Nonsteroidal anti-inflammatory drug-induced gastrointestinal toxicity: new insights into an old problem

Glycomacropeptide Ameliorates Indomethacin-Induced Enteropathy in Rats by Modifying Intestinal Inflammation and Oxidative Stress

Nonsteroidal anti-inflammatory drug (NSAID)-induced enteropathy is considered a serious and increasing clinical problem without available treatment. Glycomacropeptide (GMP) is a 64-amino acid peptide derived from milk κ-casein with numerous biological activities. The aim of this study was to investigate the protective effect of GMP on NSAID enteropathy in rats. Enteropathy was induced by seven days oral indomethacin administration. Rats were orally GMP treated from seven days previous and during the establishment of the enteropathy model. Changes in metabolism, hematological and biochemical blood alterations, intestinal inflammation and oxidative damage were analyzed. Integrity barrier markers, macroscopic intestinal damage and survival rate were also evaluated. GMP treatment prevented anorexia and weight loss in animals. Furthermore, prophylaxis with GMP ameliorated the decline in hemoglobin, hematocrit, albumin and total protein levels. The treatment had no therapeutic efficacy on the decrease of occludin and mucin (MUC)-2 expression in intestinal tissue. However, GMP markedly decreased neutrophil infiltration, and CXCL1, interleukin-1β and inducible nitric oxide synthase expression. Nitric oxide production and lipid hydroperoxide level in the small intestine were also diminished. These beneficial effects were mirrored by preventing ulcer development and increasing animal survival. These results suggest that GMP may protect against NSAID enteropathy through anti-inflammatory and antioxidant properties.

Novel aryl carboximidamide and 3-aryl-1,2,4-oxadiazole analogues of naproxen as dual selective COX-2/15-LOX inhibitors: Design, synthesis and docking studies

A series of novel naproxen analogues containing 3-aryl-1,2,4-oxadiazoles moiety (4b-g) and their reaction intermediates aryl carboximidamides moiety (3b-g) was synthesized and evaluated in vitro as dual COXs/15-LOX inhibitors. Compounds 3b-g exhibited superior inhibitory activity than celecoxib as COX-2 inhibitors. Compounds 3b-d and 3g were the most potent COX-2 inhibitors with IC50 range of 6.4 - 8.13 nM and higher selectivity indexes (3b, SI = 26.19; 3c, SI = 13.73; 3d, SI = 29.27; 3g, SI = 18.00) comparing to celecoxib (IC50 = 42.60 nM, SI = 8.05). Regarding 15-LOX inhibitory activity, compounds belonging to aryl carboximidamide backbone 3b-e and 3g were the most potent with IC50 range of 1.77-4.91 nM comparing to meclofenamate sodium (IC50 = 5.64 µM). Data revealed that The levels of NO released by aryl carboximidamides 3b-g were more higher than 3-aryl-1,2,4-oxadiazole derivatives 4b-g, which correlated well with their COX-2 inhibitory activities.

Inhibitory effects of sodium pentosan polysulfate on formation and function of osteoclasts derived from canine bone marrow

BACKGROUND

Sodium pentosan polysulfate (NaPPS) was testified as a chondroprotective drug in with a detailed rationale of the disease-modifying activity. This study was undertaken to determine whether anti-osteoarthritis drug, NaPPS inhibited osteoclasts (OC) differentiation and function. Canine bone marrow mononuclear cells (n = 6) were differentiated to OC by maintaining with receptor activator of nuclear factor kappa B ligand (RANKL) and macrophage colony-stimulating factor (M-CSF) for up to 7 days with the treatment of NaPPS at concentration of 0, 0.2, 1 and 5 μg/mL. Differentiation and function of OC were accessed using tartrate-resistant acid phosphate (TRAP) staining and bone resorption assay, while monitoring actin ring formation. Invasion and colocalization patterns of fluorescence-labeled NaPPS with transcribed gene in OC were monitored. Gene expression of OC for cathepsin K (CTK), matrix metallopeptidase-9 (MMP-9), nuclear factor of activated T-cells cytoplasmic 1 (NFATc1), c-Fos, activator protein-1(AP-1) and carbonic anhydrase II was examined using real-time PCR.

RESULTS

Significant inhibition of OC differentiation was evident at NaPPS concentration of 1 and 5 μg/mL (p < 0.05). In the presence of 0.2 to 5 μg/mL NaPPS, bone resorption was attenuated (p < 0.05), while 1 and 5 μg/mL NaPPS achieved significant reduction of actin ring formation. Intriguingly, fluorescence-labeled NaPPS invaded in to cytoplasm and nucleus while colocalizing with actively transcribed gene. Gene expression of CTK, MMP-9 and NFATc1 were significantly inhibited at 1 and 5 μg/mL (p < 0.05) of NaPPS whereas inhibition of c-Fos and AP-1 was identified only at concentration of 5 μg/mL (p < 0.05).

CONCLUSIONS

Taken together, all the results suggest that NaPPS is a novel inhibitor of RANKL and M-CSF-induced CTK, MMP-9, NFATc1, c-Fos, AP-1 upregulation, OC differentiation and bone resorption which might be a beneficial for treatment of inflammatory joint diseases and other bone diseases associated with excessive bone resorption.

A Double Whammy: Targeting Both Fatty Acid Amide Hydrolase (FAAH) and Cyclooxygenase (COX) To Treat Pain and Inflammation

Pain states that arise from non-resolving inflammation, such as inflammatory bowel disease or arthritis, pose an unusually difficult challenge for therapy because of the complexity and heterogeneity of their underlying mechanisms. It has been suggested that key nodes linking interactive pathogenic pathways of non-resolving inflammation might offer novel targets for the treatment of inflammatory pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), which inhibit the cyclooxygenase (COX)-mediated production of pain- and inflammation-inducing prostanoids, are a common first-line treatment for this condition, but their use is limited by mechanism-based side effects. The endogenous levels of anandamide, an endocannabinoid mediator with analgesic and tissue-protective functions, are regulated by fatty acid amide hydrolase (FAAH). This review outlines the pharmacological and chemical rationale for the simultaneous inhibition of COX and FAAH activities with designed multitarget agents. Preclinical studies indicate that such agents may combine superior anti-inflammatory efficacy with reduced toxicity.

Role of enterohepatic recirculation in drug disposition: cooperation and complications

Enterohepatic recirculation (EHC) concerns many physiological processes and notably affects pharmacokinetic parameters such as plasma half-life and AUC as well as estimates of bioavailability of drugs. Also, EHC plays a detrimental role as the compounds/drugs are allowed to recycle. An in-depth comprehension of this phenomenon and its consequences on the pharmacological effects of affected drugs is important and decisive in the design and development of new candidate drugs. EHC of a compound/drug occurs by biliary excretion and intestinal reabsorption, sometimes with hepatic conjugation and intestinal deconjugation. EHC leads to prolonged elimination half-life of the drugs, altered pharmacokinetics and pharmacodynamics. Study of the EHC of any drug is complicated due to unavailability of the apposite model, sophisticated procedures and ethical concerns. Different in vitro and in vivo methods for studies in experimental animals and humans have been devised, each having its own merits and demerits. Involvement of the different transporters in biliary excretion, intra- and inter-species, pathological and biochemical variabilities obscure the study of the phenomenon. Modeling of drugs undergoing EHC has always been intricate and exigent models have been exploited to interpret the pharmacokinetic profiles of drugs witnessing multiple peaks due to EHC. Here, we critically appraise the mechanisms of bile formation, factors affecting biliary drug elimination, methods to estimate biliary excretion of drugs, EHC, multiple peak phenomenon and its modeling.

Potent multitarget FAAH-COX inhibitors: Design and structure-activity relationship studies

Non-steroidal anti-inflammatory drugs (NSAIDs) exert their pharmacological effects by inhibiting cyclooxygenase (COX)-1 and COX-2. Though widely prescribed for pain and inflammation, these agents have limited utility in chronic diseases due to serious mechanism-based adverse events such as gastrointestinal damage. Concomitant blockade of fatty acid amide hydrolase (FAAH) enhances the therapeutic effects of the NSAIDs while attenuating their propensity to cause gastrointestinal injury. This favorable interaction is attributed to the accumulation of protective FAAH substrates, such as the endocannabinoid anandamide, and suggests that agents simultaneously targeting COX and FAAH might provide an innovative strategy to combat pain and inflammation with reduced side effects. Here, we describe the rational design and structure-active relationship (SAR) properties of the first class of potent multitarget FAAH-COX inhibitors. A focused SAR exploration around the prototype 10r (ARN2508) led to the identification of achiral (18b) as well as racemic (29a-c and 29e) analogs. Absolute configurational assignment and pharmacological evaluation of single enantiomers of 10r are also presented. (S)-(+)-10r is the first highly potent and selective chiral inhibitor of FAAH-COX with marked in vivo activity, and represents a promising lead to discover novel analgesics and anti-inflammatory drugs.

Changing prevalence of Helicobacter pylori infection and peptic ulcer among dyspeptic Sardinian patients

Over the past 50 years, the prevalence of Helicobacter pylori infection has fallen as standards of living improved. The changes in the prevalence of infection and its manifestations (peptic ulcer disease and gastric mucosal lesions) were investigated in a large cohort of Sardinians undergoing upper endoscopy for dyspepsia. A retrospective observational study was conducted involving patients undergoing endoscopy for dyspepsia from 1995 to 2013. H. pylori status was assessed by histology plus the rapid urease test or 13C-UBT. Gastric mucosal lesions were evaluated histologically. Data including non-steroidal anti-inflammatory drugs (NSAIDs) use and the presence of peptic ulcers were collected. The prevalence of H. pylori was calculated for each quartile and for each birth cohort from 1910 to 2000. 11,202 records were retrieved for the analysis (62.9% women). The overall prevalence of H. pylori infection was 43.8% (M: 46.6% vs. F: 42.0%; P = 0.0001). A dramatic decrease in the prevalence of infection occurred over the 19-year observation period. The birth cohort effect was evident in each category (quartile) reflecting the continuous decline in H. pylori acquisition. Over time, the prevalence of peptic ulcers also declined, resulting in an increase in the proportion of H. pylori negative/NSAID positive and H. pylori negative/NSAID negative peptic ulcers. The prevalence of gastric mucosal changes also declined despite aging. The decline in H. pylori prevalence over time likely reflects the improvement in socioeconomic conditions in Sardinia such that H. pylori infection and its clinical outcomes including peptic ulcer are becoming less frequent even among dyspeptic patients.

A Case of Ischemic Colitis Related with Usual Dosage of Ibuprofen in a Young Man

<title>Abstract Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although unoommon in the general p㢌pulation, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Other possible causes include medications s䴸ch as NSAIDs(non-steroidal antiinflammatory drugs), oral contraceptives, diuretics and others. In recent years, many of NSAID use in young age can cause ischemic lesions, but it is not common. Here we report a case of ischemic colitis in a 31-year-old man who had no specific medical history except taking 200mg of ibuprofen three times a day for seven days. It suggests the importance of precise history taking, including medications usage such as NSAIDs and other risk factors.</p>

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.

Minimizing risks of NSAIDs: cardiovascular, gastrointestinal and renal

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating inflammation, pain and fever, but their cardiovascular, renal and gastrointestinal toxicity can result in significant morbidity and mortality to patients. Techniques for minimizing the adverse risks of NSAIDs include avoiding use of NSAIDs where possible, particularly in high-risk patients; keeping NSAID dosages low; prescribing modified-release and enteric-coated NSAIDs; prescribing cyclooxygenase-2-selective inhibitors where appropriate; monitoring for early signs of side effects; prescribing treatments designed to minimize NSAID side effects; and developing new therapeutic strategies beyond the inhibition of cyclooxygenase. All of the above strategies can be useful in reducing the risk of NSAID complications. The optimal use and management of NSAIDs involves an individualized paradigm approach to establish efficacy with optimal tolerability given the patient risk factors for adverse events.

The mechanism of the down-regulation of hepatic transporters in rats with indomethacin-induced intestinal injury

BACKGROUND

Previously, we reported that hepatic transporters were down-regulated consistent with intestinal injury in indomethacin (IDM)-treated rats.

AIM

The purpose of this study was to characterize this mechanism of the down-regulation of hepatic transporters in IDM-treated rats.

METHODS

Hepatic nuclear receptor expressions, oxidative stress condition and the expression of hepatic transporters were evaluated in rats with IDM-induced intestinal injury with or without the administration of mucosal protectant ornoprostil, a prostaglandin E1 analogue, or aminoguanidine (AG), an iNOS inhibitor.

RESULTS

All the nuclear receptors examined in the present study, which regulates hepatic transporters, were decreased by the administration of IDM. Hepatic glutathione, an indicator of oxidative stress, was significantly reduced compared with control. We then determined the expression of hepatic transporters by semi-quantitative real-time RT-PCR and Western blot analysis in IDM-treated rats with or without the administration of ornoprostil or AG. Ornoprostil recovered the gene expression of Oatp1a1, Oatp1b2 and Mrp2 and protein expression of Mrp2 while it had no effect on Oatp1a1 and Oatp1b2 proteins. These results indicated that the gene expression of hepatic transporters was down-regulated in association with the intestinal injury. On the other hand, there is no effect of AG on the reduced gene expression of hepatic Oatp1a1, Oatp1b2 and Mrp2. In protein expression, AG slightly recovered Mrp2 expression accompanied by a partial decrease in portal NO levels.

CONCLUSIONS

We suggest that the transcriptional process influenced by a dysfunction of hepatic nuclear receptors as well as the effect of NO on the post-transcriptional process due to intestinal injury are partially involved in the down-regulation of hepatic transporters.

[123I]Iodooctyl fenbufen amide as a SPECT tracer for imaging tumors that over-express COX enzymes

This study is concerned with the development of an agent for single photon emission computer tomography (SPECT) for imaging inflammation and tumor progression. [(123)I]Iodooctyl fenbufen amide ([(123)I]IOFA) was prepared from the precursor N-octyl-4-oxo-4-(4'-(trimethylstannyl)biphenyl-4-yl)butanamide with a radiochemical yield of 15%, specific activity of 37 GBq/μmol, and radiochemical purity of 95%. Analysis of the binding of [(123)I]IOFA to COX-1 and COX-2 enzymes by using HPLC and a gel filtration column showed a selectivity ratio of 1:1.3. An assay for the competitive inhibition of substrate transfer showed that IOFA exhibited a comparable IC(50) value compared to fenbufen. In the normal rat liver, a lower level and homogeneous pattern of [(123)I]IOFA radioactivity was observed by SPECT. In contrast, in the rat liver with thioacetamide-induced cholangiocarcinoma, a higher uptake and heterogeneous pattern of [(123)I]IOFA radioactivity was seen as hot spots in tumor lesions by SPECT imaging. Importantly, elevated COX-1 and COX-2 expressions from immunostaining were found in the bile ducts of tumor rats but not of normal rats. Therefore, [(123)I]IOFA was found to exhibit the potential for imaging tumors that over-express COX.

Gastrointestinal effects of aspirin

Aspirin is being used as an effective analgesic and anti-inflammatory agent at doses >325 mg daily. At low doses (75-325 mg daily), aspirin is the key antiplatelet drug in the pharmacological prevention of cardiovascular diseases. Topical and systemic effects of aspirin in the gastrointestinal mucosa are associated with mucosal damage in the upper and lower gastrointestinal tract. The risk of upper gastrointestinal bleeding with aspirin is increased with old age, male sex, ulcer history and concomitant medication with NSAIDs, cyclooxygenase 2 selective inhibitors, corticosteroids or other antithrombotic agents. In some patients, the cardiovascular benefits of low-dose aspirin might be overcome by the risk of gastrointestinal complications, but withdrawal of aspirin therapy can precipitate a cardiovascular event. These patients will need concomitant therapy with antisecretory agents, especially PPIs, to reduce the gastrointestinal risk. Eradication of Helicobacter pylori infection might be an additional option in patients with a history of ulcer. Furthermore, there is growing evidence that long-term use of aspirin decreases the risk of colorectal cancer, even at low doses. As aspirin is one of the most prescribed drugs worldwide and its clinical impact is huge, physicians need to consider the benefits and harms for each individual patient in order to maximize the benefits of aspirin.

Gastroduodenal toxicity of low-dose acetylsalicylic acid: a comparison with non-steroidal anti-inflammatory drugs

BACKGROUND

Low-dose acetylsalicylic acid (ASA; aspirin; 75-325 mg/day) is effective for the prevention of cardiovascular events, and its use in this indication is rapidly increasing. However, the use of ASA and, indeed, other non-steroidal anti-inflammatory drugs (NSAIDs) is limited by the incidence of adverse gastroduodenal events. OBJECTIVES AND SCOPE: To review the clinical evidence for, and the pharmacodynamic basis of, ASA-induced gastroduodenal toxicity in comparison with NSAIDs, and address the question of whether low-dose ASA is 'safe' from a gastroduodenal perspective. This was a narrative, descriptive review, rather than a formal systematic review.

FINDINGS

Adverse gastroduodenal effects, which are well known to occur with NSAIDs, are also prevalent in patients receiving low-dose ASA for cardiovascular protection even at doses as low as 75 mg/day. The risk of gastroduodenal toxicity is particularly high among 'at-risk' low-dose ASA patients (aged >70 years, previous ulcer or upper gastrointestinal bleeding and users of antiplatelets or NSAIDs). There are important differences in the mechanism of ASA-induced gastroduodenal toxicity, relative to NSAIDs. These differences include the effects on the cyclooxygenase (COX)-1 isoenzyme, local effects on the gastroduodenal mucosa specific to ASA and a reduction in platelet aggregation.

CONCLUSION

Data suggest that ASA causes significant gastroduodenal damage even at the low doses used for cardiovascular protection. These effects (both systemic and possibly local) may be pharmacodynamically distinct from the gastroduodenal toxicity seen with NSAIDs. Studies are required to establish strategies for improving the tolerability of low-dose ASA, allowing patients to continue to benefit from the cardiovascular protection associated with such therapy.

Orengedokuto and berberine improve indomethacin-induced small intestinal injury via adenosine

BACKGROUND

Recent endoscopic technology has revealed that small intestinal injury is a serious threat to patients receiving nonsteroidal anti-inflammatory drugs (NSAIDs). We previously showed that Japanese herbal medicine, Orengedokuto (OGT; Huang-Lian-Jie-Du-Tang in Chinese), protects mice from lethal indomethacin (IND)-induced enteropathy. To elucidate the mechanism of the protective effect of OGT, we performed microarray analyses and high power statistical analyses of microarray data using new bioinformatics tools.

METHODS

Female BALB/c mice were subcutaneously injected with IND (20 mg/kg) once a day for 2 days. OGT-treated mice received a diet containing OGT from the first IND injection until the end of the experiment. Gene expression signals of small intestine were obtained with GeneChip. Analyses for overrepresentation of Gene Ontology categories were conducted using MetaGene Profiler (MGP) and the changes were visualized by Cell Illustrator Online (CIO). Furthermore, active ingredients of OGT were investigated.

RESULTS

MGP and CIO suggested a critical role for the adenosine system, especially adenosine deaminase (ADA), a key enzyme of adenosine catabolism. Quantitative real time RT-PCR and in situ hybridization showed that OGT decreased the expression of ADA, which possibly resulted in the elevation of the anti-inflammatory nucleoside adenosine. Blockade of the adenosine A2a receptor abrogated the protective effect of OGT. Berberine, a major ingredient of OGT, suppressed ADA expression and reduced the incidence of lethality.

CONCLUSIONS

OGT may prevent IND-induced enteropathy by decreasing ADA which results in the elevation of adenosine. Modulation of the adenosine system may be an efficient therapeutic strategy for NSAID-induced enteropathy.

Rescue strategies against non-steroidal anti-inflammatory drug-induced gastroduodenal damage

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed drugs worldwide, which attests to their efficacy as analgesic, antipyretic and anti-inflammatory agents as well as anticancer drugs. However, NSAID use also carries a risk of major gastroduodenal events, including symptomatic ulcers and their serious complications that can lead to fatal outcomes. The development of "coxibs" (selective cyclooxygenase-2 [COX-2] inhibitors) offered similar efficacy with reduced toxicity, but this promise of gastroduodenal safety has only partially been fulfilled, and is now dented with associated risks of cardiovascular or intestinal complications. Recent advances in basic science and biotechnology have given insights into molecular mechanisms of NSAID-induced gastroduodenal damage beyond COX-2 inhibition. The emergence of newer kinds of NSAIDs should alleviate gastroduodenal toxicity without compromising innate drug efficacy. In this review, novel strategies for avoiding NSAID-associated gastroduodenal damage will be described.

Nanocomposites of 2-arylpropionic acid drugs based on Mg-Al layered double hydroxide for dissolution enhancement

Naproxen (NP) and flurpibrofen (FB) as non-steroidal anti-inflammatory drugs (NSAIDs) of 2-arylpropionic acid derivatives have been used as host organic drugs to be intercalated into layered double hydroxide (LDH) applying reconstruction and co-precipitation techniques. The obtained NP-LDH and FB-LDH nanocomposites were characterized by X-ray powder diffraction, infrared and thermogravimetric analyses. From drug loading, thermal analysis and X-ray measurements we can decide that coprecipitaion technique is better than reconstruction technique to obtain intercalated monophase nanocomposites. In acidic medium LDH dissolved and the intercalated drug starts to release in a molecular form which is suitable for adsorption. The drug solubility has been investigated before and after intercalation. It has been found that LDH improves the drug solubility and its dissolution rate.

Cyclooxygenase-1-selective inhibitors are attractive candidates for analgesics that do not cause gastric damage. design and in vitro/in vivo evaluation of a benzamide-type cyclooxygenase-1 selective inhibitor

Although cyclooxygenase-1 (COX-1) inhibition is thought to be a major mechanism of gastric damage by nonsteroidal anti-inflammatory drugs (NSAIDs), some COX-1-selective inhibitors exhibit strong analgesic effects without causing gastric damage. However, it is not clear whether their analgesic effects are attributable to COX-1-inhibitory activity or other bioactivities. Here, we report that N-(5-amino-2-pyridinyl)-4-(trifluoromethyl)benzamide ( 18f, TFAP), which has a structure clearly different from those of currently available COX-1-selective inhibitors, is a potent COX-1-selective inhibitor (COX-1 IC 50 = 0.80 +/- 0.05 microM, COX-2 IC 50 = 210 +/- 10 microM). This compound causes little gastric damage in rats even at an oral dose of 300 mg/kg, though it has an analgesic effect at as low a dose as 10 mg/kg. Our results show that COX-1-selective inhibitors can be analgesic agents without causing gastric damage.

Modulation of indomethacin-induced gastric injury by spermine and taurine in rats

This study investigated the involvement of neutrophil infiltration, nitric oxide (NO) generation, and oxidative stress in indomethacin-induced ulcer and the possible gastroprotective potentials of spermine and taurine, known for their tissue regenerating and antioxidant effects, respectively. Male Wistar albino rats (180-220 g) were allocated into a normal control group, ulcer control group (received a single dose of indomethacin 40 mg-kg p.o.), and two ulcer groups pretreated with spermine (150 mg-kg p.o. 1 h before ulcer induction) and taurine (250 mg-kg i.p. for three consecutive days before ulcer induction). The animals were killed 6 h after indomethacin administration, and the gastric juice, serum, and mucosal tissue were used for gastric injury evaluation. Both modulators significantly ameliorated the indomethacin-induced gastric lesions in glandular mucosa. Notably, spermine exhibited the most pronounced effect as manifested by great reduction in the gastric ulcer index, normalization of the elevated gastric acidity, and triggering of mucin production. Spermine and taurine were able to decrease the elevated levels of gastric myeloperoxidase, conjugated diene, and serum NO. However, the lowered tissue NO content was markedly elevated only by taurine. The antioxidant action of taurine was illustrated by restoration of the depressed content of glutathione, normalization of the inhibited activities of glutathione reductase, and superoxide dismutase. These results suggest that spermine and taurine confer significant gastroprotection against indomethacin-induced gastric injury with the priority of spermine.

Pharmacological activity and hydrolysis behavior of novel ibuprofen glucopyranoside conjugates

Novel ester prodrugs (II, III and IV) of ibuprofen (I) were synthesized using alpha-methyl, ethyl and propyl glucopyranoside as promoieties and tested for their anti-inflammatory, analgesic and ulcerogenic activities. Study of their chemical hydrolysis in aqueous buffer (pH 3.0-10.0) showed that these compounds acted as true prodrugs of ibuprofen, giving the ibuprofen and alkyl glucopyranoside. Additionally, all the derivatives studied did cleave rapidly inside the biological system and on oral administration did elicit a pharmacological profile quite similar to that of ibuprofen, but, unlike this drug, they displayed reduced gastric ulceration. In conclusion, these alkyl glucopyranoside esters have promising properties as prodrugs for oral delivery of ibuprofen.

Synthesis and anti-inflammatory activity of a series of N-substituted naproxen glycolamides: nitric oxide-donor naproxen prodrugs

A series of glycolamide naproxen prodrugs containing a nitrate group as a nitric oxide (NO) donor moiety has been synthesized. These compounds were evaluated for their anti-inflammatory activity, naproxen release, and gastric tolerance. Compounds 4a, 4b, 5a, 5b, 7b, and 7c exhibited anti-inflammatory activity equivalent to that of the parent NSAID, naproxen-Na, in the rat carrageenan paw edema model. At equimolar doses relative to naproxen-Na, the NO-donor glycolamide derivatives 4a, 4b, 5a, 5b, 7b, and 7c were gastro-sparing in the rat. Naproxen formation from these NO-donor glycolamides varied among the structures examined, with the N-substituent on the amide group having a particular influence, and demonstrated their prodrug nature. Compound 7b was selected for exemplary demonstration that the glycolamide nitrates can be bioactivated to release NO. These data open the possibility that naproxen glycolamide nitrates may represent a safer alternative to naproxen as anti-inflammatory medicines.

Nitric oxide releasing derivatives of tolfenamic acid with anti-inflammatory activity and safe gastrointestinal profile

Tolfenamic acid esters with nitrooxyalcohols are synthesized. They are anti-inflammatory agents reducing carrageenan rat paw edema, with low gastrointestinal and general toxicity. In vitro, they are nitric oxide donors, inhibitors of lipoxygenase and cyclooxygenases. A two to three carbon chain between carboxylic and nitric ester groups seems optimal for activity.

Strictures, diaphragms, erosions or ulcerations of ischemic type in the colon should always prompt consideration of nonsteroidal anti-inflammatory drug-induced lesions

AIM: To investigate whether NSAIDs/ASA lesions in the colon can histologically be diagnosed on the basis of ischemic necrosis similar to biopsy-based diagnosis of NSAIDs/ASA-induced erosions and ulcers of the stomach.

METHODS: In the period between 1997 and 2002, we investigated biopsy materials obtained from 611 patients (415 women, 196 men, average age 60.5 years) with endoscopic focal erosions, ulcerations, strictures or diaphr-agms in the colon. In the biopsies obtained from these lesions, we always established the suspected diagnosis of NSAID-induced lesions whenever necroses of the ischemic type were found. Together with the histological report, we enclosed a questionnaire to investigate the use of medication. The data provided by the questionnaire were then correlated with the endoscopic findings, the location, number and nature of the lesions, and the histological findings.

RESULTS: At the time of their colonoscopy, 86.1% of the patients had indeed been taking NSAID/ASA medication for years (43.9%) or months (29.5%). The most common indication for the use of these drugs was pain (64.3%), and the most common indication for colonoscopy was bleeding (55.5%). Endoscopic inspection revealed multiple erosions and/or ulcers in 60.6%, strictures in 15.8%, and diaphragms in 3.0% of the patients. The lesions were located mainly in the right colon including the transverse colon (79.9%). A separate analysis of age and sex distribution, endoscopic and histological findings for NSAIDs alone, ASA alone, combined NSAID/ASA, and for patients denying the use of such drugs, revealed no significant differences among the groups.

CONCLUSION: This uncontrolled retrospective study based on the histological finding of an ischemic necrosis shows that the histologically suspected diagnosis of NSAID-induced lesions in the colon is often correct. The true diagnostic validity of this finding and the differentiation from ischemic colitis should, however, be investigated in a prospective controlled study.

Training Room Management of Medical Conditions: Sports Gastroenterology

Gastrointestinal (GI) illnesses are common in athletes. Various causes include adverse physiologic adaptations of the gut during exercise; excess ingestion of carbohydrate drinks, alcohol, and anti-inflammatory medications; emotional stressors; exposure to pathogens in closed environments and during travel; trauma; and abdominal wall pressure overload. Unfortunately, evidence-based management of GI illnesses in athletes is limited because most studies have compared various GI illnesses between different sports, rather than comparing athletes to nonathletes. This article reviews the evidence that is available specifically relating to etiology, pathophysiology, clinical presentation, relevant differential diagnoses, acute management, and recommendations for specialist consultation of various GI illnesses in the training-room setting.

Time dependent risk of gastrointestinal complications induced by non-steroidal anti-inflammatory drug use: a consensus statement using a meta-analytic approach

OBJECTIVES

To provide an updated document assessing the global, NSAID-specific, and time dependent risk of gastrointestinal (GI) complications through meta-analyses of high quality studies.

METHODS

An exhaustive systematic search was performed. Inclusion criteria were: RCT or controlled study, duration of 5 days at least, inactive control, assessment of minor or major NSAID adverse effects, publication range January 1985 to January 2003. The publications retrieved were assessed during a specifically dedicated WHO meeting including leading experts in all related fields. Statistics were performed conservatively. Meta-regression was performed by regressing NSAID adjusted estimates against study duration categories.

RESULTS

Among RCT data, indolic derivates provided a significantly higher risk of GI complications related to NSAID use than for non-users: RR = 2.25 (1.00; 5.08) than did other compounds: naproxen: RR = 1.83 (1.25; 2.68); diclofenac: RR = 1.73 (1.21; 2.46); piroxicam: RR = 1.66 (1.14; 2.44); tenoxicam: RR = 1.43 (0.40; 5.14); meloxicam: RR = 1.24 (0.98; 1.56), and ibuprofen: RR = 1.19 (0.93; 1.54). Indometacin users had a maximum relative risk for complication at 14 days. The other compounds presented a better profile, with a maximum risk at 50 days. Significant additional risk factors included age, dose, and underlying disease. The controlled cohort studies provided higher estimates: RR = 2.22 (1.7; 2.9). Publication bias testing was significant, towards a selective publication of deleterious effects of NSAIDs from small sized studies.

CONCLUSION

This meta-analysis characterised the "compound" and "time" aspects of the GI toxicity of non-selective NSAIDs. The risk/benefit ratio of such compounds should thus be carefully and individually evaluated at the start of long term treatment.

Epidemiology of perforated colonic diverticular disease

Perforated colonic diverticular disease results in considerable mortality and morbidity. This review appraises existing evidence on the epidemiology and mechanisms of perforation, highlights areas of further study, and suggests an epidemiological approach towards preventing the condition. Computerised searches were used to identify published articles relating to the epidemiology, pathophysiology, and clinical features of perforated colonic diverticular disease. Several drug and dietary exposures have potential biological mechanisms for causing perforation. Of these only non-steroidal anti-inflammatory drugs have been consistently identified as risk factors in aetiological studies. The causes of perforated colonic diverticular disease remain largely unknown. Further aetiological studies, looking specifically at perforation, are required to investigate whether cause-effect relationships exist for both drug and dietary exposures. The identification of risk factors for perforation would allow primary public health prevention, secondary risk factor modification, and early prophylactic surgery to be aimed at people at high risk.

Mechanisms of NSAID-induced hepatotoxicity: focus on nimesulide

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with idiosyncratic hepatotoxicity in susceptible patients. The molecular mechanisms underlying this toxicity have not yet been fully elucidated. However, experimental evidence suggests that they include increased concentration of the drugs in the hepatobiliary compartment, formation of reactive metabolites that covalently modify proteins and produce oxidative stress, and mitochondrial injury. Genetic and/or acquired patient factors can either augment the pathways leading to hepatic toxicity or impede the protective and detoxifying pathways. An example is nimesulide, a selective cyclo-oxygenase-2 inhibitor widely used for the treatment of inflammatory and pain conditions, which has been recently associated with rare but serious and unpredictable adverse reactions in the liver (increases in serum aminotransferase activities, hepatocellular necrosis, and/or intrahepatic cholestasis). Similar to other drugs causing idiosyncratic hepatotoxicity, both the molecule and the patient contribute to the hazard. Here, the weakly acidic sulfonanilide drug undergoes bioreductive metabolism of the nitroarene group to reactive intermediates that have been implicated in oxidative stress, covalent binding, and mitochondrial injury. It is only in a small number of susceptible patients, however, that genetic or nongenetic factors will cause this potential toxicity to become clinically manifest. In view of the very large recipient population, the incidence of nimesulide-induced liver injury has been low (approximately 0.1 per 100,000 patients treated). Although this estimation is based on spontaneous reporting data versus sales units and needs correction due to the classical bias of this system, the type and incidence of these rare but severe hepatic adverse reactions are comparable to that of other NSAIDs.

A novel microassay for the quantitation of the sulfated glycosaminoglycan content of histological sections: its application to determine the effects of Diacerhein on cartilage in an ovine model of osteoarthritis

OBJECTIVE

A new micro-histological method of assessing the sulfated glycosaminoglycan (S-GAG) content in unstained histological sections of articular cartilage was developed and used to study the effects of orally administered Diacerhein (DIA) on joint cartilage in an ovine model of osteoarthritis (OA).

METHODS

Twenty adult, age-matched Merino wethers were subjected to bilateral lateral meniscectomy, while 10 served as non-operated controls (NOC groups). Half of the operated sheep (N=10) remained untreated (MEN groups), while the other 10 animals were given DIA (25 mg/kg orally) daily for 3 months, then 50 mg/kg daily for a further 6 months (DIA groups). Five animals each of the DIA, MEN and NOC groups, respectively, were sacrificed at 3 months post-operatively, and the remainder 6 months later. For the present study only one knee joint of each animal was used for histological processing. The tissues studied were from the lateral femoral condyles (LFC) and lateral tibial plateaux (LTP). Each of these joint regions was further subdivided into inner (I), middle (M), and outer (O) zones. Unstained histological sections from these AC regions and zones were then analysed for S-GAG content using the following procedure. Images of each section of 6 microm thickness were acquired using a flatbed scanner and the area determined with an image analysis software program. The sections were then transferred to wells of a microtiter plate, digested with papain and the S-GAG content quantitated using a modification of the 1,9-dimethylmethylene blue dye binding assay. The data was represented as microg S-GAG/mm(3)of each tissue section. These data were also compared with toluidine blue stained sections from the same paraffin blocks.

RESULTS

The results obtained showed that the area of histological sections could be very accurately determined by computer assisted image analysis using a 10 mmx10 mm calibration grid. Cartilage sections of areas ranging from 1 mm(2)up to 25 mm(2)were analysed for S-GAG content with this simple technique. There was a linear relationship between section thickness (2-10 microm) and S-GAG content per unit area (R(2)=0.993). Sections of 6 microm thickness were found to be optimal. S-GAG analyses of serial sections from tibial and femoral articular cartilage (I, M and O zones) revealed an average coefficient of variation of 7.0+/-2.3% (range 4.9-10.2%) confirming the accuracy and reproducibility of this assay method. A separate experiment showed that no significant losses of S-GAG occurred during the histological sample processing. The different regions and zones of the knee joint AC in the six experimental groups revealed variable levels of S-GAG which did not necessarily correlate with the histochemical distribution of toluidine blue staining. The major S-GAG changes occurred in the middle (lesion zone) and outer zones (hypertrophic zone) of both the LFC and LTP of the MEN groups. In the lesion (M) zone the S-GAG content was reduced while in the O zone levels were increased at both 3 and 6 months post-surgery. In animals receiving Diacerhein S-GAG levels in the M zone were lower than or equivalent to those of non-drug treated OA or non-operated controls for both joint regions at 3 and 6 months. While the hypertrophic response in the outer zone of the LFC, as assessed by S-GAG content, was enhanced by drug treatment, the cartilage of the outer zones of the LTP was not affected by drug treatment.

CONCLUSION

The results of this study have demonstrated that the S-GAG (and therefore proteoglycan [PG]) content in different cartilage zones of OA joints can be readily quantitated by direct biochemical analysis of unstained histological sections. By this means subtle changes in PG distribution in different cartilage zones, which were not evident using traditional histochemical staining methods, could be readily detected.

Barrier dysfunction and Crohn's disease

Crohn's disease is a debilitating illness of unknown etiology. A current hypothesis of disease pathogenesis suggests that this illness represents an abnormal immunological reaction to a luminal antigen. As part of this theory it is suggested that the luminal antigen is delivered to the mucosal immune system by a paracellular route. If this theory is correct several testable predictions can be made. In this manuscript these predictions are presented and the evidence to support or refute them is presented.

Effects of food intake and oxidative stress on intestinal lesions caused by meloxicam and piroxicam in rats

Large intestinal ulcers, bleeding and perforation are occasionally due to non-steroidal anti-inflammatory drugs (NSAID). In addition to suppression of prostaglandins synthesis, a number of factors have been implicated, including enterohepatic recirculation, food intake and vascular injury with oxygen free-radical generation. The present study aimed to determine the effect of food intake and the role of oxidative stress in the pathogenesis of intestinal injury induced by oral administration of meloxicam (preferential cyclooxygenase-2 inhibitor) vs. piroxicam (preferential cyclooxygenase-1 inhibitor). Therefore, the activity of oxidative stress-related enzymes such as myeloperoxidase, xanthine oxidase and superoxide dismutase, as well as levels of lipid peroxides and glutathione homeostasis were studied in an experimental model using re-fed rats. The animals treated with piroxicam (10-20 mg/kg) had a dose-dependent increase in the severity of intestinal lesions, but only the highest dose of meloxicam (15 mg/kg) caused macroscopic damage. The severity of piroxicam and meloxicam-induced damage was correlated with a significant increase of xantine oxidase activity and a decrease of superoxide dismutase activity and glutathione levels (P<0.05 and P<0.001 vs. control). In contrast, there was no significant neutrophil infiltration of the intestine after dosing. Our results support the hypothesis that oxygen free radicals, probably derived via the action of xantine oxidase, the decrease in superoxide dismutase activity, and depletion of mucosal glutathione contribute to the pathogenesis of meloxicam and piroxicam-induced intestinal ulceration in re-fed rats.

Antiulcer effect of lafutidine on indomethacin-induced gastric antral ulcers in refed rats

Lafutidine is a new type antiulcer agent with antisecretory and gastroprotective activities. We investigated the effect of lafutidine on indomethacin-induced antral ulcer in refed rats. Subcutaneous indomethacin injection resulted in the formation of gastric antral ulcer. Lafutidine (1-10 mg/kg, p.o.) reduced the area of ulcer in a dose-dependent manner when administered immediately after the indomethacin injection. Capsaicin at 3 mg/kg, p.o. and 16,16-dimethyl prostaglandin E2 at 3 microg/kg, p.o. also reduced the ulcer area. Chemical deafferentation of capsaicin-sensitive neurons or N(G)-nitro-L-arginine treatment aggravated the ulcer formation and abolished the preventive effect of lafutidine and capsaicin. After the induction of gastric ulcer, lafutidine given twice daily for 2.5 days reduced the area of ulcer in a dose-dependent manner with a significant effect at 10 mg/kg, p.o., as compared with that of the control group. In chemically-deafferentated rats, lafutidine did not show any healing effect. Cimetidine (30 mg/kg, p.o.) and famotidine (1 mg/kg, p.o.) had no significant effect on indomethacin-induced antral ulcer. These results may suggest that lafutidine, unlike cimetidine and famotidine, can prevent the indomethacin-induced antral ulcer formation and accelerate the healing of the ulcer in refed rats through mechanisms involving the capsaicin-sensitive afferent neurons and nitric oxide.

The pathobiology of osteoarthritis and the rationale for the use of pentosan polysulfate for its treatment

OBJECTIVES

Structure-modifying osteoarthritis (OA) drugs (SMOADs) may be defined as agents that reverse, retard, or stabilize the underlying pathology of OA, thereby providing symptomatic relief in the long-term. The objective of this review was to evaluate the literature on sodium pentosan polysulfate (NaPPS) and calcium pentosan polysulfate (CaPPS), with respect to the pathobiology of OA to ascertain whether these agents should be classified as SMOADs.

METHODS

Published studies on NaPPS and CaPPS were selected on the basis of their relevance to the known pathobiology of OA, which also was reviewed.

RESULTS

Both NaPPS and CaPPS exhibit a wide range of pharmacological activities. Of significance was the ability of these agents to support chondrocyte anabolic activities and attenuate catabolic events responsible for loss of components of the cartilage extracellular matrix in OA joints. Although some of the anti-catabolic activities may be mediated through direct enzyme inhibition, NaPPS and CaPPS also have been shown to enter chondrocytes and bind to promoter proteins and alter gene expression of matrix metalloproteinases and possibly other mediators. In rat models of arthritis, NaPPS and CaPPS reduced joint swelling and inflammatory mediator levels in pouch fluids. Moreover, synoviocyte biosynthesis of high-molecular-weight hyaluronan, which is diminished in OA, was normalized when these cells were incubated with NaPPS and CaPPS or after intraarticular injection of NaPPS into arthritic joints. In rabbit, canine, and ovine models of OA, NaPPS and CaPPS preserved cartilage integrity, proteoglycan synthesis, and reduced matrix metalloproteinase activity. NaPPS and CaPPS stimulated the release of tissue plasminogen activator (t-PA), superoxide dismutase, and lipases from vascular endothelium while concomitantly decreasing plasma levels of the endogenous plasminogen activator inhibitor PAI-1. The net thrombolytic and lipolytic effects exhibited by NaPPS and CaPPS may serve to improve blood flow through subchondral capillaries of OA joints and improve bone cell nutrition. In geriatric OA dogs, NaPPS and CaPPS reduced symptoms, as well as normalized their thrombolytic status, threshold for platelet activation, and plasma triglyceride levels. These hematologic parameters were shown to be abnormal in OA animals before drug treatment. Similar outcomes were observed in OA patients when CaPPS or NaPPS were given orally or parenterally in both open and double-blind trials.

CONCLUSIONS

The data presented in this review support the contention that NaPPS and CaPPS should be classified as SMOADs. However, additional long-term clinical studies employing methods of assessing joint structural changes will be needed to confirm this view.

Economic and gastrointestinal safety comparisons of etodolac, nabumetone, and oxaprozin from insurance claims data from patients with arthritis

This study was conducted to compare the effect of etodolac, nabumetone, and oxaprozin use on gastrointestinal (GI) safety and associated costs based on insurance claims information from practice settings. Data were obtained from a national claims database (MarketScan) for the years 1992 to 1994. The claims data of interest were for patients with arthritis who had used etodolac, nabumetone, or oxaprozin exclusively during a 9-month follow-up period (ONLY groups), or these drugs plus (PLUS groups) the other nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen, naproxen, diclofenac, sulindac, piroxicam, ketoprofen, or indomethacin. For each group, we obtained information on the use of inpatient and outpatient services for GI-related events and the associated costs. All GI admissions were classified as NSAID-induced or possibly NSAID-induced events based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. All outpatient upper GI ulcers or bleeding episodes were also identified by specific ICD-9 CM code. There were no significant between-group demographic differences. The proportions of patients with NSAID-induced and possibly NSAID-induced GI admissions were 0.1% and 0.4% for the etodolac-ONLY, 0.3% and 1.0% for the nabumetone-ONLY, and 0.1% and 0.5% for the oxaprozin-ONLY groups, respectively (P > 0.05), and a similar pattern was observed among the PLUS groups. In outpatient settings, 3.9%, 4.2%, and 4.9% of the etodolac-, nabumetone-, and oxaprozin-ONLY patients, respectively (P > 0.05), and 6.0%, 5.3%, and 4.7% of the etodolac-, nabumetone-, and oxaprozin-PLUS patients, respectively, had at least one upper GI ulcer/bleeding claim (P > 0.05). The total health care costs for 9 months were approximately $3000 each for the etodolac-, nabumetone-, and oxaprozin-ONLY groups. Oxaprozin, nabumetone, and etodolac had similar GI-safety and associated-costs profiles based on information from practice settings. Also, in patients who used multiple NSAIDs, the groups did not differ in their GI-safety and cost profiles.

Clinical pharmacokinetics of nabumetone. The dawn of selective cyclo-oxygenase-2 inhibition?

Nabumetone is a nonsteroidal anti-inflammatory drug (NSAID) of the 2,6-disubstituted naphthyl-alkanone class. Nabumetone is metabolised to an active metabolite 6-methoxy-2-napthylacetic acid (6-MNA) which is a relatively selective cyclo-oxygenase-2 inhibitor that has anti-inflammatory and analgesic properties. Nabumetone and its metabolites bind extensively to plasma albumin. Nabumetone is eliminated following biotransformation to 6-MNA, which does not undergo enterohepatic circulation and the respective glucoroconjugated metabolites are excreted in urine. Substantial concentrations of 6-MNA are attained in synovial fluid, which is he proposed site of action in chronic inflammatory arthropathies. A smaller area under the plasma concentration-time curve (AUC) is evident at steady state as compared with a single dose; this is possibly due to an increase in the volume of distribution and saturation of protein binding. Relationships between 6-MNA concentrations and the therapeutic and toxicological effects have yet to be elucidated for this NSAID. Renal failure significantly reduces 6-MNA elimination but steady-state concentrations of 6-MNA are not increased, possibly because of nonlinear protein binding. Elderly patients with osteoarthritis demonstrate decreased elimination and increased plasma concentrations of nabumetone as compared with young healthy volunteers. Rheumatic disease activity also influences 6-MNA plasma concentrations, as patients with more active disease and lower serum albumin concentrations demonstrate a lower area under the plasma concentration versus time curve. A reduced bioavailability of 6-MNA in patients with severe hepatic impairment is also evident. Dosage adjustment may be required in the elderly, patients with active rheumatic disease and those with hepatic impairment, but not in patients with mild-to-moderate renal failure.