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Lin YE, Chen MC. Dextran-40 Reduces Partial Flap Failure: A Systematic Review and Meta-analysis for Antithrombotics after Free Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5812. [PMID: 38752217 PMCID: PMC11095965 DOI: 10.1097/gox.0000000000005812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/22/2024] [Indexed: 05/18/2024]
Abstract
Background Antithrombotic agents are used after free-flap surgery to prevent thrombus formation and improve flap outcomes. However, the reports vary. Therefore, this meta-analysis aimed to elucidate the need for antithrombotic agents in this context. Methods We searched for studies that compared the outcomes of patients undergoing free-flap surgery with or without postoperative antithrombotic agents in the PubMed, Cochrane, and ClinicalTrials.gov databases. The primary outcome was total flap failure, with secondary outcomes including partial flap failure, pedicle thrombosis, and bleeding/hematoma. The relative risks (RRs) of outcomes with or without antithrombotic use were evaluated. Results Fifteen studies (n = 6755 cases) were included. Antithrombotic agents did not reduce flap failure or pedicle thrombosis risks but increased bleeding and hematoma risks (RR, 1.535). Subgroup analyses by antiplatelet and anticoagulant use demonstrated results similar to those of antithrombotic use. The RR of bleeding/hematoma was 1.761 and 2.740 in the antiplatelet and anticoagulant groups, respectively. Postoperative dextran-40 administration reduced the risk of partial flap failure, with an RR of 0.535. Conclusions Postoperative antithrombotic, antiplatelet, or anticoagulant use did not change the risk of total/partial flap failure or pedicle thrombosis but increased the risk of hematoma/bleeding. Postoperative use of dextran-40 reduced the risk of partial flap failure. Increased intraflap blood flow may decrease the risk of partial flap failure. However, dextran-40 may cause severe pulmonary distress. Further prospective studies are required to evaluate the effects of these agents on thrombus formation, intraflap blood flow, and partial flap failure risk.
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Affiliation(s)
- Yi-En Lin
- From Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mei-Chun Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Schlüter J, Cunningham S, Zimmermann R, Achenbach S, Kramer R, Erdmann M, Beckmann M, Heinzerling L, Hackstein H. Characterization of the impact of immune checkpoint inhibitors on platelet activation and aggregation. Immunobiology 2023; 228:152311. [PMID: 36495598 DOI: 10.1016/j.imbio.2022.152311] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Immune checkpoint inhibitors (ICIs) are effective oncological drugs which block cellular check-point receptors typically targeted by tumor immune evasion strategies. Despite their benefits, clinicians have reported treatment-associated thromboembolism during ICI therapy in recent years. Though several theories on this ICI-associated pathogenesis exist, the direct effects of ICIs on platelets remains unknown. We therefore investigated the potential direct and indirect effect of PD-1, PD-L1 and CTLA-4-targeting ICIs on platelet functionality in multifaceted in vitro experiments. Interestingly, we could not observe a clear effect of ICI on platelet aggregation and primary hemostasis in whole blood and platelet concentrate-based assays. Furthermore, the presence of ICIs in toll-like receptor stimulation had no significant impact on platelet surface marker expression. In a second approach, we investigated the indirect immunological impact of ICIs on platelet activation by exposing platelets to supernatants from ICI- and Staphylococcal enterotoxin B-exposed PBMCs. Whereas ICIs affected IL-2 levels in supernatants, we could not detect clear differences in the secretion of pro-thrombogenic factors and platelet responses. The obtained data suggest that the direct influence of ICIs on platelet activation or the influence of altered T cell function on platelet activation cannot be considered a major factor in the development of thrombotic events.
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Affiliation(s)
- Julian Schlüter
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
| | - Sarah Cunningham
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany.
| | - Robert Zimmermann
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
| | - Susanne Achenbach
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
| | - Rafaela Kramer
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany
| | - Michael Erdmann
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany
| | - Malte Beckmann
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany
| | - Lucie Heinzerling
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Erlangen 91054, Germany; Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich 80539, Germany
| | - Holger Hackstein
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Erlangen 91054, Germany
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Ma L, He Y, Bai L, Li M, Sui X, Liu B, Tian B, Liu Y, Fu Q. Preclinical studies of a high drug-loaded meloxicam nanocrystals injection for analgesia. Colloids Surf B Biointerfaces 2022; 218:112777. [PMID: 36007315 DOI: 10.1016/j.colsurfb.2022.112777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/04/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Abstract
Meloxicam (MLX) is considered to have significant analgesic properties. However, the analgesic effects of MLX are compromised by its poor water solubility and thus the low drug loading. The purpose of this study was to develop a high drug-loaded MLX injection by formulating it into nanocrystals (NCs) for the treatment of analgesia. The developed MLXNCs exhibited satisfactory particle sizes and remarkably in vitro dissolution behaviors. In addition, the plasma concentrations of MLXNCs were comparable with the MLX solution (formulated with 1.0% polyoxyethylene castor oil 35) in rats. The acetic acid-induced writhing tests, hot plate tests and hind paw incision experiments demonstrated that the MLXNCs had significant analgesic effects. The findings provide insights into the developed high drug-loaded MLXNCs and provide new therapeutic options for acute and chronic pain management.
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Affiliation(s)
- Lixue Ma
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Yan He
- Department of Anesthesiology, Chinese PLA General Hospital, No. 28, Fuxing Road, Beijing 100089, China
| | - Lijun Bai
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Mo Li
- Liaoning Institute for Drug Control, No. 7 Chongshan West Road, Shenyang 110036, China
| | - Xiaofan Sui
- Liaoning Institute for Drug Control, No. 7 Chongshan West Road, Shenyang 110036, China
| | - Bingyang Liu
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Baocheng Tian
- School of Pharmacy, Binzhou Medical University, No. 346, Guanhai Road, Yantai 264003, China
| | - Yanhua Liu
- Department of Pharmaceutics, Ningxia Medical University, 1160 Shengli Street, Yinchuan 750004, China
| | - Qiang Fu
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China.
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Abujbarah SM, Jogerst K, Kosiorek HE, Ahmad S, Cronin PA, Casey W, Craner R, Rebecca A, Pockaj BA. Postoperative Hematomas in the Era of Outpatient Mastectomy: Is Ketorolac Really to Blame? Ann Surg Oncol 2022; 29:6395-6403. [PMID: 35849298 DOI: 10.1245/s10434-022-12141-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/16/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols following mastectomy with or without implant-based breast reconstruction (IBBR) include ketorolac for multimodal perioperative analgesia. There are concerns that ketorolac could be associated with increased risk of postoperative hematoma formation. METHODS Retrospective review of patients undergoing mastectomy with or without IBBR between January 2013 and December 2019 at a single institution. Patients received 15 mg, 30 mg, or no ketorolac depending on ERAS protocol adherence, patient characteristics, and surgeon preference. Clinically significant hematoma was defined as requiring surgical intervention on day of surgery or postoperative day 1. Patients were compared by demographics, surgical characteristics, ketorolac dose, and hematoma prevalence. Univariable and multivariable logistic regression evaluated hematoma formation odds. RESULTS Eight hundred patients met inclusion criteria: 477 received ketorolac. Those who received ketorolac were younger, had lower ASA scores, were more likely to have bilateral procedures and undergo concomitant IBBR, had longer operative times, were less likely to take antiplatelet or anticoagulation medications, had higher PACU pain scores, and had higher incidence of hematomas requiring surgical intervention. Of the cohort, 4.4% had clinically significant hematomas. The 15 mg and 30 mg ketorolac groups had similar prevalence (6.0% vs 5.8%, p = 0.95). On univariable regression, there were increased odds of hematoma formation in patients who were younger, had bilateral procedures, had longer OR times, and who received ketorolac. On multivariable regression, none of the prior variables remained significant. CONCLUSION After accounting for associations with longer operative times, concomitant IBBR, and bilateral procedures, ketorolac administration did not remain an independent risk factor for hematoma formation.
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Affiliation(s)
- Sami M Abujbarah
- Mayo Clinic Alix School of Medicine, Arizona Campus, Scottsdale, AZ, USA
| | - Kristen Jogerst
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Heidi E Kosiorek
- Department of Research-Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Sarwat Ahmad
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Patricia A Cronin
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - William Casey
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Craner
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alanna Rebecca
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of General Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Carter JA, Black LK, Deering KL, Jahr JS. Budget Impact and Cost-Effectiveness of Intravenous Meloxicam to Treat Moderate-Severe Postoperative Pain. Adv Ther 2022; 39:3524-3538. [PMID: 35678995 DOI: 10.1007/s12325-022-02174-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/26/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study assesses the budget impact and cost-effectiveness of intravenous meloxicam (MIV) to treat moderate-severe acute postoperative pain in adults. METHODS A two-part Markov cohort model captured the pharmacoeconomic impact of MIV versus non-opioid intravenous analgesics (acetaminophen, ibuprofen, ketorolac) among a hypothetical adult cohort undergoing selected inpatient procedures and experiencing moderate-severe acute postoperative pain: Part 1 (postoperative hour 0 to discharge, cycled hourly), health states were defined by pain level. Pain transition rates, adverse event probabilities, and concomitant opioid utilization were derived from a network meta-analysis. Part 2 (discharge to week 52, cycled weekly), health states were defined by the presence/absence of pain-related readmission and opioid use disorder as determined by literature-based inputs relating to pain control outcomes. Healthcare utilization and direct medical costs were derived from an administrative claims database analysis. Primary outcomes were the incremental cost per member per month (PMPM) and cost per quality-adjusted life year (QALY) gained. Scenario, univariate, and probabilistic sensitivity analyses were conducted. The model assumed a private payer perspective in the USA (no discounting, 2019 US$). RESULTS Modeled outcomes indicated MIV was associated with lower accumulated postoperative pain, fewer adverse events, and less opioid utilization for most procedures and comparators, with longer-term outcomes also generally favoring MIV. The budget impact of MIV was - $0.028 PMPM. From a cost-effectiveness perspective, MIV had lower costs and better outcomes for all comparisons except against ketorolac in orthopedic procedures where the former was cost-effective but not cost saving ($95,925/QALY). Scenario and sensitivity analyses indicated that modeled outcomes were robust to alternative inputs and underlying input uncertainty. Differences in direct medical costs were driven by reduced costs attributable to length of stay and opioid-related adverse drug events. CONCLUSION MIV was associated with modeled clinical and economic benefits compared to commonly used non-opioid intravenous analgesics.
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Affiliation(s)
- John A Carter
- Blue Point LLC, 711 Warrenville Road, Wheaton, IL, 60189-0000, USA.
| | | | | | - Jonathan S Jahr
- Professor Emeritus of Anesthesiology, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, USA
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Putilina M, Teplova N. Possibilities of individual choice of NSAIDs on the example of the oxicam class, taking into account clinical and pharmacological characteristics. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:36-41. [DOI: 10.17116/jnevro202212207136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Khan KU, Minhas MU, Sohail M, Badshah SF, Abdullah O, Khan S, Munir A, Suhail M. Synthesis of PEG-4000-co-poly (AMPS) nanogels by cross-linking polymerization as highly responsive networks for enhancement in meloxicam solubility. Drug Dev Ind Pharm 2021; 47:465-476. [PMID: 33651645 DOI: 10.1080/03639045.2021.1892738] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Poor solubility is an ongoing issue and the graph of poorly soluble drugs has increased markedly which critically affect their dissolution, bioavailability, and clinical effects. This common issue needs to be addressed, for this purpose a series of polyethylene glycol (PEG-4000) based nanogels were developed by free radical polymerization technique to enhance the solubility, dissolution, and bioavailability of poorly soluble drug meloxicam (MLX), as improved solubility is the significant application of nanosystems. Developed nanogels formulations were characterized by FTIR, XRD, SEM, zeta sizer, percent equilibrium swelling, drug loaded content (DLC), drug entrapment efficiency (DEE), solubility studies, and in vitro dissolution studies. Furthermore, cytotoxicity studies were conducted in order to determine the bio-compatibility of the nanogels drug delivery system to biological environment. Nanogels particle size was found to be 156.19 ± 09.33 d.nm. Solubility study confirmed that the solubility of poorly soluble drug MLX was significantly enhanced up to 36 folds as compared to reference product (Mobic®). The toxicity study conducted on rabbits and MTT assay endorsed the safety of the developed nanogels formulations to the biological system.
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Affiliation(s)
- Kifayat Ullah Khan
- Department of Pharmaceutics, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Punjab, Pakistan
| | | | - Muhammad Sohail
- Department of Pharmacy, COMSATS Institute of Information Technology, Abbottabad, Pakistan
| | - Syed Faisal Badshah
- Department of Pharmaceutics, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Punjab, Pakistan
| | - Orva Abdullah
- Hamdard Institute of Pharmaceutical Science, Hamdard University Islamabad, Islamabad, Pakistan
| | - Shahzeb Khan
- Department of Pharmacy, University of Malakand, Chakdara, Pakistan.,School of Health Sciences, Discipline of Pharmaceutical Sciences, University of Kawazulu Natal, Durban, South Africa
| | - Abubakar Munir
- Department of Pharmacy, Superior University, Lahore, Pakistan
| | - Muhammad Suhail
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
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Berkowitz RD, Mack RJ, McCallum SW. Meloxicam for intravenous use: review of its clinical efficacy and safety for management of postoperative pain. Pain Manag 2020; 11:249-258. [PMID: 33291975 DOI: 10.2217/pmt-2020-0082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Meloxicam for intravenous use (meloxicam iv.) is a nanocrystal formulation with improved dissolution properties and shortened time to peak plasma concentrations versus oral meloxicam. In Phase III and IIIb trials, 30 mg once daily relieved pain following pre- or postoperative administration in orthopedic, abdominal and colorectal surgeries. Meloxicam iv. was associated with reduced opioid consumption, the clinical benefit of which remains unclear. The drug may be administered alone or in combination with other non-nonsteroidal anti-inflammatory drugs. In Phase III trials, it demonstrated adverse event profile similar to placebo, with nausea, constipation, vomiting and headache occurring most frequently. Meloxicam iv. does not appear to adversely affect platelet function or wound-healing parameters. No new safety signals were detected in the Phase IIIb studies.
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Baker DE. Meloxicam Intravenous Injection. Hosp Pharm 2020. [DOI: 10.1177/0018578720965432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.
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