Protective activity of ketoprofen lysine salt against the pulmonary effects induced by bradykinin in guinea-pigs

Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition

There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.

Novel drug OMS103HP reduces pain and improves joint motion and function for 90 days after arthroscopic meniscectomy

PURPOSE

This phase 2 study compared OMS103HP (Omeros, Seattle, WA) with control (lactated Ringer's) irrigation solution in patients undergoing arthroscopic partial meniscectomy.

METHODS

This was a prospective, multicenter, double-blind, randomized, vehicle-controlled, parallel-group study. Safety and postoperative pain, range of motion, and self-reported function were evaluated for 90 days. Statistical results were based on univariate analysis of variance and repeated-measures analyses.

RESULTS

Mean visual analog scale (VAS) pain scores within 24 hours after discharge from the recovery room showed more pain in the control group beginning at 2 hours and peaking at 8 hours. Univariate analysis of variance of mean VAS scores over the 24-hour period did not meet statistical significance. Repeated-measures analysis yielded a statistically significant difference (P = .004) for time-by-treatment interaction, showing a clear drug benefit over time based on VAS scores. There were statistically significant differences at day 7 between the groups in passive flexion without pain (P = .022). The proportion of patients achieving flexion of 95° or greater, 110°, and 125° was greater for the OMS103HP group. The Knee Injury and Osteoarthritis Outcome Score (KOOS) showed statistically significant differences (P ≤ .05) between the OMS103HP and control groups for 4 of 5 outcomes (symptoms, pain, sport and recreation, and knee-based quality of life but not activities of daily living). All scores showed a treatment effect through day 90. The overall incidence of adverse events and abnormal laboratory values for the OMS103HP and control groups was similar. Serious adverse events occurred in 1 control patient.

CONCLUSIONS

In this study of patients with meniscal tears who underwent simple debridement, the use of OMS103HP resulted in reduced acute postoperative pain (measured by VAS over the first 24 hours postoperatively), reduced pain during recovery (measured by the KOOS pain subscale, which measures both background levels of pain and exacerbations caused by movements or activities), improved postoperative knee motion, and improved functional outcomes as assessed with the KOOS Knee Survey. Clinical benefits of OMS103HP were consistent and sustained throughout 90 days of postoperative follow-up.

LEVEL OF EVIDENCE

Level I, prospective, randomized, controlled trial.

Novel drug product to improve joint motion and function and reduce pain after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

OMS103HP, an investigational drug product containing ketoprofen, amitriptyline, and oxymetazoline, is added to arthroscopic irrigation solution. OMS103HP was evaluated in patients undergoing arthroscopic anterior cruciate ligament reconstruction to assess the drug's safety and ability to improve postoperative knee function and motion, reduce postoperative pain, and allow earlier return to work.

METHODS

This was a prospective, double-blind, vehicle-controlled, parallel-group, randomized study. Allograft anterior cruciate ligament reconstruction patients in both treatment and vehicle control groups were monitored for safety and efficacy (e.g., measurements of knee function and motion, pain, and return to work) over a 30-day postoperative period. The efficacy endpoints of primary interest were assessed by use of both responder and time-to-event analyses.

RESULTS

There were statistically significant differences (P < or = .05) between the OMS103HP and vehicle control groups in the endpoints of knee function (knee function composite and straight-leg raise component of knee function composite), range of motion (median number of days to maximum passive flexion of 90 degrees or greater without pain and time to discontinuation of continuous passive motion), quadriceps and hamstring muscle strength, successful pain management, and return to work. The overall incidences of adverse events and abnormal clinical laboratory values for both OMS103HP- and vehicle-treated subjects were similar, and none was attributed to OMS103HP.

CONCLUSIONS

The clinical benefits of OMS103HP in this study were reduced postoperative pain; improved postoperative knee motion, quadriceps and hamstring muscle strength, and knee function; and earlier return to work as measured by surgeons, nurses, and physical therapists across repeated clinic visits and rehabilitation sessions and recorded by patients in daily diaries. The drug was well tolerated.

Preclinical enantioselective pharmacology of (R)- and (S)- ketorolac

Many of the nonsteroidal anti-inflammatory drugs (NSAIDs) are marketed as racemic mixtures, composed of (R)- and (S)- enantiomers. Racemic NSAIDs are potent cyclooxygenase (COX) inhibitors only through the action of the (S)- enantiomers, as the (R)- enantiomers do not exhibit COX inhibition. However, the (R)- enantiomer of ketoprofen exhibits potent analgesic activity and minimal ulcerogenic potential. To extend these observations, we examined the (R)- and (S)- enantiomers of RS- ketorolac, (S)- ketorolac exhibited potent COX1 and COX2 enzyme inhibition, whereas (R)- ketorolac was > 100-fold less active on both COX subtypes. Both enantiomers did not affect norepinephrine or serotonin uptake sites, and nitric oxidase or lipoxygenase activities, nor did they demonstrate any affinity for opioid receptors (mu, delta, or kappa). In experimental models, (S)- ketorolac exhibited about 10-fold greater activity than (R)- ketorolac in the murine phenylquinone writhing model. In this model, morphine sulfate was effective at much lower doses, however, and neither (R)- nor (S)- ketorolac showed any morphine-sparing effect. In the rat gait test for analgesia in the foot paw after injection of brewers yeast suspension, neither (R)- nor (S)- ketorolac affected paw volume. However, both provoked changes in gait scores, the (S)- enantiomer being 30-fold more potent than the (R)- enantiomer. A similar reduction was observed with respect to ulcerogenic potential, measured by direct microscopic changes after test conclusion. These findings suggest that (R)- ketorolac may possess analgesic activity that is independent of COX inhibition and may be associated with reduced ulcerogenic potential compared to effects exhibited by (S)- ketorolac.