflavonoids bind directly to HNE and inhibit its enzymatic activity based on the CDOCKER algorithm. The data provided evidence for the potential use of D. bicolor against certain diseases related to allergy and inflammation.

A Comprehensive Review of Non-Steroidal Anti-Inflammatory Drug Use in The Elderly

NSAIDs, non-steroidal anti-inflammatory drugs, are one of the most commonly prescribed pain medications. It is a highly effective drug class for pain and inflammation; however, NSAIDs are known for multiple adverse effects, including gastrointestinal bleeding, cardiovascular side effects, and NSAID induced nephrotoxicity. As our society ages, it is crucial to have comprehensive knowledge of this class of medication in the elderly population. Therefore, we reviewed the pharmacodynamics and pharmacokinetics, current guidelines for NSAIDs use, adverse effect profile, and drug interaction of NSAIDs and commonly used medications in the elderly.

Effects of freshwater clam extract on fracture induced inflammation at early stage

The inflammatory process after traumatic fracture and soft tissue injury includes release of inflammatory cytokines and activated polymorph nuclear cells (PMN) that can cause subsequent affected limbs delayed healing and vital organ complications. Analgesics have good effect on relief of the symptom but may cause further burden for hepatic and renal metabolism. Freshwater clam extract (FCE) has been demonstrated to suppress the release of the pro-inflammatory cytokine tumor necrosis factor-α production after hemorrhagic shock, and decrease the level of liver injury marker in rats. The aim of the present study was to determine whether FCE is able to affect the inflammation induced by unilateral tibial fracture in a rat model. The rats were randomly divided into control, fracture, FCE and fracture with FCE groups. The fracture group received left tibia and fibula shaft fractures using a consistent three point bending method. For the fracture with FCE group, FCE (40 mg/kg) was administered orally after fracture. Their physiological changes were continuously monitored for 48 h. Blood samples were extracted from the femoral arterial catheter at 1, 3, 6, 9, 12, 18, 24 and 48 h after fracture. In comparison with fracture group, those whom were fed with FCE had more stable heart rate frequency, lower central temperature at the initial h, and lower serum level of the proinflammatory cytokines and muscle damage markers induced by fracture. FCE was also associated with decreased recruitment of inflammatory cells in the adjacent soft tissue. Thus, the present results suggest that FCE could decrease fracture induced inflammation reaction and have beneficial regulatory effect on post inflammatory response.

Risk factors for and the prevention of acute kidney injury after abdominal surgery

Postoperative acute kidney injury in patients undergoing abdominal surgery is not rare and often results in bad outcomes for patients. The incidence of postoperative acute kidney injury is hard to evaluate reliably due to its non-unified definitions in different studies. Risk factors for acute kidney injury specific to abdominal surgery include preoperative renal insufficiency, intraabdominal hypertension, blood transfusion, bowel preparation, perioperative dehydration, contrast agent and nephrotoxic drug use. Among these, preoperative renal insufficiency is the strongest predictor of acute kidney injury. The peri-operative management of high-risk patients should include meticulous selection of fluid solutions. Balanced crystalloid solutions and albumin are generally thought to be relatively safe, while the safety of hydroxyethyl starch solutions has been controversial. The purpose of the present review is to discuss the current knowledge regarding postoperative acute kidney injury in abdominal surgical settings to help surgeons make better decisions concerning the peri-operative management.

Perioperative COX-2 inhibitors may increase the risk of post-operative acute kidney injury

BACKGROUND

In enhanced recovery protocols (ERP), a restrictive fluid regimen is proposed. Patients who undergo major surgery have an increased risk of post-operative acute kidney injury (AKI). This combination may pose difficulties when ERP is used for patients undergoing major surgery. The aim of this study was to evaluate whether patients undergoing pancreatic surgery and treated with a restrictive fluid regimen are at greater risk of post-operative AKI. Furthermore, if there was an increased risk of AKI, we aimed to identify its cause.

METHODS

We reviewed the medical records of patients who underwent pancreatic surgery during 2014 (preERP, n = 58) and 2015 (ERP, n = 65). Fluid balance, the administration of cyclooxygenase-2 inhibitors, creatinine levels and mean arterial pressure were recorded. The Kidney Disease: Improving Global Outcomes criteria were used to define AKI.

RESULTS

The incidence of AKI was higher in the ERP group than in the PreERP group (12.5% vs. 1.8%, respectively, P = 0.035). The increased incidence of AKI could not be explained by differences in comorbidities, age, pre-operative creatinine or perioperative hypotension. Administration of coxibs was higher in the ERP group and was associated with increased incidence of post-operative AKI (P = 0.018). The combination of coxibs and restrictive fluid regimen seems particularly harmful.

CONCLUSION

Pancreatic surgery with a restrictive fluid regimen carries an increased risk of post-operative AKI if patients are also treated with cyclooxygenase-2 inhibitors. It is therefore suggested that in protocols including a restrictive fluid regimen for open pancreatic surgery, the use of cyclooxygenase-2 inhibitors should be avoided.

Non-steroidal anti-inflammatory drug induced acute kidney injury in the community dwelling general population and people with chronic kidney disease: systematic review and meta-analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are a common cause of adverse drug events (ADEs), but renal risks of NSAIDs are less well quantified than gastrointestinal and cardiac risks. This paper reports a systematic review of published population-based observational studies examining the risk of acute kidney injury (AKI) associated with NSAIDs in community-dwelling adults and those with pre-existing chronic kidney disease (CKD).

METHODS

MEDLINE and EMBASE databases were searched until June 2016, and 3789 papers screened. Ten studies reporting NSAID risk of AKI in the general population were included in random effects meta-analysis, of which five additionally reported NSAID risk in people with CKD.

RESULTS

In the general population, the pooled odds ratio (OR) of AKI for current NSAID exposure was 1.73 (95%CI 1.44 to 2.07), with somewhat higher risk observed in older people (OR 2.51, 95%CI 1.52 to 2.68). In people with CKD, individual study OR of AKI due to current NSAID exposure ranged from 1.12 to 5.25, with pooled estimate OR 1.63 (95% CI 1.22 to 2.19).

CONCLUSIONS

No study reported baseline risk of AKI in different populations meaning absolute risks could not be estimated, but baseline risk and therefore the absolute risk of NSAID exposure is likely to be higher in people with CKD and older people. Large population based studies measuring AKI using current definitions and estimating the absolute risk of harm are needed in order to better inform clinical decision making.

Low-dose diclofenac in patients with fragility fractures

Most osteoporotic patients complain of back pain one year after a fragility vertebral fracture and the frequency of chronic back pain increases with increasing age. The use of the lowest effective dose of an analgesic which is able to control symptoms seems to be a possible solution in order to limit potential side effects in multi-treated elderly patients. Non-steroidal anti-inflammatory drugs (NSAIDs) have a proven efficacy in the treatment of back pain associated with fragility vertebral fractures and diclofenac is available at low-dose subcutaneous injective formulation. This is the rational of ImPAVeDic study, acronym of Improvement of back Pain Associated with fragility Vertebral fractures with low-dose Diclofenac, an observational study that will be performed in a group of 50 elderly (≥ 65 years), male and female osteoporotic patients with symptomatic fragility vertebral fractures. The objective of the study is to evaluate the improvement of back pain in the study population treated with low-dose diclofenac and regularly monitored for 2-6 months. Visual Analogic Scale (VAS) and Numerical Rating Scale (NRS) will be used for pain monitoring. The reduction of the risk of occurrence of drug side effects can favour the optimization of elderly patients' care.

Inhaled nitric oxide prevents NSAID-induced renal impairment in pseudo-normovolaemic piglets

Objective

Inhaled nitric oxide (iNO) is commonly used as a treatment of pulmonary hypertension. Its action is purported to be specific to the lung, but extrapulmonary effects have been reported. The objective of this study was to evaluate if iNO could compensate the renal impairment induced by ketoprofen, a conventional non-steroidal anti-inflammatory drug (NSAID), during general anaesthesia.

Methods

Under pseudo-normovolaemic condition, thirty piglets were randomly assigned into 5 equal groups and equipped for renal and systemic parameters measurements. A first experiment was carried out to validate methods and reproduce the renal effects of iNO (40 ppm) in comparison with a placebo (100% oxygen). In a second experiment, iNO was inhaled for 120 minutes right after NSAID treatment (ketoprofen 2 mg×kg^-1 IV, and 40 ppm iNO; group KiNO) and its effects were compared to ketoprofen alone (2 mg×kg^-1 IV; group K) and placebo (saline; group C).

Results

In this model, iNO increased significantly renal blood flow measured by ultrasonic (RBF_UL: +53.2±17.2%; p = 0.008) and by PAH clearance (RBF_PAH:+78.6±37.6%; p = 0.004) methods, glomerular filtration rate (GFR: +72.6±32.5%; p = 0.006) and urinary output (UO: +47.4±24.2%; p = 0.01). In the second experiment, no significant temporal variation was noted for renal parameters in groups KiNO and C, whereas a significant and constant decrease was observed in the group K for RBF_UL (max -19.0±7.1%), GFR (max -26.6±10.4%) and UO (max -30.3±10.5%).

Clinical significance

Our experiments show that iNO, released from its transport forms after its inhalation, can improve renal safety of NSAIDs. This result is promising regarding the use of NSAIDs in critical conditions, but needs to receive clinical confirmation.

Indirect comparisons of the efficacy of biological agents in patients with active ankylosing spondylitis: a systematic review and meta-analysis

Patients with ankylosing (AS) often do not have a satisfactory response to, or could not tolerate, non-steroidal anti-inflammatory drugs (NSAIDs). Several biologic agents are available for such patients. However, the comparative efficacy of these treatments remains unknown as head-to-head randomized controlled trials (RCTs) are not available. RCTs examining the efficacy of biologic agents in patients with AS who had inadequate response to, or could not tolerate, NSAIDs were identified. If at least two RCTs were available for a given biologic agent, the pooled odds ratio (OR) and 95% confidence interval (CI) of achieving 20% improvement according to the Ankylosing Spondylitis Assessment Study group response criteria 20 (ASAS20) across trials were calculated. The pooled OR for each biologic agent was then compared to each other using the indirect comparison technique. A total of 14 RCTs of older TNF inhibitors, two RCTs of secukinumab, one RCT of certolizumab, and one RCT of tofacitinib were identified. No significant difference in any indirect comparisons was observed with the p values ranging from 0.12 to 0.74. The likelihood of achieving the ASAS20 response in patients AS who failed or could not tolerate NSAIDs was not significantly different between older TNF inhibitors, secukinumab, certolizumab, and tofacitinib. However, the analysis is limited by the small sample size with only one RCT for certolizumab and tofacitinib.

Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data

Objective To characterise the determinants, time course, and risks of acute myocardial infarction associated with use of oral non-steroidal anti-inflammatory drugs (NSAIDs).Design Systematic review followed by a one stage bayesian individual patient data meta-analysis.Data sources Studies from Canadian and European healthcare databases.Review methods Eligible studies were sourced from computerised drug prescription or medical databases, conducted in the general or an elderly population, documented acute myocardial infarction as specific outcome, studied selective cyclo-oxygenase-2 inhibitors (including rofecoxib) and traditional NSAIDs, compared risk of acute myocardial infarction in NSAID users with non-users, allowed for time dependent analyses, and minimised effects of confounding and misclassification bias. Exposure and outcomes Drug exposure was modelled as an indicator variable incorporating the specific NSAID, its recency, duration of use, and dose. The outcome measures were the summary adjusted odds ratios of first acute myocardial infarction after study entry for each category of NSAID use at index date (date of acute myocardial infarction for cases, matched date for controls) versus non-use in the preceding year and the posterior probability of acute myocardial infarction.Results A cohort of 446 763 individuals including 61 460 with acute myocardial infarction was acquired. Taking any dose of NSAIDs for one week, one month, or more than a month was associated with an increased risk of myocardial infarction. With use for one to seven days the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations.Conclusions All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction. Risk of myocardial infarction with celecoxib was comparable to that of traditional NSAIDS and was lower than for rofecoxib. Risk was greatest during the first month of NSAID use and with higher doses.

A minimal impact of long-term S-flurbiprofen plaster application on kidney function in osteoarthritis patients

Background

The number of kidney injury due to nonsteroidal anti-inflammatory drugs (NSAIDs) is the largest among drug-induced kidney diseases. Newly developed NSAID plaster containing S-flurbiprofen (SFP) shows innovative percutaneous absorption. However, systemic exposure to SFP following the repeated application of 80 mg/day was estimated as comparable to that of oral 120 mg/day flurbiprofen and prolonged use of topical NSAIDs is common in clinical practice. Thus, we report the safety focusing on the kidney function after long-term application of SFP plaster (SFPP).

Methods

A total of 201 osteoarthritis patients (mean age; 66.3, 151 females, mean estimated glomerular filtration rate; 74.6 mL/min/1.73 mm²) were applied 40 or 80 mg SFPP for 52 weeks, and kidney function was examined by blood urea nitrogen (BUN), serum creatinine (SCr), eGFR, and urinalysis.

Results

161 (80.1%) patients completed 52-week application. In both groups of 40 and 80 mg, small but statistically significant increases were observed in BUN (mean 1.91 and 1.89 mg/dL, p < 0.05) and SCr (mean 0.019 and 0.022 mg/dL, p < 0.05). Although abnormal changes in laboratory test for renal function were observed in seven patients, all the changes were small and subclinical. Acute kidney injury was observed in two patients. Meanwhile, the investigators denied the relevance of SFPP according to the clinical course.

Conclusion

Toward the end of 52-week application, a statistically significant increase in SCr was observed in both 40 and 80 mg, but increment was small and subclinical. Attention should be paid to kidney function when applying SFPP to patients with multiple risk factors.

Vinpocetine reduces diclofenac-induced acute kidney injury through inhibition of oxidative stress, apoptosis, cytokine production, and NF-κB activation in mice

Acute kidney injury (AKI) represents a complex clinical condition associated with significant morbidity and mortality. Approximately, 19-33% AKI episodes in hospitalized patients are related to drug-induced nephrotoxicity. Although, considered safe, non-steroidal anti-inflammatory drugs such as diclofenac have received special attention in the past years due to the potential risk of renal damage. Vinpocetine is a nootropic drug known to have anti-inflammatory properties. In this study, we investigated the effect and mechanisms of vinpocetine in a model of diclofenac-induced AKI. We observed that diclofenac increased proteinuria and blood urea, creatinine, and oxidative stress levels 24h after its administration. In renal tissue, diclofenac also increased oxidative stress and induced morphological changes consistent with renal damage. Moreover, diclofenac induced kidney cells apoptosis, up-regulated proinflammatory cytokines, and induced the activation of NF-κB in renal tissue. On the other hand, vinpocetine reduced diclofenac-induced blood urea and creatinine. In the kidneys, vinpocetine inhibited diclofenac-induced oxidative stress, morphological changes, apoptosis, cytokine production, and NF-κB activation. To our knowledge, this is the first study demonstrating that diclofenac-induced AKI increases NF-κB activation, and that vinpocetine reduces the nephrotoxic effects of diclofenac. Therefore, vinpocetine is a promising molecule for the treatment of diclofenac-induced AKI.

Evaluation of Anti-Inflammatory Properties of Isoorientin Isolated from Tubers of Pueraria tuberosa

Inflammation is the major causative factor of different diseases such as cardiovascular disease, diabetes, obesity, osteoporosis, rheumatoid arthritis, inflammatory bowel disease, and cancer. Anti-inflammatory drugs are often the first step of treatment in many of these diseases. The present study is aimed at evaluating the anti-inflammatory properties of isoorientin, a selective cyclooxygenase-2 (COX-2) inhibitor isolated from the tubers of Pueraria tuberosa, in vitro on mouse macrophage cell line (RAW 264.7) and in vivo on mouse paw edema and air pouch models of inflammation. Isoorientin reduced inflammation in RAW 264.7 cell line in vitro and carrageenan induced inflammatory animal model systems in vivo. Cellular infiltration into pouch tissue was reduced in isoorientin treated mice compared to carrageenan treated mice. Isoorientin treated RAW 264.7 cells and animals showed reduced expression of inflammatory proteins like COX-2, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), 5-lipoxygenase (5-LOX), and interleukin 1-β (IL-1-β) both in vitro and in vivo. The antioxidant enzyme levels of catalase and GST were markedly increased in isoorientin treated mice compared to carrageenan treated mice. These results suggest that isoorientin, a selective inhibitor of COX-2, not only exerts anti-inflammatory effects in LPS induced RAW cells and carrageenan induced inflammatory model systems but also exhibits potent antioxidant properties.

Colorectal Carcinoma: A General Overview and Future Perspectives in Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death. Most cases of CRC are detected in Western countries, with its incidence increasing year by year. The probability of suffering from colorectal cancer is about 4%–5% and the risk for developing CRC is associated with personal features or habits such as age, chronic disease history and lifestyle. In this context, the gut microbiota has a relevant role, and dysbiosis situations can induce colonic carcinogenesis through a chronic inflammation mechanism. Some of the bacteria responsible for this multiphase process include Fusobacterium spp, Bacteroides fragilis and enteropathogenic Escherichia coli. CRC is caused by mutations that target oncogenes, tumour suppressor genes and genes related to DNA repair mechanisms. Depending on the origin of the mutation, colorectal carcinomas can be classified as sporadic (70%); inherited (5%) and familial (25%). The pathogenic mechanisms leading to this situation can be included in three types, namely chromosomal instability (CIN), microsatellite instability (MSI) and CpG island methylator phenotype (CIMP). Within these types of CRC, common mutations, chromosomal changes and translocations have been reported to affect important pathways (WNT, MAPK/PI3K, TGF-β, TP53), and mutations; in particular, genes such as c-MYC, KRAS, BRAF, PIK3CA, PTEN, SMAD2 and SMAD4 can be used as predictive markers for patient outcome. In addition to gene mutations, alterations in ncRNAs, such as lncRNA or miRNA, can also contribute to different steps of the carcinogenesis process and have a predictive value when used as biomarkers. In consequence, different panels of genes and mRNA are being developed to improve prognosis and treatment selection. The choice of first-line treatment in CRC follows a multimodal approach based on tumour-related characteristics and usually comprises surgical resection followed by chemotherapy combined with monoclonal antibodies or proteins against vascular endothelial growth factor (VEGF) and epidermal growth receptor (EGFR). Besides traditional chemotherapy, alternative therapies (such as agarose tumour macrobeads, anti-inflammatory drugs, probiotics, and gold-based drugs) are currently being studied to increase treatment effectiveness and reduce side effects.

One-pot preparation of polylactic acid-ibuprofen conjugates and their performance characterization

Merging esterification modification, carrier preparation, and chemical conjugation into a one-pot reaction as a new strategy for developing the polylactic acid-ibuprofen conjugates is described.

Gastric and renal effects of COX-2 selective and non-selective NSAIDs in rats receiving low-dose aspirin therapy

The consumption of low-dose aspirin (LDA) to prevent cardiovascular disease continues to increase worldwide. Consequently, the number of chronic LDA users seeking dental procedures that require complementary acute anti-inflammatory medication has also grown. Considering the lack of literature evaluating this interaction, we analyzed the gastric and renal effects caused by a selective COX-2 inhibitor (etoricoxib) and a non-selective COX-2 inhibitor (ibuprofen) nonsteroidal anti-inflammatory drug (NSAID) in rats receiving chronic LDA therapy. Male Wistar rats were divided into six experimental groups (carboxymethylcellulose (CMC) - vehicle; LDA; LDA + ibuprofen; ibuprofen; LDA + etoricoxib; and etoricoxib) and submitted to long-term LDA therapy with a subsequent NSAID administration for three days by gavage. After the experimental period, we analyzed gastric and renal tissues and quantified serum creatinine levels. The concomitant use of LDA with either NSAID induced the highest levels of gastric damage when compared to the CMC group (F = 20.26, p < 0.05). Treatment with either LDA or etoricoxib alone was not associated with gastric damage. No significant damage was observed on kidney morphology and function (F = 0.5418, p > 0.05). These results suggest that even the acute use of an NSAID (regardless of COX-2 selectivity) can induce gastric damage when combined with the long-term use of low-dose aspirin in an animal model. Additional studies, including clinical assessments, are thus needed to clarify this interaction, and clinicians should be careful of prescribing NSAIDs to patients using LDA.

Selective cyclooxygenase-2 inhibitor use and progression of renal function in patients with chronic kidney disease: a single-center retrospective cohort study

Background

The use of selective COX-2 (sCOX-2) inhibitors with acute kidney injury, salt water retention, and cardiovascular events have been correlated in subjects with normal kidney function, but sCOX-2 inhibitor use concerning the progression of chronic kidney disease (CKD) remains uncertain.

Objectives

To determine the progression of renal function and electrolyte abnormalities among CKD patients after using sCOX-2 inhibitors during short- and long-term periods.

Methods

The study employed a retrospective cohort design comprising all types of CKD patients with and without sCOX-2 inhibitors (celecoxib and etoricoxib). Data collected included medical data, estimated glomerular filtration rate (eGFR), and serum electrolytes at 3 and 6 months between January 2009 and January 2014. Subjects attended the outpatient clinic and were then followed up until discontinuation of the drugs at years 1 and 2 until May 2016.

Results

Ninety-two CKD patients on sCOX-2 inhibitors and 92 CKD patients without sCOX-2 inhibitors were included. The sCOX-2 inhibitor group showed more decline in eGFR than the control group at 3 and 6 months of follow-up (–8.27±9.75 vs –1.64±6.05 mL/min/1.73 m², P<0.001 and –12.36±6.48 vs –4.31±5.11 mL/min/1.73 m², P=0.001, respectively) and at 1 and 2 years of follow-up after subjects discontinued sCOX-2 (–6.84±10.34 vs –1.61±8.93 mL/min/1.73 m², P=0.004 and –10.26±10.19 vs –5.12±8.61 mL/min/1.73 m², P=0.005, respectively). In addition, the sCOX-2 inhibitor group had significantly more increased serum potassium during the study follow-up than the control group.

Conclusion

The sCOX-2 inhibitors are associated with an increased risk for rapid eGFR decline and hyperkalemia in both the short term and in the long term after sCOX-2 inhibitors were terminated in the setting of a community-based CKD population. For CKD patients, these results suggest that sCOX-2 inhibitors should be closely monitored and chronic exposure to any sCOX-2 inhibitors should be avoided.

Clinical outcomes of acute kidney injury developing outside the hospital in elderly

PURPOSE

Although various studies have improved our knowledge about the clinical features and outcomes of acute kidney injury developing in the hospital (AKI-DI) in elderly subjects, data about acute kidney injury developing outside the hospital (AKI-DO) in elderly patients (age ≥ 65 years) are still extremely limited. This study was performed to investigate prevalence, clinical outcomes, hospital cost and related factors of AKI-DO in elderly and very elderly patients.

METHODS

We conducted a prospective, observational study in patients (aged ≥ 65 years) who were admitted to our center between May 01, 2012, and May 01, 2013. Subjects with AKI-DO were divided into two groups as "elderly" (group 1, 65-75 years old) and "very elderly" (group 2, >75 years old). Control group (group 3) consisted of the hospitalized patients aged 65 years and older with normal serum creatinine level. In-hospital outcomes and 6-month outcomes were recorded. Rehospitalization rate within 6 months of discharge was noted. Hospital costs and mortality rates of each group were investigated. Risk factors for AKI-DO were determined.

RESULTS

The incidence of AKI-DO that required hospitalization in elderly and very elderly patients was 5.8 % (136/2324) and 11 % (100/905), respectively (p < 0.001), with an overall incidence of 7.3 % (236/3229). Chronic kidney disease (CKD) was developed in 43.4 % of group 1 and 67 % of group 2 within the 6 months of discharge (p < 0.001). Progression to CKD was significantly lower in the control group than in groups 1 and 2 (p < 0.001). Mortality rates for groups 1, 2 and 3 were 23.5 % (n = 32), 31 % (n = 31) and 4.2 % (n = 8), respectively (p < 0.05). Rehospitalization rate within the 6 months of discharge for the groups with AKI-DO was higher than for the control group (p < 0.001). Hospital cost of groups 1 and 2 was significantly higher than that of the control group (p < 0.001). Nonsteroidal anti-inflammatory drugs (NSAIDs) (OR: 6.839, 95 % CI = 4.392-10.648), angiotensin-converting enzyme inhibitors (ACEI) (OR: 7.846, 95 % CI = 5.161-11.928), angiotensin receptor blockers (ARB) (OR: 6.466, 95 % CI = 4.813-8.917), radiocontrast agents (OR: 8.850, 95 % CI = 5.857-13.372), hypertension (OR: 4.244, 95 % CI = 2.729-6.600), diabetes mellitus (OR: 2.303, 95 % CI = 1.411-3.761), heart failure (OR: 3.647, 95 % CI = 2.276-5.844) and presence of infection (OR: 3.149, 95 % CI = 1.696-5.845) were found as the risk factors for AKI-DO in elderly patients (p < 0.001 for all). Patients with AKI-DO had higher 6-month mortality rate (HR 1.721, 95 % CI: 1.451-2.043, p < 0.001). Mortality risk increased 0.519 times at 20th day.

CONCLUSIONS

The incidence of AKI-DO requiring hospitalization is higher in very elderly patients than elderly ones, especially in male gender. Use of ACEI, ARB, NSAID and radiocontrast agents is the main risk factors for the development of AKI-DO in the elderly.

Pharmacological and Interventional Management of Pain After Whiplash Injury

Synopsis Whiplash-associated disorder (WAD) is a group of symptoms and clinical manifestations resulting from rear-end or side impact. Despite the wide use of medications in WAD, the published research does not allow recommendations based on high evidence level. It may be meaningful to use nonsteroidal anti-inflammatory drugs in the acute posttraumatic phase. In chronic WAD, the use of nonsteroidal anti-inflammatory drugs is more concerning due to potential gastrointestinal and renal complications with prolonged use and lack of evidence for long-term benefits. Antidepressants can be used in patients with clinically relevant hyperalgesia, sleep disorder associated with pain, or depression. Anticonvulsants are unlikely first-choice medications, but can be considered if other treatments fail. The use of opioids in patients with chronic pain has become the object of severe concern, due to the lack of evidence for long-term benefits and the associated risks. Extreme caution in prescribing and monitoring opioid treatment is mandatory. Nerve blocks of the zygapophyseal (facet) joints have validity for the diagnosis of facet joint pain, which is one of the possible manifestations of WAD. One randomized sham-controlled trial and several high-quality prospective studies support the efficacy of radiofrequency neurotomy for the treatment of facet joint pain. The efficacy of trigger point treatments is uncertain. They can be offered due to possible efficacy and limited risks. Any medication or procedure has to be considered in the frame of a comprehensive patient evaluation. As for any chronic pain condition, concomitant consideration of rehabilitation and psychosocial interventions is mandatory. J Orthop Sports Phys Ther 2016;46(10):845-850. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6906.

A case of reversible hyperoxaluria nephropathy early after roux-en-y-gastric bypass induced by vitamin C intake

Roux-en-y-gastric bypass (RYGB) is the most commonly performed bariatric procedure worldwide which is taking the lead in resolving of comorbid conditions. Short- and long-term complications of RYGB procedure have been recognized, including osteopenia, osteomalacia and more rarely neurological disorders. Oxalate nephropathy is a complication of RYGB that has been described earlier in the literature and may end with renal failure and dialysis if not recognized and treated early. The etiology of this phenomenon is still unclear, but the length of common limb remains the theory that mostly contributed to its development. We believe that this limb should be more than 100 cm to prevent severe malabsorption. Here, we report a reversible case of oxalate nephropathy 3 months after RYGB in a 51-year-old patient.

Contemporary Reflections on the Safety of Long-Term Aspirin Treatment for the Secondary Prevention of Cardiovascular Disease

Aspirin has been the cornerstone of therapy for the secondary prevention treatment of patients with cardiovascular disease since landmark trials were completed in the late 1970s and early 1980s that demonstrated the efficacy of aspirin for reducing the risk of ischemic events. Notwithstanding the consistent benefits demonstrated with aspirin for both acute and chronic cardiovascular disease, there are a number of toxicities associated with aspirin that have been showcased by recent long-term clinical trials that have included an aspirin monotherapy arm. As an inhibitor of cyclooxygenase (COX), aspirin impairs gastric mucosal protective mechanisms. Previous trials have shown that up to 15-20 % of patients developed gastrointestinal symptoms with aspirin monotherapy, and approximately 1 % of patients per year had a clinically significant bleeding event, including 1 in 1000 patients who suffered an intracranial or fatal bleed. These risks have been shown to be compounded for patients with acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention (PCI) who are also treated with other antithrombotic agents during the acute care/procedural period, as well as for an extended time period afterwards. Given observations of substantial increases in bleeding rates from many prior long-term clinical trials that have evaluated aspirin together with other oral platelet inhibitors or oral anticoagulants, the focus of contemporary research has pivoted towards tailored antithrombotic regimens that attempt to either shorten the duration of exposure to aspirin or replace aspirin with an alternative antithrombotic agent. While these shifts are occurring, the safety profile of aspirin when used for the secondary prevention treatment of patients with established cardiovascular disease deserves further consideration.

Salidroside suppresses solar ultraviolet-induced skin inflammation by targeting cyclooxygenase-2

Solar ultraviolet (SUV) irradiation causes skin disorders such as inflammation, photoaging, and carcinogenesis. Cyclooxygenase-2 (COX-2) plays a key role in SUV-induced skin inflammation, and targeting COX-2 may be a strategy to prevent skin disorders. In this study, we found that the expression of COX-2, phosphorylation of p38 or JNKs were increased in human solar dermatitis tissues and SUV-irradiated human skin keratinocyte HaCaT cells and mouse epidermal JB6 Cl41 cells. Knocking down COX-2 inhibited the production of prostaglandin E2 (PGE2), the phosphorylation of p38 or JNKs in SUV-irradiated cells, which indicated that COX-2 is not only the key enzyme for PGs synthesis, but also an upstream regulator of p38 or JNKs after SUV irradiation. The virtual ligand screening assay was used to search for natural drugs in the Chinese Medicine Database, and indicated that salidroside might be a COX-2 inhibitor. Molecule modeling indicated that salidroside can directly bind with COX-2, which was proved by in vitro pull-down binding assay. Ex vivo studies showed that salidroside has no toxicity to cells, and inhibits the production of PGE2, phosphorylation of p38 or JNKs, and secretion of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) caused by SUV irradiation. In vivo studies demonstrated that salidroside attenuates the skin inflammation induced by SUV. In brief, our data provided the evidences for the protective role of salidroside against SUV-induced inflammation by targeting COX-2, and salidroside might be a promising drug for the treatment of SUV-induced skin inflammation.

Risk of acute and serious liver injury associated to nimesulide and other NSAIDs: data from drug-induced liver injury case-control study in Italy

Aim

Drug‐induced liver injury is one of the most serious adverse drug reactions and the most frequent reason for restriction of indications or withdrawal of drugs. Some nonsteroidal anti‐inflammatory drugs (NSAIDs) were withdrawn from the market because of serious hepatotoxicity. We estimated the risk of acute and serious liver injury associated with the use of nimesulide and other NSAIDs, with a prevalence of use greater than or equal to 5%.

Methods

This is a multicentre case–control study carried out in nine Italian hospitals from October 2010 to January 2014. Cases were adults, with a diagnosis of acute liver injury. Controls presented acute clinical disorders not related to chronic conditions, not involving the liver. Adjusted odds ratio (ORs) with 95% confidence interval (CI) were calculated initially with a bivariate and then multivariate analysis.

Results

We included 179 cases matched to 1770 controls. Adjusted OR for acute serious liver injury associated with all NSAIDs was 1.69, 95% CI 1.21–2.37. Thirty cases were exposed to nimesulide (adjusted OR 2.10, 95% CI 1.28–3.47); the risk increased according to the length of exposure (OR > 30 days: 12.55, 95% CI 1.73–90.88) and to higher doses (OR 10.69, 95% CI 4.02–28.44). Risk of hepatotoxicity was increased also for ibuprofen, used both at recommended dosages (OR 1.92, 95% CI 1.13–3.26) and at higher doses (OR 3.73, 95% CI 1.11–12.46) and for ketoprofen ≥ 150 mg (OR 4.65, 95% CI 1.33–10.00).

Conclusion

Among all NSAIDs, nimesulide is associated with the higher risk, ibuprofen and high doses of ketoprofen are also associated with a modestly increased risk of hepatotoxicity.

Adverse Effects of Oral Nonselective and cyclooxygenase-2-Selective NSAIDs on Hospitalization for Acute Kidney Injury: A Nested Case-Control Cohort Study

To investigate the association between the use of nonselective or cyclooxygenase (COX)-2-selective nonsteroidal antiinflammatory drugs (NSAIDs) and risk of acute kidney injury (AKI) in a general Asian population. We conducted an observational, nationwide, nested case-control cohort study using Taiwan's National Health Insurance Research Database between 2010 and 2012. AKI cases were defined as hospitalization with a principle diagnosis of AKI. Each case was matched to 4 randomly selected controls based on age, sex, and the month and year of cohort entry. Odds ratios (ORs) were used to demonstrate the association between hospitalization for AKI and current, recent, or past use of an oral NSAID. During the study period, we identified 6199 patients with AKI and 24,796 matched controls. Overall, current users (adjusted OR 2.73, 95% confidence interval [CI] 2.28-3.28) and recent users (adjusted OR 1.17, 95% CI 1.01-1.35) were associated with increased risk of hospitalization for AKI. The risk was also similar for nonselective NSAIDs. However, neither current nor recent use of COX-2 inhibitors was significantly associated with AKI events. Our study supported that the initiation of nonselective NSAIDs rather than COX-2 inhibitors is associated with an increased risk of AKI requiring hospitalization. Future randomized trials are needed to elucidate these findings.

Nonsteroidal Anti-inflammatory Drugs and Risk of Incident Heart Failure: A Systematic Review and Meta-analysis of Observational Studies

BACKGROUND

The association between the development of heart failure (HF) and use of nonsteroidal anti-inflammatory drugs (NSAIDs) is not well established.

HYPOTHESIS

Use of NSAIDs may increase the risk of incident HF.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of incident HF in NSAID users vs nonusers. Pooled risk ratios (RR) and 95% confidence intervals (CI) for all NSAIDs and both subclasses (conventional NSAIDs and highly selective cyclooxygenase-2 inhibitors [COXIBs]) were calculated using a random-effect, generic inverse variance method.

RESULTS

Seven studies with 7,543,805 participants were identified and included in our data analysis. Use of NSAIDs was associated with a significantly higher risk of developing HF, with a pooled RR of 1.17 (95% CI: 1.01-1.36). Subgroup analysis showed a significantly elevated risk among users of conventional NSAIDs (RR: 1.35, 95% CI: 1.15-1.57) but not users of COXIBs (RR: 1.03, 95% CI: 0.92-1.16).

CONCLUSIONS

A significantly elevated risk of incident HF was observed among users of NSAIDs.

Non-steroidal anti-inflammatory drugs and risk of heart failure exacerbation: A systematic review and meta-analysis

BACKGROUND

The association between exacerbation of heart failure (HF) and use of non-steroidal anti-inflammatory drugs (NSAIDs) has long been recognized but the data on this adverse effect are limited.

METHODS

To further characterize this possible association, we conducted a systematic review and meta-analysis of observation studies that reported odds ratio, relative risk, hazard ratio or standardized incidence ratio comparing risk of exacerbation of HF in patients with pre-existing HF who took NSAIDs versus non-users. Pooled risk ratios (RR) and 95% confidence intervals for conventional NSAIDs, celecoxib and rofecoxib were calculated using random-effect, generic inverse variance method.

RESULTS

Six studies were identified and included in our data analysis. Use of conventional NSAIDs was associated with a significantly higher risk of development of exacerbation of HF with the pooled RR of 1.39 (95% CI 1.20-1.62). Elevated risk was also observed among celecoxib and rofecoxib users (RR 1.34, 95% CI 0.98-1.85 and RR 2.04, 95% CI 1.68-2.48). The pooled RR of rofecoxib was significantly higher than conventional NSAIDs (p=0.02).

CONCLUSION

Use of NSAIDs is associated with an increased risk of HF exacerbation among patients with pre-existing HF. The excess risk was approximately 40% for conventional NSAIDs and celecoxib. The highest risk was observed among rofecoxib users.

Food Polyphenols Fail to Cause a Biologically Relevant Reduction of COX-2 Activity

Epidemiologic studies show a correlation between the dietary intake of food polyphenols and beneficial health effects. Several in vitro studies indicate that the anti-inflammatory potential of polyphenols is, at least in part, mediated by a modulation of the enzymes of the arachidonic acid cascade, such as the prostaglandin forming cyclooxygenases (COXs). Evidence that this mode of action can be transferred to the situation in vivo is scarce. This study characterized effects of a subset of polyphenols on COX–2 expression and activity in vitro and compared the potency with known drugs. Next, the in vivo relevance of the observed in vitro effects was tested. Enzyme assays and incubations of polyphenols with the cancer cell line HCA–7 and lipopolysaccharide (LPS) stimulated primary monocytes support the hypothesis that polyphenols can effect COX–2 expression and activity in vitro. The effects were most pronounced in the monocyte assay for wogonin, apigenin, resveratrol and genistein with IC₅₀ values of 1.5 μM, 2.6 μM, 2.8 μM and 7.4 μM. However, these values are 100- to 1000-fold higher in comparison to those of the known pharmaceuticals celecoxib, indomethacin and dexamethasone. In an animal model of LPS induced sepsis, pretreatment with polyphenols (i. p. 100 mg/kg bw) did not result in decreased plasma or tissue prostaglandin levels, whereas the positive control celecoxib effectively attenuated LPS induced prostaglandin formation. These data suggest that despite the moderate potency in vitro, an effect of polyphenols on COX–2 during acute inflammation is unlikely, even if a high dose of polyphenols is ingested.