Nonsteroidal antiinflammatory drugs and the gastrointestinal tract. The double-edged sword

Evaluation of analgesic and anti-inflammatory activities and molecular docking analysis of steroidal lactones from Datura stramonium L

BACKGROUND

Datura stramonium L. is widely used across the world for its therapeutic potential to treat inflammatory disorders. The current work was designed to isolate and identify steroidal lactones from D. stramonium leaves and evaluate their anti-inflammatory and analgesic properties.

METHODS

Several compounds were isolated from D. stramonium leaves and characterized by nuclear magnetic resonance and high-resonance electron spray ionization mass spectrometry techniques. Further, anti-inflammatory properties of these compounds were evaluated by in vitro assays, such as release of NO and pro-inflammatory cytokines by lipopolysaccharide (LPS)-activated J774A.1 macrophages. Using in vivo models, anti-inflammatory and analgesic effects were examined by mouse tail-flick, carrageenan-induced inflammation in rat paw model, vascular permeability in rats, and acetic acid-induced writhing in mice. The docking studies were performed for assessing the binding efficiency of the test compounds with cyclooxygenase-1 (COX-1) and COX-2, lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), inducible nitric oxide synthases (iNOS) and nuclear factor-κB (NF-κB).

RESULTS

Three lactones were isolated and confirmed as daturalactone (D1), 12-deoxywithastramonolide (D23), and daturilin (D27). Further, the isolated compounds showed nitric oxide inhibition and pro-inflammatory cytokines released by LPS-activated J774A.1 macrophages. The in vivo results suggest that D1, D23 and D27 (20 mg/kg) were able to reduce the pain and inflammation in various animal models. The docking analysis showed that these three compounds actively bind with COX-1, COX-2, LOX-1, NF-κB, and iNOS, validating the anti-inflammatory effects of the lactones.

CONCLUSION

These findings demonstrate substantial anti-inflammatory and analgesic properties of D. stramonium-derived lactones and their potential as anti-inflammatory agents to treat chronic inflammatory ailments.

Molecular Targets of Natural Products for Chondroprotection in Destructive Joint Diseases

Osteoarthritis (OA) is the most common type of arthritis that occurs in an aged population. It affects any joints in the body and degenerates the articular cartilage and the subchondral bone. Despite the pathophysiology of OA being different, cartilage resorption is still a symbol of osteoarthritis. Matrix metalloproteinases (MMPs) are important proteolytic enzymes that degrade extra-cellular matrix proteins (ECM) in the body. MMPs contribute to the turnover of cartilage and its break down; their levels have increased in the joint tissues of OA patients. Application of chondroprotective drugs neutralize the activities of MMPs. Natural products derived from herbs and plants developed as traditional medicine have been paid attention to, due to their potential biological effects. The therapeutic value of natural products in OA has increased in reputation due to their clinical impact and insignificant side effects. Several MMPs inhibitor have been used as therapeutic drugs, for a long time. Recently, different types of compounds were reviewed for their biological activities. In this review, we summarize numerous natural products for the development of MMPs inhibitors in arthritic diseases and describe the major signaling targets that were involved for the treatments of these destructive joint diseases.

Synergistic anti-inflammatory activities of a new flavone and other flavonoids from Tephrosia hildebrandtii vatke

A new flavone, named hildeflavone (1) along with 7 other known flavonoids were isolated from the aerial parts of Tephrosia hildebrandtii Vatke. Their characterisation was based on NMR and MS data analysis. The anti-inflammatory properties of the crude extract, isolated compounds and combination of the compounds were investigated in lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMCs). Treatment of the LPS-stimulated PBMCs with the isolated flavonoids at a concentration of 100 µM significantly reduced the production of interleukins (IL-1β, IL-2 and IL-6), interferon-gamma (IFN-γ), granulocyte macrophage-colony stimulating factor (GM-CSF) and tumour necrosis factor-alpha (TNF-α). It was also found that the combination of a flavone and flavanones exhibited remarkable synergistic anti-inflammatory effects on the production of the cytokines.

The pharmacokinetics and metabolism of diclofenac in chimeric humanized and murinized FRG mice

The pharmacokinetics of diclofenac were investigated following single oral doses of 10 mg/kg to chimeric liver humanized and murinized FRG and C57BL/6 mice. In addition, the metabolism and excretion were investigated in chimeric liver humanized and murinized FRG mice. Diclofenac reached maximum blood concentrations of 2.43 ± 0.9 µg/mL (n = 3) at 0.25 h post-dose with an AUC_inf of 3.67 µg h/mL and an effective half-life of 0.86 h (n = 2). In the murinized animals, maximum blood concentrations were determined as 3.86 ± 2.31 µg/mL at 0.25 h post-dose with an AUC_inf of 4.94 ± 2.93 µg h/mL and a half-life of 0.52 ± 0.03 h (n = 3). In C57BL/6J mice, mean peak blood concentrations of 2.31 ± 0.53 µg/mL were seen 0.25 h post-dose with a mean AUC_inf of 2.10 ± 0.49 µg h/mL and a half-life of 0.51 ± 0.49 h (n = 3). Analysis of blood indicated only trace quantities of drug-related material in chimeric humanized and murinized FRG mice. Metabolic profiling of urine, bile and faecal extracts revealed a complex pattern of metabolites for both humanized and murinized animals with, in addition to unchanged parent drug, a variety of hydroxylated and conjugated metabolites detected. The profiles in humanized mice were different to those of both murinized and wild-type animals, e.g., a higher proportion of the dose was detected in the form of acyl glucuronide metabolites and much reduced amounts as taurine conjugates. Comparison of the metabolic profiles obtained from the present study with previously published data from C57BL/6J mice and humans revealed a greater, though not complete, match between chimeric humanized mice and humans, such that the liver humanized FRG model may represent a model for assessing the biotransformation of such compounds in humans.

Effectiveness of topical gel of medical leech (Hirudo medicinalis) saliva extract on patients with knee osteoarthritis: A randomized clinical trial

Leech saliva extract (LSE) in the liposome-based gel was used as a supplementary treatment to relief the signs and symptoms of osteoarthritis (OA). The saliva of medical leech was extracted and nano liposomes were used to formulate the supplement to enhance skin absorption. A clinical trial was designed to evaluate the therapeutic effects of LSE liposomal gel. Lenquesne and VAS questionnaires were used as indexes of this supplement therapy efficacy for 30 days. Questionnaires analysis showed that after one-month administration of LSE liposomal gel, patients' pain was relieved approximately up to 50%; also, due to reduction in joint inflammation and stiffness, the range of motion was increased and the patients' quality of life was enhanced (p < 0.001). LSE nano scaled liposomal gel as an innovative supplement therapy in OA patients, makes desirable therapeutic approach, which seems to make a significant impact on patient's quality of life and self-care capability.

Potential anti-inflammatory, antioxidant and antimicrobial activities of Sambucus australis

CONTEXT

Sambucus australis Cham. & Schltdl. (Adoxaceae) is used in Brazilian folk medicine to treat inflammatory disorders.

OBJECTIVE

To evaluate the in vitro anti-inflammatory, antioxidant and antimicrobial properties of S. australis.

MATERIALS AND METHODS

The anti-inflammatory activity of ethanol extracts of the leaf and bark of S. australis (1-100 μg/mL) were studied in lipopolysaccharide/interferon γ stimulated murine macrophages RAW 264.7 cells (24 h incubation) by investigating the release of nitric oxide (NO) and tumour necrosis factor-alpha (TNF-α) and in the TNF-α-induced nuclear factor kappa (NF-κB) assay. Minimum inhibitory concentration (MIC) was determined by the microdilution test (24 h incubation). Antioxidant activity was determined by 2,2-diphenyl-1-picrylhydrazyl (DPPH), ferric reducing antioxidant power (FRAP) and the NO scavenging assays. Chemical composition was assessed by LC-MS/MS.

RESULTS

Antioxidant activities in the DPPH (IC₅₀ 43.5 and 66.2 μg/mL), FRAP (IC₅₀ 312.6 and 568.3 μg/mL) and NO radical scavenging assays (IC₅₀ 285.0 and 972.6 μg/mL) were observed in the leaf and bark ethanol extracts, respectively. Solely the leaf extract showed significant inhibition of NO and TNF-α production in RAW264.7 cells at concentrations of 2 and 100 μg/mL, respectively, and suppression of TNF-α inhibition of NF-κB by 12.8 and 20.4% at concentrations of 50 and 100 μg/mL, respectively. The extract also exhibited antibacterial activity against Salmonella typhimurium (MIC 250 μg/mL) and Klebsiella pneumoniae (MIC 250 μg/mL). LC-MS/MS revealed the presence of chlorogenic acid and rutin as major compounds.

DISCUSSION AND CONCLUSION

The results indicate that the ethanol leaf extract of S. australis exhibit prominent anti-inflammatory effects.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Research to Help Your Patients Use them Safely

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective medications for the treatment of many chronically painful medical conditions. However, it is estimated that 25% of all serious adverse drug reactions involve NSAIDs, with more than 100,000 hospitalizations and 16,000 deaths occurring annually due to NSAID-induced gastrointestinal (GI) events. Advanced age; concurrent anticoagulant, aspirin, corticosteroid, or antacid use; and a history of cardiovascular disease, peptic ulcer disease, or GI hemorrhage all increase the risk of NSAID-induced gastropathy. Home care patients often have many of these characteristics. This article will provide evidence-based information about interventions that can reduce patients’ NSAID-induced gastropathy risk, including knowledge gained from a home care–specific study.

Liver injury from nonsteroidal anti-inflammatory drugs in the United States

BACKGROUND & AIMS

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used and have been associated with hepatotoxicity. Studies of liver injury from NSAIDs have been retrospective and prospective data are lacking. The aim was to report the features and outcomes of the subjects with severe drug-induced liver injury from NSAIDS.

METHODS

The U.S. Drug Induced Liver Injury Network is a prospective registry of idiosyncratic drug hepatotoxicity. All patients are evaluated in a standard fashion and followed up for at least 6 months.

RESULTS

Of 1221 Drug Induced Liver Injury Network cases that were adjudicated, 30 cases were attributed to eight different NSAIDs. The mean age was 52 years old, 24 (80%) were women, and 21 (70%) were Caucasian. The mean latency was 67 days. Common signs and symptoms at presentation were nausea (73%), jaundice (67%) and dark urine (67%). Mean peak serum aspartate aminotransferase, alanine aminotransferase, total bilirubin and alkaline phosphatase were 898 U/L, 1060 U/L, 12.2 mg/dl and 326 U/L. The most common pattern of injury was hepatocellular (70%) and autoantibodies were detected in 33% of cases. Diclofenac, was the most frequently implicated NSAID (16/30 cases), and characterized by hepatocellular injury. Seventeen cases resulted in hospitalization or prolongation of hospitalization and one patient died from complications of Stevens-Johnson syndrome because of diclofenac.

CONCLUSIONS

Hepatocellular injury is the most common pattern seen with NSAID hepatotoxicity, and diclofenac is the most frequently implicated agent. Given the number of NSAID alternatives, diclofenac should be reserved for patients who fail other NSAIDs and a high level of suspicion for hepatotoxicity should be maintained.

Enhancing Skin Permeation of Biphenylacetic Acid (BPA) Using Salt Formation with Organic and Alkali Metal Bases

In the present study, a series of organic and alkali metal salts of biphenylacetic acid (BPA) have been prepared and evaluated in vitro for percutaneous drug delivery. The physicochemical properties of BPA salts were determined using solubility measurements, DSC, and IR. The DSC thermogram and FTIR spectra confirmed the salt formation with organic and alkali metal bases. Among the series, salts with organic amines (ethanolamine, diethanolamine, triethanolamine, and diethylamine) had lowered melting points while the alkali metal salt (sodium) had a higher melting point than BPA. The in vitro study showed that salt formation improves the physicochemical properties of BPA, leading to improved permeability through the skin. Amongst all the prepared salts, ethanolamine salt (1b) showed 7.2- and 5.4-fold higher skin permeation than the parent drug at pH 7.4 and 5.0, respectively, using rat skin.

Effects of pentosan polysulfate in osteoarthritis of the knee: A randomized, double-blind, placebo-controlled pilot study

BACKGROUND

Recent recommendations from the Group for the Respect of Excellence and Ethics in Science for the clinical assessment of the effects of disease-modifying osteoarthritis (OA) drugs suggest that improvement in joint space narrowing, pain, and function relative to a control group should be the primary end points.

OBJECTIVE

The aim of this study was to assess the ability of sodium pentosan polysulfate (NaPPS) to improve pain and function in patients with OA of the knee.

METHODS

This randomized, double-blind, placebo-controlled pilot study was performed at the Queen Elizabeth II Medical Centre, Perth, Australia. Patients aged ≥18 years with OA of the knee were randomly assigned to receive NaPPS 3 mg/kg or Ringer's solution (control), IM QW for 4 weeks. Efficacy was assessed at enrollment and weekly during the 4 weeks of treatment and at weeks 8, 12, 16, and 24. Seven direct clinical assessments were made, including intensity of early morning joint stiffness, pain at rest, and pain on walking. A 10-cm visual analog scale (VAS) was used to assess pain at rest and on walking and early morning joint stiffness. Response was defined as a change from baseline in VAS score ≥2 cm. Function was assessed using the 10-cm VAS to rate 13 activities of daily living (ADLs), including stair climbing and domestic chores. Patient global assessment of the overall effectiveness of the study drug comprised a 4-point Likert scale (0 = not effective to 3 = maximally effective). An aggregate score for all ADL functions was calculated as the mean change from baseline score of all of the ADLs as determined at 4, 8, 12, 16, and 24 weeks after commencement of the study. For tolerability monitoring, hematology and biochemistry were used, and patients were questioned about adverse events at each visit.

RESULTS

A total of 114 patients were enrolled (83 women, 31 men; mean [SD] age, 63.3 [1.5] years; NaPPS group, 54 patients; control group, 60 patients). Significant differences in scores of 3 of the 7 direct clinical assessments were found between the 2 groups (duration of joint stiffness at 4, 8, 12, and 16 weeks [all, P:5 0.015]; pain at rest at 8, 12, 16, and 24 weeks [all, P ≤ 0.017]; and patient global assessment at 4, 8, 12, 16, and 24 weeks [all, P <- 0.006]). The rates of trial continuation were higher in the NaPPS group compared with those in the control group at 8, 12, and 24 weeks (all, P < 0.05). Mean scores for 3 of 13 ADLs were significantly higher in the NaPPS group compared with those in the control group at weeks 8 and 12 (all, P ≤ 0.03). On combining all of the ADL scores, functional improvement from baseline was found at weeks 8 and 12 in the NaPPS group (both, P = 0.02). Mild bruising at the injection site occurred in <1% of patients in both treatment groups.

CONCLUSIONS

In this pilot study, 4 weekly injections of NaPPS were associated with significantly improved duration of joint stiffness and pain at rest compared with controls for 20 weeks after the cessation of treatment, and significantly improved pain on walking and overall function for 8 weeks after the cessation of treatment in these patients with OA of the knee.

Celecoxib treatment does not alter recruitment and activation of osteoclasts in the initial phase of experimental tooth movement

In a previous study, we reported that the short-term treatment with celecoxib, a non-steroidal anti-inflammatory drug (NSAID) attenuates the activation of brain structures related to nociception and does not interfere with orthodontic incisor separation in rats. The conclusion was that celecoxib could possibly be prescribed for pain in orthodontic patients. However, we did not analyze the effects of this drug in periodontium. The aim of this follow-up study was to analyze effects of celecoxib treatment on recruitment and activation of osteoclasts and alveolar bone resorption after inserting an activated orthodontic appliance between the incisors in our rat model. Twenty rats (400–420 g) were pretreated through oral gavage with celecoxib (50 mg/kg) or vehicle (carboxymethyl-cellulose 0.4%). After 30 min, they received an activated (30 g) orthodontic appliance, set not to cause any palate disjunction. In sham animals, the appliance was immediately removed after introduction. All animals received ground food and, every 12 h, celecoxib or vehicle. After 48 h, they were anesthetized and transcardiacally perfused through the aorta with 4% formaldehyde. Subsequently, maxillae were removed, post-fixed and processed for histomorphometry or immunohistochemical analyses. As expected, incisor distalization induced an inflammatory response with certain histological changes, including an increase in the number of active osteoclasts at the compression side in group treated with vehicle (appliance:32.2±2.49 vs sham: 4.8±1.79, P<0.05) and celecoxib (appliance: 31.0±1.45 vs sham: 4.6±1.82, P<0.05). The treatment with celecoxib did not modify substantially the histological alterations and the number of active osteoclasts after activation of orthodontic appliance. Moreover, we did not see any difference between the groups with respect to percentage of bone resorption area. Taken together with our previous results we conclude that short-term treatment with celecoxib can indeed be a therapeutic alternative for pain relieve during orthodontic procedures.

The relative contribution of NSAIDs and Helicobacter pylori to the aetiology of endoscopically-diagnosed peptic ulcer disease: observations from a tertiary referral hospital in the UK between 2005 and 2010

BACKGROUND

Recent data from Western countries indicate that the aetiology of peptic ulcer disease (PUD) is changing as the prevalence of Helicobacter pylori is decreasing while the use of low-dose aspirin (LDA, ≤325 mg/day) is increasing.

AIM

To investigate the changing aetiology and demographics of PUD in a well-characterised patient cohort at a large tertiary hospital in the UK between July 2005 and June 2010.

METHODS

Patients diagnosed with PUD following endoscopy were categorised as non-steroidal anti-inflammatory drug (NSAID)-users or non-users, and their H. pylori status determined. Comparisons between NSAID-users and non-users, and between non-aspirin NSAID-users and LDA-users were summarised using counts and corresponding percentages (for categorical variables) and means and standard deviations (for continuous variables).

RESULTS

Overall, 386 patients were enrolled; 57% used NSAIDs (51% LDA only) and 43% were non-users. 57% of the whole cohort was H. pylori-positive (including 66% with duodenal ulcers and 47% with gastric ulcers). Compared with non-users, NSAID-users were older (mean age 68 vs. 61 years) and fewer were H. pylori-positive (52% vs. 63%). LDA-users were older (mean age 71 vs. 62 years) and more likely to be H. pylori-positive (61% vs. 41%) than those using non-aspirin NSAIDs. Twelve per cent of the patients were neither using NSAIDs nor were H. pylori-positive.

CONCLUSIONS

The NSAIDs, particularly LDA, were most commonly associated with PUD in this cohort. Our findings are compatible with the decline in the prevalence of H. pylori-positive PUD and increase in non-NSAID, non-H. pylori PUD previously reported.

Synergistic anti-inflammatory effects of Laminaria japonica fucoidan and Cistanche tubulosa extract

The anti-inflammatory effects of fuciodan and Cistanche tubulosa (CT) extract were investigated in vitro macrophage culture system and in vivo carrageenan-induced air pouch inflammation model. CT extract inhibited nitric oxide production from activated RAW 264.7 macrophage cells, while fucoidan was inactive. In vivo air pouch inflammation model, carrageenan-induced vascular exudation and increased nitric oxide and prostaglandin E₂ concentrations in the exudates were synergistically suppressed by co-administration of fucoidan or CT extract. Moreover, tissue inflammation was substantially attenuated by the combinational therapy. However, there was no synergistic effect against the inflammatory cell infiltration, although fucoidan and CT extract each markedly reduced the cell numbers. Therefore, it is suggested that fucoidan blocks infiltration of inflammatory cells, while CT extract inhibits activation of the cells, and that their combinational treatment could be a promising candidate for the relief of various types of inflammation.

Heme oxygenase-1 is protective against nonsteroidal anti-inflammatory drug-induced gastric ulcers

OBJECTIVES

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for the treatment of pain, fever, and inflammation. Long-term use of these drugs is associated with significant gastric injury. Activated neutrophils and oxidative stress seem to play a significant role in NSAID-induced gastric mucosal damage. The objective of our study is to examine the protective effects of an antioxidant and anti-inflammatory enzyme, heme oxygenase-1 (HO-1), in NSAID-induced gastric injury.

METHODS

Mice were intraperitoneally injected with indomethacin (10 mg/kg) or sham. A specific inducer of HO-1, cobalt protoporphyrin (5 mg/kg), was given 24 hours before indomethacin to allow for the expression of HO-1. Controls received sham treatment. Twenty-four hours after indomethacin injection, gastric tissue damage was examined with histology. HO-1 expression was measured with immunoblot; cytokine levels were measured with enzyme-linked immunosorbent assay. Neutrophil infiltration was quantified with myeloperoxidase assay. Using electron paramagnetic resonance and desferrioxamine, we measured the labile iron pool in the mouse stomach as a marker of oxidative stress.

RESULTS

Indomethacin caused gastric inflammation and ulcers, neutrophil activation, and increased tissue expression of interleukin-6 and tumor necrosis factor-alpha in mice. Inducing HO-1 with cobalt protoporphyrin reduced gastric inflammation, number of stomach ulcers, tissue neutrophil activation, and proinflammatory cytokine expression caused by indomethacin.

CONCLUSIONS

These findings suggest that the induction of an anti-inflammatory and cytoprotective enzyme HO-1 may be a strategy to overcome the gastrointestinal adverse effects limiting the use of NSAIDs.

Differential diagnosis of upper gastrointestinal bleeding proximal to the ligament of Trietz

Upper gastrointestinal bleeding (UGIB) is an important medical problem for patients and the medical system. The causes of UGIB are varied and their accurate identification guides appropriate management. The major cause of UGIB is peptic ulcer disease, for which Helicobacter pylori and nonsteroidal antiinflammatory drug use are major risk factors. Lesser causes include Dieulafoy lesion, gastric antral vascular ectasia, hemobilia, aortoenteric fistulas, and upper gastrointestinal tumors. Awareness of causes and management of UGIB should allow physicians to treat their patients more effectively.

Ethanol extract of Angelica gigas inhibits croton oil-induced inflammation by suppressing the cyclooxygenase - prostaglandin pathway

The anti-inflammatory effects of an ethanol extract of Angelica gigas (EAG) were investigated in vitro and in vivo using croton oil-induced inflammation models. Croton oil (20 microg/mL) up-regulated mRNA expression of cyclooxygenase (COX)-I and COX-II in the macrophage cell line, RAW 264.7, resulting in the release of high concentrations of prostaglandin E(2) (PGE(2)). EAG (1 approximately 10 microg/mL) markedly suppressed croton oil-induced COX-II mRNA expression and PGE(2) production. Application of croton oil (5% in acetone) to mouse ears caused severe local erythema, edema and vascular leakage, which were significantly attenuated by oral pre-treatment with EAG (50 approximately 500 mg/kg). Croton oil dramatically increased blood levels of interleukin (IL)-6 and PGE(2) without affecting tumor-necrosis factor (TNF)-alpha and nitric oxide (NO) levels. EAG pre-treatment remarkably lowered IL-6 and PGE(2), but did not alter TNF-alpha or NO concentrations. These results indicate that EAG attenuates inflammatory responses in part by blocking the COX - PGE(2) pathway. Therefore, EAG could be a promising candidate for the treatment of inflammatory diseases.

[Postoperative use of nonsteroidal anti-inflammatory agents in orthopedic surgery]

Nonsteroidal antiinflamatory drugs (NSAIDs) lead to satisfactory acute and chronic pain relief. Besides that, they exert potent antiinflamatory effect. Their analgesic potency is dose related and limited. Orthopedic patients are often on these medications preoperatively and experience opioid-sparing effect in the postoperative period. Chronic NSAIDs use is related to higher rate of sistemic adverse effects, but even short time exposure in the postoperative period is not risk-free. Although Coxibs reduce GIT bleeding incidence due to prolonged use of NSAIDs, there has to be judicious decision considering their cardiovascular adverse effects. There is evidence that NSAIDs producing moderate, dose-dependent increased bleeding time within normal values. High risk of bleeding have patients with established coagulopathy, alcohol abuse and on anticoagulant treatment. There is no strong evidence on influence of NSAIDs on bone growth. Nevertheless, there is evidence that NSAIDs do prevent heterotropic ossification. Prostaglandins are vital contributors for maintainig tissue homeostasis and NSAIDs use can lead to many unwanted effects. Those adverse effect are more common with prolonged exposure, are dose-related and risks have to be carefully and individually assesed in the postoperative pain management.

Anti-inflammatory effects of an ethanol extract of Angelica gigas in a Carrageenan-air pouch inflammation model

Anti-inflammatory effects of an ethanol extract of Angelica gigas (EAG; 50, 160, or 500 mg/kg) were investigated in a carrageenan-induced air pouch inflammation model. Injection of 1 ml of carrageenan (1%) into mouse air pouches markedly increased the exudate volume and exudate albumin concentration, which were significantly attenuated by oral pretreatment with EAG. EAG also markedly reduced carrageenan-induced infiltrations of neutrophils, monocytes, and lymphocytes, but did not influence eosinophils or basophils. Carrageenan dramatically increased levels of tumor necrosis factor-alpha and interleukin-6, which might be derived from the infiltrated cells. It also elevated nitric oxide, and slightly increased prostaglandin E(2). EAG pretreatment significantly lowered tumor necrosis factor-alpha and nitric oxide, but did not alter interleukin-6 or prostaglandin E(2) levels. These results indicate that EAG attenuates some inflammatory responses by blocking the tumor necrosis factor-alpha-nitric oxide pathway, and that EAG could be a promising anti-inflammatory drug candidate for inflammatory diseases.

Efficacy and safety of rabeprazole in non-steroidal anti-inflammatory drug-induced ulcer in Japan

AIM: To investigate the efficacy and safety of rabeprazole under continuous non-steroidal anti-inflammatory drug (NSAID) administration for NSAID-induced ulcer in Japan.

METHODS: Subjects comprised patients undergoing NSAID treatment in whom upper gastrointestinal endoscopy revealed an ulcerous lesion (open ulcer) with diameter ≥ 3 mm, who required continuous NSAID treatment. Endoscopies were performed at the start of treatment, during the treatment period, and at the conclusion (or discontinuation) of treatment. Findings were evaluated as size (maximum diameter) and stage based on the Sakita-Miwa classification. An ulcer was regarded as cured when the “white coating” was seen to have disappeared under endoscopy. As criteria for evaluating safety, all medically untoward symptoms and signs (adverse events, laboratory abnormalities, accidental symptoms, etc.) occurring after the start of rabeprazole treatment were handled as adverse events.

RESULTS: Endoscopic cure rate in 38 patients in the efficacy analysis (endoscopic evaluation) was 71.1% (27/38). Among those 38 patients, 35 had gastric ulcer with a cure rate of 71.4% (25/35), and 3 had duodenal ulcer with a cure rate of 66.7% (2/3). Three adverse drug reactions were reported from 64 patients in the safety analysis (interstitial pneumonia, low white blood cell count and pruritus); thus, the incidence rate for adverse drug reactions was 4.7% (3/64).

CONCLUSION: The treatment efficacy of rabeprazole for NSAID-induced ulcer under continuous NSAID administration was confirmed.

Glucosamine and chondroitin for osteoarthritis

Osteoarthritis (OA) is a common, chronic disease that most frequently affects the knees and is a major cause of disability in the elderly. It is characterized by progressive cartilage loss, accompanied by secondary changes such as osteophyte formation and calcium deposition. Inflammatory processes are also involved, leading to stiffness and pain, for which patients seek treatment. Conventional treatment includes analgesics or non-steroidal anti-inflammatory drugs, however life-style changes should also be recommended, such as weight reduction and specific exercises. Glucosamine and chondroitin, classed as over-the-counter supplements or nutraceuticals, are regularly self-administered by patients with OA. Both agents are produced endogenously in the human body and are essential components of cartilage. This review discusses the evidence that supports the use of these agents either alone or in combination for pain relief and as disease-modifying agents in OA.

Gastrointestinal side effects of prescription medications in the older adult

Gastrointestinal (GI) symptoms resulting from either prescription medications or over-the-counter drugs are frequently encountered in geriatric practice but often mistaken for symptoms of an organic disease leading to multiple diagnostic studies. The morbidity, mortality, and medical costs associated with drug toxicity, even when restricted to the GI tract, are probably underestimated. The consequences of drug toxicity are quite variable and range from a symptom of mild discomfort (eg, drug-induced diarrhea) at one end of the spectrum, to fatal GI hemorrhage or perforation. Better awareness of the possibility of drug-induced GI tract pathology by primary care physicians improves the recognition of these adverse effects, and ultimately, improves patient care. This review focuses on the most common and well-described drug-related side effects of the GI tract.

Endoscopic and histopathological evaluation of acute gastric injury in high-dose acetaminophen and nonsteroidal anti-inflammatory drug ingestion with suicidal intent

AIM: To evaluate endoscopic and histopathologic aspects of acute gastric injury due to ingestion of high-dose acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) with respect to some risk factors and patient characteristics.

METHODS: The study group consists of 50 patients admitted to emergency department with high dose analgesic ingestion (group I) with suicidal intent. Thirty patients with or without mild complaints of dyspepsia (group II) were selected as the control group. The study group was stratified according to the use of type and number of analgesics. Endoscopic findings were evaluated according to the Lanza score (LS), expressing the severity of the gastroduodenal damage and biopsies according to a scoring system based on histopathologic findings of acute erosive gastritis.

RESULTS: Gastroduodenal damage was signifi-cantly more severe in group I compared to group II (P < 0.01). The LS was similar in both groups Ia and Ib. However LS was significantly higher in patients who had ingested multiple NSAIDs (group Ic) compared to other patients (P < 0.01). The LS was correlated to age (P < 0.01) and total amount of drug ingested (P < 0.05) in group I; but it was not correlated with Helicobacter pylori (H pylori) infection or duration of exposure (P > 0.05). The biopsy score (BS) was higher in group I than group II (P < 0.01), and higher in group Ib than group Ia (P < 0.05).

CONCLUSION: The histopathologic damage was more severe among NSAID ingesting patients compared to those ingesting only acetaminophen and there is no significant difference in the endoscopic findings between the groups. There is no significant difference in the LS between the groups. This lack of significance is remarkable in terms of the gastric effects of high-dose acetaminophen.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

The problem with NSAIDs: what data to believe?

Patients with rheumatoid arthritis and osteoarthritis have relied upon NSAIDs as a cornerstone of their analgesic regime for decades. The choice of anti-inflammatory agents broadened for this group of patients when the selective inhibitors of cyclooxygenase-2 enzyme were developed. Much has been published in the past few years regarding the superior gastrointestinal safety of this class of drugs when compared with traditional NSAIDs. Their triumphant debut was swiftly followed by the emergence of data detailing their associated increased serious cardiovascular risks. This also led to a reevaluation of data concerning more traditional NSAIDs, and surprisingly, a similar trend was seen. The US Food and Drug Administration has recommended that both classes of drugs carry a black box warning with regard to gastrointestinal and cardiovascular risks.

Drug-induced side effects affecting the gastrointestinal tract

With the ever-growing armamentarium of pharmacological agents, the gastrointestinal drug-induced side effects of dyspepsia, nausea, vomiting, diarrhoea and constipation are increasingly seen. They are often self-limiting and without serious sequelae, but of greater concern is drug-induced mucosal ulceration that can manifest as gastrointestinal haemorrhage, stricture and perforation. These complications are mainly attributable to NSAIDs and aspirin, which can injure the mucosa anywhere along the gastrointestinal tract. These iatrogenic serious side effects can be reduced with co-prescription of a proton pump inhibitor, substitution of a COX-2 inhibitor and eradication of Helicobacter pylori when the bacterium is present. Other recognised gastrointestinal complications include small intestinal diaphragm, microscopic colitis, a range of hepatotoxic effects and pancreatitis. The introduction of new classes of drugs has resulted in new adverse effects that require consideration in patients presenting with gastroenterological symptoms. These include pill oesophagitis from bisphosphonates and ischaemic colitis relating to serotonin antagonists. Here, the authors review the literature on drug-induced complications of the gastrointestinal tract and present the pertinent management issues relevant to clinical practice.

Flurbiprofen in the symptomatic management of rheumatoid arthritis: a valuable alternative

BACKGROUND

The withdrawal of certain cyclooxygenase-2 selective drugs and the availability of over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) have increased the pressure for researching and prescribing conventional NSAIDs with a favourable efficacy/tolerance ratio in inflammatory diseases, particularly rheumatoid arthritis. The aim of this comprehensive meta-analysis was to evaluate the absolute and relative efficacy and safety of flurbiprofen in the management of rheumatoid arthritis.

METHODS

A systematic and exhaustive bibliographic research of published literature has been performed. The inclusion criteria are summarised as follows: randomised trial and rheumatoid arthritis and flurbiprofen and oral administration and anti-inflammatory doses from 100 to 300 mg and (placebo or aspirin or indomethacin or naproxen or ibuprofen or ketoprofen) and (articular pain or stiffness or swelling or mobility or patient/physician reported efficacy or tolerance or gastrointestinal (GI) tolerance). Studies were conducted from January 1975 to January 2006. Analyses have been stratified by comparisons and outcomes. Publication bias and robustness have been extensively investigated.

RESULTS

Fourteen studies, accounting for 1103 patient-years, have been included in the quantitative review. The mean daily doses administrated were 200 mg flurbiprofen, 4000 mg aspirin, 150 indomethacin, 750 mg naproxen and 1800 mg ibuprofen. Flurbiprofen was superior to placebo for all outcomes, and superior to three of four other NSAIDs in terms of formal symptomatic measures (pain, stiffness and swelling). Several patients or physicians reported the efficacy of flurbiprofen as superior to indomethacin and naproxen, while its safety, and particularly its GI tolerance were better compared with aspirin and indomethacin. Sensitivity analyses have reported a sufficient robustness against systematic publication bias assumptions.

CONCLUSION

This meta-analysis has shown that flurbiprofen is an interesting alternative to commonly prescribed NSAIDs in the symptomatic management of rheumatoid arthritis, especially given its favourable efficacy/tolerance ratio.

Impact of transdermal fentanyl on quality of life in rheumatoid arthritis

OBJECTIVES

The purpose of the study was to investigate the effectiveness and tolerability of transdermal fentanyl in a treatment regimen in patients with rheumatoid arthritis (RA).

METHODS

Two hundred twenty-six patients (mean age 66 y) with severe pain caused by RA who had not previously been treated with transdermal fentanyl were included in this prospective, open-label study. Pain intensity, functional impairment, and well-being were documented prospectively for 30 days after treatment with transdermal fentanyl had been initiated. Patients evaluated pain on an 11-point numerical rating scale. Quality of sleep, daily and social functioning, and treatment satisfaction were rated using 5-point categorical rating scales. General well-being was assessed by the Marburg questionnaire.

RESULTS

Adding transdermal fentanyl to the ongoing RA therapy reduced pain intensity significantly from 8.0 (7.82 to 8.18) to 4.0 (3.75 to 4.25). Mean functional impairment due to pain also decreased significantly from "severe" at the beginning to "mild to moderate." Treatment with transdermal fentanyl also led to a significant improvement by approximately 1.5 units for all items in the Marburg questionnaire on general well-being. At the end of the study, nearly all patients were satisfied with the pain treatment. Transdermal fentanyl was generally well tolerated. The most frequent side effects were nausea (9.7%) and vomiting (7.1%).

DISCUSSION

Patients with pain caused by RA improved in terms of pain intensity, sleep, function, and general well-being when transdermal fentanyl was added to the treatment regimen. Treatment satisfaction was high. Transdermal fentanyl also demonstrated good tolerability over a period of 30 days.

Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomised trial

BACKGROUND

Guidelines on pain management recommend that patients at risk of ulcers receive either a cyclo-oxygenase (COX 2) inhibitor or a non-steroidal anti-inflammatory drug (NSAID) with a proton-pump inhibitor (PPI). These two treatments have similar effectiveness, but they are insufficient for protection of patients at very high risk for ulcer bleeding. We aimed to test the hypothesis that in patients with previous ulcer bleeding induced by non-selective NSAIDs, combined treatment with the COX 2 inhibitor celecoxib and the PPI esomeprazole would be better than celecoxib alone for prevention of recurrent ulcer bleeding.

METHODS

441 consecutively presenting patients who were taking non-selective NSAIDs for arthritis were recruited to our single-centre, prospective, randomised, double-blind trial after admission to hospital with upper-gastrointestinal bleeding. Patients were enrolled after their ulcers had healed and a histological test for Helicobacter pylori was negative. All patients were given 200 mg celecoxib twice daily. 137 patients were randomly assigned to receive 20 mg esomeprazole twice daily (combined-treatment group), and 136 to receive a placebo (control group) for 12 months. The primary endpoint was recurrent ulcer bleeding during treatment or within 1 month of the end of treatment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00365313.

FINDINGS

Combination treatment was more effective than celecoxib alone for prevention of ulcer bleeding in patients at high risk. The 13-month cumulative incidence of the primary endpoint was 0% in the combined-treatment group and 12 (8.9%) in the controls (95% CI difference, 4.1 to 13.7; p=0.0004). The median follow-up was 13 months (range 0.4-13.0). Discontinuation of treatment and the incidence of adverse events were similar in the two treatment groups.

INTERPRETATION

Patients at very high risk for recurrent ulcer bleeding who need anti-inflammatory analgesics should receive combination treatment with a COX 2 inhibitor and a PPI. Our findings should encourage guideline committees to review their recommendations for patients at very high risk of recurrent ulcer bleeding.

Boswellic acids and glucosamine show synergistic effect in preclinical anti-inflammatory study in rats

The present study revealed the synergistic effect of boswellic acid mixture (BA) and glucosamine for anti-inflammatory and anti-arthritic activities in rats. Two studies were conducted, that is, acute anti-inflammatory by carrageenan edema and chronic anti-arthritic by Mycobacterium-induced developing arthritis. Five groups of animals were included in each of the study: the vehicle control, positive control (ibuprofen 100mg/kg), boswellic acids (250 mg/kg), glucosamine (250 mg/kg) and a combination of boswellic acids (125 mg/kg) and glucosamine (125 mg/kg). BA when administered at 250 mg/kg in rats, carrageenan-induced paw edema and Mycobacterium-induced developing arthritis were significantly inhibited. In comparison to boswellic acids, glucosamine when administered at 250 mg/kg showed a mild effect in carrageenan-induced edema and moderate inhibition of paw swelling against developing arthritis. Although the combination of boswellic acids and glucosamine did not affect the acute inflammation to a greater extent yet a significant anti-arthritic activity was observed in rats. In conclusion, a synergistic effect was observed in chronic inflammatory conditions when two chemical entities were administered in combination in preclinical study.

The use of topical diclofenac for pain in osteoarthritis of the knee: a review

Osteoarthritis (OA) is a common complaint that affects millions of people worldwide. As there is no cure for OA, drug treatment is the main form of management. This can be achieved through the use of analgesics and anti-inflammatory drugs such as the NSAID diclofenac sodium. The chronic use of diclofenac sodium can lead to adverse gastrointestinal problems. The use of a topical formulation of diclofenac sodium aims to reduce this problem. Evidence from four randomized controlled trails of the efficacy and safety of topical diclofenac sodium as a method of pain relief for the treatment of OA of the knee is presented and discussed. Findings imply that topical diclofenac sodium is an efficacious and safe method of pain control in patients with OA of the knee.

Prevention of NSAID-associated gastrointestinal lesions: a comparison study pantoprazole versus omeprazole

AIM

To investigate tolerability and efficacy of pantoprazole 20 mg, once daily (o.d.), pantoprazole 40 mg o.d., and omeprazole 20 mg o.d., in patients taking nonsteroidal anti-inflammatory drug(s) (NSAIDs).

METHODS

Included in this randomized, double-blind, multicenter, parallel-group study were rheumatic patients (>55 yr) on continual NSAIDs and with at least one more recognized risk factor that contributes to the development of gastrointestinal (GI) injury. Study duration was 6 months, and the treatment consisted of pantoprazole 20 mg o.d. (N = 196), pantoprazole 40 mg o.d. (N = 199), or omeprazole 20 mg o.d. (N = 200). Patients took NSAID(s) (except COX-2 inhibitors), had no more than five erosions/petechiae in the upper GI tract, no current peptic ulcers or reflux esophagitis, and had at most moderate intensity GI symptoms. Endoscopy was performed at baseline, 3, and 6 months. The primary end points were lack of "therapeutic failure" and lack of "endoscopic failure" at 6 months.

RESULTS

After 6 months, the probabilities to remain in remission were 90% pantoprazole 20 mg o.d., 93% pantoprazole 40 mg o.d., and 89% omeprazole 20 mg o.d. for lack of "therapeutic failure;" 91% pantoprazole 20 mg o.d., 95% pantoprazole 40 mg o.d., and 93% omeprazole 20 mg o.d. for lack of "endoscopic failure."

CONCLUSIONS

For patients taking NSAIDs continually, pantoprazole 20 mg o.d., pantoprazole 40 mg o.d., or omeprazole 20 mg o.d. provide equivalent, effective, and well-tolerated prophylaxis against GI lesions, including peptic ulcers.

Nonsteroidal Anti-inflammatory Drugs Versus Selective COX-2 Inhibitors in the Upper Gastrointestinal Tract

There are enough basic data supporting the use of coxibs with regard to the upper GI tract in patients with the need for continuous treatment of joint pain. The clinical studies available clearly show that coxibs induce fewer lesions and complications in volunteers and in patients when compared with NSAIDs. However, in Helicobacter pylori- positive patients the advantage seems less clear. The combination of NSAID plus PPI is not worse with regard to duodenal ulcers and recurrent clinical complications and is more cost effective than the use of coxibs. Similarly, with the concomitant use of aspirin even in low doses no major advantage of coxibs has been demonstrated. The combination of coxibs and PPI in high-risk patients needs to be studied. It is unclear at the moment how important are the changes in the lower GI tract. Considering the current controversy regarding cardiovascular events, there is no major reason to prefer coxibs to conventional NSAID plus PPI in patients needing long-term treatment.

Mechanisms of protection by pantoprazole against NSAID-induced gastric mucosal damage

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can be associated with severe adverse digestive effects. In clinical settings, proton pump inhibitors have proven to be effective in preventing and healing NSAID-induced gastroduodenal lesions. The present study investigates the mechanisms of protection afforded by pantoprazole against gastric injury induced by different NSAIDs in rats. Animals were orally treated with indomethacin (100 micromol/kg), diclofenac (60 micromol/kg), piroxicam (150 micromol/kg) or ketoprofen (150 micromol/kg). Thirty minutes before NSAIDs, animals received pantoprazole 6 or 60 micromol/kg orally. Four hours after NSAIDs, the following parameters were assessed: histomorphometric evaluation of gastric mucosal damage; gastric mucosal levels of myeloperoxidase (MPO), malondialdehyde (MDA), reduced glutathione as an index of non-proteic sulfhydryl compounds (GSH), and prostaglandin E2 (PGE2); mucosal cyclooxygenase-1 and -2 (COX-1, COX-2) mRNA expression by reverse transcription-polymerase chain reaction (RT-PCR). Separate experiments were carried out to assay the effects of pantoprazole on gastric acid secretion in pylorus-ligated rats. The in vitro influence of pantoprazole (1-10 microM) on the oxidation of low density lipoproteins (LDLs) induced by copper sulphate was also examined. All NSAIDs elicited mucosal necrotic lesions associated with neutrophil infiltration and reduction of PGE2 levels. Increments of MPO and MDA contents, as well as a decrease in GSH levels, were detected in the gastric mucosa of indomethacin-, piroxicam- or ketoprofen-treated animals. Indomethacin enhanced mucosal COX-2 expression, while not affecting COX-1. At the oral dose of 6 micromol/kg pantoprazole did not affect NSAID-induced mucosal damage, whereas at 60 micromol/kg it markedly reduced injuries provoked by all test NSAIDs. Pantoprazole 60 micromol/kg also reversed the effects of NSAIDs on MPO, MDA, and GSH mucosal contents, without interfering with the decrease in PGE2 levels or indomethacin-induced COX-2 expression. However, at both doses, pantoprazole inhibited acid secretion in pylorus-ligated rats. Furthermore, pantoprazole concentration dependently reduced the in vitro oxidation of LDLs. Our results suggest that besides inhibiting acid secretion, the protection afforded by pantoprazole against NSAID-induced gastric damage depends on a reduction in mucosal oxidative injury, which may also account for an increment of sulfhydryl radical mucosal bioavailability. It is also suggested that pantoprazole does not influence the down-regulation of gastric prostaglandin production associated with NSAID treatment.

Role of Helicobacter pylori eradication in aspirin or non-steroidal anti-inflammatory drug users

Helicobacter pylori (H pylori) infection and the use of non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin at any dosage and formulation represent well-established risk factors for the development of uncomplicated and complicated peptic ulcer disease accounting for the majority of such cases. Although the interaction between H pylori and NSAID/aspirin use in the same individuals was questioned in some epidemiological studies, it has now become widely accepted that they are at least independent risk factors for peptic ulcer disease. According to data from randomized intervention trials, naive NSAID users certainly benefit from testing for H pylori infection and, if positive, H pylori eradication therapy prior to the initiation of NSAID. A similar strategy is also suggested for naive aspirin users, although the efficacy of such an approach has not been evaluated yet. Strong data also support that chronic aspirin users with a recent ulcer complication should be tested for H pylori infection and, if positive, receive H pylori eradication therapy after ulcer healing, while they appear to benefit from additional long-term therapy with a proton pump inhibitor (PPI). A similar approach is often recommended to chronic aspirin users at a high risk of ulcer complication. H pylori eradication alone does not efficiently protect chronic NSAID users with a recent ulcer complication or those at a high-risk, who certainly should be treated with long-term PPI therapy, but H pylori eradication may be additionally offered even in this setting. In contrast, testing for H pylori or PPI therapy is not recommended for chronic NSAID/aspirin users with no ulcer complications or those at a low risk of complications.

Upper gastrointestinal tolerability of once weekly alendronate 70 mg with concomitant non-steroidal anti-inflammatory drug use

BACKGROUND

Both oral bisphosphonates and non-steroidal anti-inflammatory drugs have the potential to irritate the upper gastrointestinal mucosa, and are frequently used by the same patient population.

AIM

To determine the rate of upper gastrointestinal adverse events with once weekly alendronate 70 mg and concomitant non-steroidal anti-inflammatory drug use.

METHODS

A post hoc analysis was performed on 222 patients who received both medications concomitantly during a 3-month placebo-controlled study. A total of 450 (224 alendronate; 226 placebo) postmenopausal women and men with osteoporosis were randomized. Concomitant non-steroidal anti-inflammatory drug users were defined as patients who received > or =7 continuous days of any dose of a dual cyclo-oxygenase-1 and cyclo-oxygenase-2 inhibiting non-steroidal anti-inflammatory drug, a selective cyclo-oxygenase-2 inhibitor, or aspirin. A survival analysis was performed, and significance assessed. Logistic regression was used to assess consistency of treatment effect on rate of upper gastrointestinal adverse events across non-steroidal anti-inflammatory drug subgroups.

RESULTS

Similar percentages of alendronate (52.7%) and placebo (46.0%) patients used non-steroidal anti-inflammatory drugs regularly. Among concomitant non-steroidal anti-inflammatory drug users, 11 alendronate and 11 placebo patients experienced upper gastrointestinal adverse events (9.3% and 10.8%, respectively, P = 0.744). Logistic regression revealed no significant interaction (P = 0.722) between alendronate and concomitant non-steroidal anti-inflammatory drug use.

CONCLUSION

Based on this subgroup analysis, once weekly alendronate 70 mg used concomitantly with non-steroidal anti-inflammatory drugs, did not increase upper gastrointestinal adverse events relative to placebo over 3-months.