Clinical use and pharmacological properties of selective COX-2 inhibitors

Comparing pre- and postoperative etoricoxib administration versus only postoperative on third molar extraction sequelae and oral health quality of life: a prospective quasi-experimental study

OBJECTIVES

This study aimed to compare the impact of pre- and postoperative etoricoxib administration versus only postoperative on third molar extraction sequelae and oral health quality of life.

MATERIALS AND METHODS

This prospective quasi experimental study involved 56 patients, divided into a study group receiving preemptive etoricoxib 120 mg before surgery and postoperative etoricoxib 120 mg (n = 28), and a control group receiving preemptive placebo before surgery and postoperative etoricoxib 120 mg (n = 28). Follow-up assessments were conducted at 3- and 7-days post-surgery, recording swelling, trismus, and adverse events. Patients rated perceived pain using the visual analog scale (VAS) and completed an oral health-related quality of life (OHRQoL) questionnaire at specified intervals. Statistical analysis employed non-parametric tests (i.e., the Mann-Whitney test, Friedman test, and Wilcoxon sign test) with P < 0.05.

RESULTS

Significantly lower VAS scores were reported in the study group throughout the follow-up period (P < 0.05). Pharmacological protocol did not have a significant impact on postoperative edema and trismus (P > 0.05). However, double etoricoxib intake significantly improved postoperative quality of life on day 3 after surgery (P < 0.05).

CONCLUSIONS

Pre- and postoperative etoricoxib 120 mg intake in third molar surgery reduced postoperative pain and enhanced postoperative quality of life on day 3 after surgery. Importantly, it was equally effective in managing swelling and trismus compared to exclusive postoperative intake.

CLINICAL RELEVANCE

Preemptive etoricoxib use may decrease patient discomfort following impacted mandibular third molar extraction.

Selective COX-2 inhibitors after bariatric surgery: Celecoxib, etoricoxib and etodolac post-bariatric solubility/dissolution and pharmacokinetics

Anatomical/physiological gastrointestinal changes after bariatric surgery may influence the fate of orally administered drugs.Since non-selective NSAIDs are not well-tolerated post-surgery, selective cyclooxygenase-2 (COX-2) inhibitors may be important for these patients. In this work we investigated celecoxib, etoricoxib and etodolac, for impaired post-bariatric solubility/dissolution and absorption. Solubility was studied in-vitro, and ex-vivoin aspirated gastric contents from patients pre- vs. post-surgery. Dissolution was studied in conditions simulating pre- vs. post-surgery stomach. Finally, the experimental solubility data were used in physiologically-based biopharmaceutics model (PBBM) (GastroPlus®) to simulate pre- vs. post-surgery celecoxib/etoricoxib/etodolac pharmacokinetic (PK) profiles.For etoricoxib and etodolac (but not celecoxib), pH-dependent solubility was demonstrated: etoricoxib solubility decreased ∼1000-fold, and etodolac solubility increased 120-fold, as pH increased from 1 to 7, which was also confirmed ex-vivo. Hampered etoricoxib dissolution and improved etodolac dissolution post-surgery was revealed. Tablet crushing, clinically recommended after surgery, failed to improve post-bariatric dissolution. PBBM simulations revealed significantly impaired etoricoxib absorption post-surgery across all conditions; for instance, 79% lower Cmax and 53% decreased AUC was simulated post-gastric bypass procedure, after single 120 mg dose. Celecoxib and etodolac maintained unaffected absorption after bariatric surgery.This mechanistically-based analysis suggests to prefer the acidic drug etodolac or the neutral celecoxib as selective COX-2 inhibitors, over the basic drug etoricoxib, after bariatric surgery.

Disconnect between COX-2 selective inhibition and cardiovascular risk in preclinical models

INTRODUCTION

Secondary pharmacology profiling is routinely applied in pharmaceutical drug discovery to investigate the pharmaceutical effects of a drug at molecular targets distinct from (off-target) the intended therapeutic molecular target (on-target). Data from a randomized, placebo-controlled clinical trial, the APPROVe (Adenomatous Polyp Prevention on VIOXX, rofecoxib) trial, raised significant concerns about COX-2 inhibition as a primary or secondary target, shaping the screening and decision-making processes of some pharmaceutical companies. COX-2 is often included in off-target screens due to cardiovascular (CV) safety concerns about secondary interactions with this target. Several potential mechanisms of COX-2-mediated myocardial infarctions have been considered including, effects on platelet stickiness/aggregation, vasal tone and blood pressure, and endothelial cell activation. In the present study, we focused on each of these mechanisms as potential effects of COX-2 inhibitors, to find evidence of mechanism using various in vitro and in vivo preclinical models.

METHODS

Compounds tested in the study, with a range of COX-2 selectivity, included rofecoxib, celecoxib, etodolac, and meloxicam. Compounds were screened for inhibition of COX-2 vs COX-1 enzymatic activity, ex vivo platelet aggregation (using whole blood from multiple species), ex vivo canine femoral vascular ring model, in vitro human endothelial cell activation (with and without COX-2 induction), and in vivo cardiovascular assessment (anesthetized dog).

RESULTS

The COX-2 binding assessment generally confirmed the COX-2 selectivity previously reported. COX-2 inhibitors did not have effects on platelet function (spontaneous aggregation or inhibition of aggregation), cardiovascular parameters (mean arterial pressure, heart rate, and left ventricular contractility), or endothelial cell activation. However, rofecoxib uniquely produced an endothelial mediated constriction response in canine femoral arteries.

CONCLUSION

Our data suggest that rofecoxib-related cardiovascular events in humans are not predicted by COX-2 potency or selectivity. In addition, the vascular ring model suggested possible adverse cardiovascular effects by COX-2 inhibitors, although these effects were not seen in vivo studies. These results may also suggest that COX-2 inhibition alone is not responsible for rofecoxib-mediated adverse cardiovascular outcomes.

Discovery, total syntheses and potent anti-inflammatory activity of pyrrolinone-fused benzoazepine alkaloids Asperazepanones A and B from Aspergillus candidus

Natural products are well established as an important resource and play an important role in drug discovery. Here, two pyrrolinone-fused benzoazepine alkaloids, (+)-asperazepanones A (1) and B (2) with a 6/7/5 ring system, together with the artifact (-)-asperazepanone A (1), were isolated from the coral-derived Aspergillus candidus fungus. Their structures including absolute configurations were elucidated by extensive spectroscopic methods, single crystal X-ray diffraction, and ECD calculations. Furthermore, total syntheses of (±)-1 and (±)-2 have been achieved starting from the commercially L-aspartic acid diethyl ester hydrochloride and monoethyl malonate in 7 and 8 steps, respectively. The key step in the syntheses was an intramolecular Friedel-Crafts reaction to build the unique tricyclic skeleton. Interestingly, (+)-2 not only showed obviously inhibitory activity against NO production, but also inhibited potent LPS-induced expression of TNF-α and IL-6 at the concentration of 0.1 μM. It thus represents a potentially promising lead for anti-inflammatory drug discovery.

Anti-Inflammatory, Analgesic and Antioxidant Potential of New (2S,3S)-2-(4-isopropylbenzyl)-2-methyl-4-nitro-3-phenylbutanals and Their Corresponding Carboxylic Acids through In Vitro, In Silico and In Vivo Studies

In the current study, a series of new (2S,3S)-2-(4-isopropylbenzyl)-2-methyl-4-nitro-3-phenylbutanals (FM1-6) with their corresponding carboxylic acid analogues (FM7-12) has been synthesized. Initially, the aldehydic derivatives were isolated in the diastereomeric form, and the structures were confirmed with NMR, MS and elemental analysis. Based on the encouraging results in in vitro COX 1/2, 5-LOX and antioxidant assays, we oxidized the compounds and obtained the pure single (major) diastereomer for activities. Among all the compounds, FM4, FM10 and FM12 were the leading compounds based on their potent IC₅₀ values. The IC₅₀ values of compounds FM4, FM10 and FM12 were 0.74, 0.69 and 0.18 µM, respectively, in COX-2 assay. Similarly, the IC₅₀ values of these three compounds were also dominant in COX-1 assay. In 5-LOX assay, the majority of our compounds were potent inhibitors of the enzyme. Based on the potency and safety profiles, FM10 and FM12 were subjected to the in vivo experiments. The compounds FM10 and FM12 were observed with encouraging results in in vivo analgesic and anti-inflammatory models. The molecular docking studies of the selected compounds show binding interactions in the minimized pocked of the target proteins. It is obvious from the overall results that FM10 and FM12 are potent analgesic and anti-inflammatory agents.

Effect of Celecoxib vs Placebo as Adjuvant Therapy on Disease-Free Survival Among Patients With Breast Cancer: The REACT Randomized Clinical Trial

IMPORTANCE

Patients with breast cancer remain at risk of relapse after adjuvant therapy. Celecoxib has shown antitumor effects in preclinical models of human breast cancer, but clinical evidence is lacking.

OBJECTIVE

To evaluate the role of celecoxib as an addition to conventional therapy for women with ERBB2 (formerly HER2)-negative primary breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

The Randomized European Celecoxib Trial (REACT) was a phase 3, randomized, double-blind study conducted in 160 centers across the UK and Germany testing 2 years of adjuvant celecoxib vs placebo among 2639 patients recruited between January 19, 2007, and November 1, 2012, with follow-up 10 years after treatment completion. Eligible patients had completely resected breast cancer with local and systemic therapy according to local practice. Patients with ERBB2-positive or node-negative and T1, grade 1 tumors were not eligible. Randomization was in a 2:1 ratio between celecoxib or placebo. Statistical analysis was performed from May 5, 2019, to March 5, 2020.

INTERVENTIONS

Patients received celecoxib, 400 mg, or placebo once daily for 2 years.

MAIN OUTCOMES AND MEASURES

The primary end point was disease-free survival (DFS), analyzed in the intention-to-treat population using Cox proportional hazards regression and log-rank analysis. Follow-up is complete.

RESULTS

A total of 2639 patients (median age, 55.2 years [range, 26.8-86.0 years]) were recruited; 1763 received celecoxib, and 876 received placebo. Most patients' tumors (1930 [73%]) were estrogen receptor positive or progesterone receptor positive and ERBB2 negative. A total of 1265 patients (48%) had node-positive disease, and 1111 (42%) had grade 3 tumors. At a median follow-up of 74.3 months (interquartile range, 61.4-93.6 years), DFS events had been reported for 487 patients (19%): 18% for those who received celecoxib (n = 323; 5-year DFS rate = 84%) vs 19% for those who received placebo (n = 164; 5-year DFS rate = 83%); the unadjusted hazard ratio was 0.97 (95% CI, 0.80-1.17; log-rank P = .75). Rates of toxic effects were low across both treatment groups, with no evidence of a difference.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, patients showed no evidence of a DFS benefit for 2 years' treatment with celecoxib compared with placebo as adjuvant treatment of ERBB2-negative breast cancer. Longer-term treatment or use of a higher dose of celecoxib may lead to a DFS benefit, but further studies would be required to test this possibility.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02429427 and isrctn.org Identifier: ISRCTN48254013.

Synthesis of novel 3,5,6-trisubstituted 2-pyridone derivatives and evaluation for their anti-inflammatory activity

The inflammatory response is the reaction of living tissue to an injury of a foreign nature, such as infection and irritants, and occurs as part of the body's natural defence response. Compounds capable of inhibiting cyclooxygenase (COX) enzymes, especially COX-2, have great potential as anti-inflammatory agents. Herein we present the regioselective synthesis of 49 novel compounds based on the 2-pyridone nucleus. The topical anti-inflammatory activity of seventeen compounds was evaluated in mice by croton oil (CO) induced ear edema assay. Most of the compounds exhibited a high level of in vivo anti-inflammatory activity, reducing ear edema and myeloperoxidase (MPO) activity. The most active compounds (2a and 7a) were inhibitors of COX enzymes. Compound 2a selectively inhibited the COX-2, while 7a was nonselective. Further, the compound 2a showed effective binding at the active site of COX-2 co-crystal by docking molecular study.

Celecoxib in Cancer Therapy and Prevention - Review

BACKGROUND AND OBJECTIVES

It is generally accepted that inflammatory cells found in the tumor microenvironment are involved in the neoplastic process, promoting cell proliferation, survival, and migration. Therefore, administering anti-inflammatory medication in cancer therapy seems to be justified. A potential pathway associated with the aforementioned issue is cyclooxygenase-2 inhibition, particularly as the overexpression of this enzyme has been proven to occur in cancer tissues and is also associated with a poor prognosis in several types of human malignancies. Celecoxib, a COX-2 selective inhibitor, has been utilized for over 20 years, particularly as an anti-inflammatory, analgesic and antipyretic medication. However, to date, its antineoplastic properties have not been sufficiently investigated. In recent years, the number of research studies on the antineoplastic effects of celecoxib has increased considerably. The vast majority of publications refers to preclinical studies attempting to elucidate its mechanisms of action. Clinical trials concerning celecoxib have focused primarily on the treatment of cancers of the colon, breast, lung, prostate, stomach, head and neck, as well as premalignant lesions such as familial adenoma polyposis. In this review article authors attempt to summarise the latest research which has elucidated celecoxib use in the treatment and prevention of cancer.

CONCLUSION

Both preclinical and clinical studies have demonstrated promising results of the role of celecoxib in the treatment and prevention of cancer - the best outcome was observed in colon, breast, prostate and head and neck cancers. However, more clinical trials providing real evidence-based clinical advances of celecoxib use are needed.

Discovery of a Celecoxib Binding Site on Prostaglandin E Synthase (PTGES) with a Cleavable Chelation-Assisted Biotin Probe

The coxibs are a subset of nonsteroidal anti-inflammatory drugs (NSAIDs) that primarily target cyclooxygenase-2 (COX-2) to inhibit prostaglandin signaling and reduce inflammation. However, mechanisms to inhibit other members of the prostaglandin signaling pathway may improve selectivity and reduce off-target toxicity. Here, we report a novel binding site for celecoxib on prostaglandin E synthase (PTGES), which is an enzyme downstream of COX-2 in the prostaglandin signaling pathway, using a cleavable chelation-assisted biotin probe 6. Evaluation of the multifunctional probe 6 revealed significantly improved tagging efficiencies attributable to the embedded picolyl functional group. Application of the probe 6 within the small molecule interactome mapping by photoaffinity labeling (SIM-PAL) platform using photo-celecoxib as a reporter for celecoxib identified PTGES and other membrane proteins in the top eight enriched proteins from A549 cells. Four binding sites to photo-celecoxib were mapped by the probe 6, including a binding site with PTGES. The binding interaction with PTGES was validated by competitive displacement with celecoxib and licofelone, which is a known PTGES inhibitor, and was used to generate a structural model of the interaction. The identification of photo-celecoxib interactions with membrane proteins, including the direct binding site on the membrane protein PTGES, will inform further functional followup and the design of new selective inhibitors of the prostaglandin signaling pathway.

Evaluation of the efficacy of celecoxib and ibuprofen on postoperative pain, swelling, and mouth opening after surgical removal of impacted third molars: a randomized, controlled clinical trial

The objective of this study was to compare the efficacy of celecoxib and ibuprofen in reducing postoperative sequelae following the surgical removal of impacted mandibular third molars. Ninety-eight subjects who needed surgical extraction of an impacted mandibular third molar were selected for the study. All subjects were randomly allocated to receive one of the following treatments twice a day for 5days after surgery: placebo (n=32), ibuprofen (n=33), or celecoxib (n=33). The primary outcome chosen was postoperative pain, which was evaluated using the visual analogue scale (VAS) score recorded by each patient. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with celecoxib and ibuprofen resulted in improvements in the primary outcome. Furthermore, when compared to the other groups, patients in the celecoxib group showed a significant reduction in postoperative pain scores at 6h (P<0.001), 12h (P=0.011), and 24h (P=0.041) after surgery. Regarding swelling and maximum mouth opening values, there were no significant differences between the groups at each follow-up session. This study demonstrated that treatment with celecoxib decreased the incidence and severity of postoperative pain following third molar surgery compared to ibuprofen and placebo.

Coadministration of lithium and celecoxib attenuates the behavioral alterations and inflammatory processes induced by amphetamine in an animal model of mania

The present study evaluated the effects of the coadministration of lithium (Li) and Cel on inflammatory parameters in an animal model of mania induced by dextroamphetamine (D-amph). It was used Wistar rats 60 days old (250-350 g). The animals (n = 10 per group) received D-amph (2 mg/kg) or saline solution of NaCl 0.9% (Sal) intraperitoneally once a day for 14 days. From day eight until 14, the animals from the D-amph and Sal groups received Li (24 mg/kg), Cel (20 mg/kg), Li + Cel or water via gavage. Behavioral analyses were performed using the open-field test. The levels of IL-1β, IL-4, IL-10, and TNF-α were evaluated. The administration of D-amph induced hyperactivity in the rats, as well increased the IL-4, IL-10, and TNF-α levels in the serum, frontal cortex, and striatum of rats compared to those of the controls, and treatment with Li plus Cel reversed these alterations. In general, the administration of Li or Cel per se did not have effects on the behavioral and biochemical parameters. However, the treatment with Cel per se decreased only the IL-10 levels in the serum of animals. Besides, the treatment with Li or Cel decreased the IL-4 levels in the serum and reversed the effects of D-amph on this parameter in the frontal cortex. The treatment with Li reversed the effects of D-amph on the TNF-α levels in all tissues evaluated, and the administration of Cel reversed this alteration only in the striatum. It can be observed that treatment with Li plus Cel was more effective against damages caused by D-amph when compared to the administration of both treatments per se, suggesting that the coadministration can be more effective to treat BD rather than Li or Cel itself. The treatment with Li plus Cel was effective against the inflammation induced by D-amph.

A comparison of the efficacy and safety of complementary and alternative therapies for the primary dysmenorrhea: A network meta-analysis protocol

BACKGROUND

There are a number of complementary and alternative therapies for the primary dysmenorrhea (PD) and their efficacy has been assessed by several systematic reviews. But only pair-wised drugs have been evaluated in the traditional meta-analyses and conflicting interpretation of results also existed among different studies. Here, a protocol for a network meta-analysis will be presented aimed to compare the efficacy and safety of different complementary and alternative therapies for PD.

METHODS

All randomized controlled trials of complementary and alternative therapies for the PD will be included. The primary outcomes of our interest are pain intensity and pain duration and the secondary outcomes are quality of life, clinical effective rate, and adverse events. We will search relevant database, the ongoing trial, previous relevant reviews and reference lists, and so on. The identification and selection of studies and data extraction will be conducted by two independent reviewers. We will perform a battery of pairwise meta-analyses and Bayesian network meta-analyses to assess the relative outcomes of different complementary and alternative therapies. We will use the surface under the cumulative ranking curve values and the mean ranks to get the treatment hierarchy, and then use the node-splitting method to evaluate consistency. The softwares WinBUGS 1.4.3 and STATA will be selected and the quality of the evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation instrument.

ETHICS AND DISSEMINATION

This review does not require ethical approval.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018107763.

Selective cyclooxygenase inhibition and ulcerogenic liability of some newly prepared anti-inflammatory agents having thiazolo[4,5-d]pyrimidine scaffold

Novel candidates of thiazolo[4,5-d]pyrimidines (9a-l) were synthesized and their structures were elucidated by spectral and elemental analyses. All the novel derivatives were screened for their cyclooxygenase inhibitory effect, anti-inflammatory activity and ulcerogenic liability. All the new compounds exhibited anti-inflammatory activity, especially 1-(4-[7-(4-nitrophenyl)-5-thioxo-5,6-dihydro-3H-thiazolo[4,5-d]pyrimidin-2-ylideneamino]phenyl)ethanone (9g) was the most active derivative with 57%, 88% and 88% inhibition of inflammation after 1, 3 and 5h, respectively. Furthermore, this derivative 9g recorded higher anti-inflammatory activity than celecoxib which showed 43%, 43% and 54% inhibition after 1, 3 and 5h, sequentially. Moreover, the target derivatives 9a-l demonstrated moderate to high potent inhibitory action towards COX-2 (IC₅₀ = 0.87-3.78 µM), in particular, the derivatives 9e (IC₅₀ = 0.92 µM), 9g (IC₅₀ = 0.87 µM) and 9k (IC₅₀ = 1.02 µM) recorded higher COX-2 inhibitory effect than the selective COX-2 inhibitor drug celecoxib (IC₅₀ = 1.11 µM). The in vivo potent compounds (9e, 9g and 9k) caused variable ulceration effect (ulcer index = 5-12.25) in comparison to that of celecoxib (ulcer index = 3). Molecular docking was performed to the most potent COX-2 inhibitors (9e, 9g and 9k) to explore the binding mode of these derivatives with Cyclooxygenase-2 enzyme.

Development and Evaluation of Poorly Water-Soluble Celecoxib as Solid Dispersions Containing Nonionic Surfactants Using Fluidized-Bed Granulation

The purpose of this study is to develop a solid dispersion system with improved dissolution, absorption, and patient compliance of poorly water-soluble celecoxib (CXB). Instead of sodium lauryl sulfate (SLS), an anionic surfactant used in the marketed product (Celebrex^®), solubilization was performed using non-ionic surfactants with low toxicity. Cremophor RH40 (Cre-RH) was selected as the optimal solubilizer. Granules and tablets containing CXB and Cre-RH were prepared via fluid-bed and tableting processes, respectively. The morphology, crystallinity, flowability, dissolution, and pharmacokinetics for CXB-solid dispersion granules (SDGs) and the hardness and friability for CXB-solid dispersion tablets (SDTs) were evaluated. The solubility of CXB was found to be increased by about 717-fold when using Cre-RH. The dissolution of granules containing Cre-RH was found to be increased greatly compared with CXB API and Celebrex^® (66.9% versus 2.3% and 37.2% at 120 min). The improvement of the dissolution was confirmed to be the same as that of granules in tablets. The CXB formulation resulted in 4.6- and 4.9-fold higher AUC_inf and C_max of CXB compared with those of an oral dose of CXB powder in rats. In short, these data suggest that the solid dispersion based on Cre-RH—a non-toxic solubilizer, non-ionic surfactant— may be an effective formulation for CXB to enhance its oral bioavailability and safety.

Rationally synthesized coumarin based pyrazolines ameliorate carrageenan induced inflammation through COX-2/pro-inflammatory cytokine inhibition

In the present work, coumarin based pyrazolines (7a-g) have been synthesized and investigated for their in vitro and in vivo anti-inflammatory potential. Amongst the synthesized compounds, compounds 7a, 7d and 7f exhibited significant in vitro anti-inflammatory activity as compared to the standard etoricoxib. Keeping this in mind, in vivo investigations were carried out via carrageenan induced inflammation and acetic acid induced writhing models in male Wistar rats and compound 7a was found to possess appreciable anti-inflammatory and analgesic potential. The mode of action of compound 7a was also investigated by using substance P as the biomarker, which shows promising results. Further, the selectivity of the most active compound 7a against the cyclooxygenase enzyme was supported by molecular docking studies which reveal that compound 7a has greater binding affinity towards COX-2 over COX-1 and 5-LOX enzymes. In silico ADME analysis of compound 7a confirms the drug-like characteristics and the in vivo acute toxicity study showed the safety of the compound even up to a 2000 mg kg-1 dose. Thus, compound 7a was identified as an effective anti-inflammatory agent, and can be explored for further analgesic/anti-inflammatory drug design and development.

Network pharmacology for antiepileptogenesis: Tolerability and neuroprotective effects of novel multitargeted combination treatments in nonepileptic vs. post-status epilepticus mice

Network-based approaches in drug discovery comprise both development of novel drugs interacting with multiple targets and repositioning of drugs with known targets to form novel drug combinations that interact with cellular or molecular networks whose function is disturbed in a disease. Epilepsy is a complex network phenomenon that, as yet, cannot be prevented or cured. We recently proposed multitargeted, network-based approaches to prevent epileptogenesis by combinations of clinically available drugs chosen to impact diverse epileptogenic processes. In order to test this strategy preclinically, we developed a multiphase sequential study design for evaluating such drug combinations in rodents, derived from human clinical drug development phases. Because pharmacokinetics of such drugs are known, only the tolerability of novel drug combinations needs to be evaluated in Phase I in öhealthy" controls. In Phase IIa, tolerability is assessed following an epileptogenic brain insult, followed by antiepileptogenic efficacy testing in Phase IIb. Here, we report Phase I and Phase IIa evaluation of 7 new drug combinations in mice, using 10 drugs (levetiracetam, topiramate, gabapentin, deferoxamine, fingolimod, ceftriaxone, α-tocopherol, melatonin, celecoxib, atorvastatin) with diverse mechanisms thought to be important in epileptogenesis. Six of the 7 drug combinations were well tolerated in mice during prolonged treatment at the selected doses in both controls and during the latent phase following status epilepticus induced by intrahippocampal kainate. However, none of the combinations prevented hippocampal damage in response to kainate, most likely because treatment started only 16-18 h after kainate. This suggests that antiepileptogenic or disease-modifying treatment may need to start earlier after the brain insult. The present data provide a rich collection of tolerable, network-based combinatorial therapies as a basis for antiepileptogenic or disease-modifying efficacy testing.

In the Realm of Psychoneuroimmunology: The Role of Celecoxib as an Add-On Treatment for Bipolar Mania

Bipolar affective disorder (BPAD) is a chronic debilitating psychiatric illness seriously affecting the quality of patients' life. The available treatment is effective in about half of those suffering from the illness. The neurobiological basis of the disorder is not fully unraveled. With such lacunae, attempts have been made to decipher the underlying neuroimmunological process of the illness as is the case with other mental disorders. As a result, some inflammatory processes have been implicated in the etiology of BPAD, as described in this communication. Subsequently, the role of anti-inflammatory agents such as celecoxib was investigated by treating different phases of BPAD. Given the promising outcomes of several trials and reviews, celecoxib has gained momentum and has been recommended as an adjunctive treatment by some guidelines for treating resistant BPAD cases. This brief communication highlights some of the caveats in the randomized trials using celecoxib as an add-on treatment in bipolar mania specifically, which need to be addressed in future work.

Design and Synthesis of Aza-/Oxa Heterocycle-Based Conjugates as Novel Anti-Inflammatory Agents Targeting Cyclooxygenase-2

A library of hybrid molecules was procured by the combination of triazine-indole adduct with morpholine/piperidine/pyrrolidine and pyrazole/pyrimidine/oxindole moieties. Enzyme immunoassays on cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) identified compound 6 having an IC₅₀ value of 20 nM for COX-2 and 3000 nM for COX-1. The significant reduction in the formation of prostaglandin E₂ in the lipopolysaccharide-treated (COX-2-activated) human whole blood, almost no change in the production of thromboxane B₂ in the calcium ionophore-treated (COX-1-activated) sample of human whole blood, and the mechanistic studies on Swiss albino mice ensured that compound 6 is selective for COX-2. The association constant (K_a) of compound 6 with COX-2 was found to be of the order of 0.48 × 10⁶ M^-1. The diffusion spectroscopy experiments and relaxation time (T₁) calculations of compound 6 in the presence of COX-2 assisted in identifying the site-specific interactions of 6 with the enzyme, and these results fall into nice correlation with the theoretical data obtained from molecular docking and quantitative structure-activity relationship studies. With maximum tolerable dose >2000 mg kg^-1, compound 6 made 68 and 32% reduction in formalin-induced analgesia and carrageenan-induced inflammation in Swiss albino mice.

Celecoxib Does Not Protect against Fibrosis and Inflammation in a Carbon Tetrachloride-Induced Model of Liver Injury

The cyclooxygenase-2 (COX-2) selective inhibitor celecoxib is widely used in the treatment of pain and inflammation. Celecoxib has been explored as a possible treatment of liver fibrosis with contradictory results, depending on the model. The present study reports the effect of celecoxib in a 5-week carbon tetrachloride (CCl₄)-induced liver fibrosis mouse model. Celecoxib alone and in combination with inhibitors of the enzyme-soluble epoxide hydrolase (sEH), as well as a dual inhibitor that targets both COX-2 and sEH, were administered via osmotic minipump to mice receiving intraperitoneal injections of CCl₄ Collagen deposition was elevated in the mice treated with both celecoxib and CCl₄ compared with the control or CCl₄-only groups, as assessed by trichrome staining. Histopathology revealed more extensive fibrosis and cell death in the animals treated with both celecoxib and CCl₄ compared with all other experimental groups. Although some markers of fibrosis, such as matrix metalloprotease, were unchanged or lowered in the animals treated with both celecoxib and CCl₄, overall, hepatic fibrosis was more severe in this group. Cotreatment with celecoxib and an inhibitor of sEH or treatment with a dual inhibitor of COX-2 and sEH decreased the elevated levels of fibrotic markers observed in the group that received both celecoxib and CCl₄ Oxylipid analysis revealed that celecoxib reduced the level of prostaglandin E₂ relative to the CCl₄ only group. Overall, celecoxib treatment did not decrease liver fibrosis in CCl₄-treated mice.

Impact of structural alterations on the radiopharmacological profile of 18F-labeled pyrimidines as cyclooxygenase-2 (COX-2) imaging agents

INTRODUCTION

Non-invasive imaging of COX-2 in cancer represents a powerful tool for assessing COX-2-mediated effects on chemoprevention and radiosensitization using potent and selective COX-2 inhibitors as an emerging class of anticancer drugs. Careful assessment of the pharmacokinetic profile of radiolabeled COX-2 inhibitors is of crucial importance for the development of suitable radiotracers for COX-2 imaging in vivo. The delicate balance between the selection of typical COX-2 pharmacophores and the resulting physicochemical characteristics of the COX-2 inhibitor represents a formidable challenge for the search of radiolabeled COX-2 imaging agents. Several pyrimidine-based COX-2 inhibitors demonstrated favorable in vitro and in vivo COX-2 imaging properties in various COX-2 expressing cancer cell lines. Here, we describe a comparative radiopharmacological study of three ¹⁸F-labeled COX-2 inhibitors based on a pyrimidine scaffold. The objective of this study was to investigate how subtle structural alterations influence the pharmacokinetic profile of lead compound [¹⁸F]1a ([¹⁸F]Pyricoxib) to afford ¹⁸F-labeled pyrimidine-based COX-2 inhibitors with improved COX-2 imaging properties in vivo.

METHODS

Radiosynthesis of radiotracers was accomplished through reaction with 4-[¹⁸F]fluorobenzyl amine on a methyl-sulfone labeling precursor ([¹⁸F]1a and [¹⁸F]2a) or late-stage radiofluorination using a iodyl-containing labeling precursor ([¹⁸F]3a). Radiopharmacological profile of ¹⁸F-labeled pyrimidine-based COX-2 inhibitors [¹⁸F]1a, [¹⁸F]2a and [¹⁸F]3a was studied in COX-2-expressing human HCA-7 colorectal cancer cell line, including cellular uptake studies in HCA-7 cells and dynamic PET imaging studies in HCA-7 xenografts.

RESULTS

Cellular uptake of radiotracers [¹⁸F]2a and [¹⁸F]3a in HCA-7 cells was 450% and 300% radioactivity/mg protein, respectively, after 90 min incubation, compared to 600% radioactivity/mg protein for radiotracer [¹⁸F]1a. Dynamic PET imaging studies revealed a tumor SUV of 0.53 ([¹⁸F]2a) and 0.54 ([¹⁸F]3a) after 60 min p.i. with a tumor-to-muscle ratio of ~1. Tumor SUV for [¹⁸F]1a (60 min p.i.) was 0.76 and a tumor-to-muscle ratio of ~1.5. Pyricoxib analogues [¹⁸F]2a and [¹⁸F]3a showed distinct pharmacokinetic profiles in comparison to lead compound [¹⁸F]1a with a significantly improved lung clearance pattern. Replacing the 4-[¹⁸F]fluorobenzyl amine motif in radiotracer [¹⁸F]1a with a 4-[¹⁸F]fluorobenzyl alcohol motif in radiotracer [¹⁸F]3a resulted in re-routing of the metabolic pathway as demonstrated by a more rapid liver clearance and higher initial kidney uptake and more rapid kidney clearance compared to radiotracers [¹⁸F]1a and [¹⁸F]2a. Moreover, radiotracer [¹⁸F]3a displayed favorable rapid brain uptake and retention.

CONCLUSION

The radiopharmacological profile of three ¹⁸F-labeled COX-2 inhibitors based on a pyrimidine scaffold were evaluated in COX-2 expressing human colorectal cancer cell line HCA-7 and HCA-7 xenografts in mice. Despite the overall structural similarity and comparable COX-2 inhibitory potency of all three radiotracers, subtle structural alterations led to significantly different in vitro and in vivo metabolic profiles.

ADVANCES IN KNOWLEDGE

Among all tested pyrimidine-based ¹⁸F-labeled COX-2 inhibitors, lead compound [¹⁸F]1a remains the most suitable radiotracer for assessing COX-2 expression in vivo. Radiotracer [¹⁸F]3a showed significantly improved first pass pulmonary passage in comparison to radiotracer [¹⁸F]1a and might represents a promising lead compound for the development of radiotracers for PET imaging of COX-2 in neuroinflammation.

Safety assessment of vitacoxib: 180-day chronic oral toxicity studies

Vitacoxib, a selective COX-2 inhibitor, is approved for the relief of pain and inflammation associated with orthopedic surgery and osteoarthritis in dogs. In the current study, a chronic toxicity research was performed to evaluate the safety of vitacoxib in male and female rats for long-term. Vitacoxib was dosed orally to groups of rats for 180 days at 1.2, 6, 30 mg/kg bw/day by gavage. The chronic study oral administration of vitacoxib did not show observational or toxicological effects on the body or organ weights, food consumption, hematology and biochemistry at dose 6 mg/kg bw. However, vitacoxib (30 mg/kg) showed minor alterations to histopathology of liver, kidney and stomach related to treatment. These results provide further indication that vitacoxib is safe and well-tolerated in rats after 180 days of daily oral administration at 6 mg/kg bw and the NOAEL for both sexes was 6 mg/kg bw for 180 consecutive days.

A Randomized, Double-Blind Placebo-Controlled Trial on Effectiveness and Safety of Celecoxib Adjunctive Therapy in Adolescents with Acute Bipolar Mania

OBJECTIVE

Recent studies have focused on the role of inflammatory cascades as one of the possible etiologic factors of bipolar disorder. We hypothesize that celecoxib, through its anti-inflammatory properties, may have a therapeutic role in acute bipolar mania.

PATIENTS AND METHODS

Forty-two adolescent inpatients with the diagnosis of acute bipolar mania participated in a parallel, randomized, double-blind controlled trial, and 40 patients underwent an 8-week treatment with either celecoxib (100 mg twice daily) or placebo as an adjunctive treatment to lithium and risperidone. Patients were evaluated using Young Mania Rating Scale (YMRS) at baseline and weeks 2, 4, and 8. The primary outcome measure was to assess the efficacy of celecoxib compared with placebo in improving mania symptoms.

RESULT

General linear model repeated measures showed significant effect for time × treatment interaction on YMRS scores [F (2.54, 96.56) = 3.21, p = 0.03]. Significantly greater improvement was observed in YMRS scores in the celecoxib group compared with the placebo group from baseline YMRS score at week 8 (p = 0.04). Although a 35% greater response to treatment (considering a Clinical Global Impressions-Improvement score of ≤2, very much/much improved) was observed in the celecoxib group compared with the placebo group, the difference did not reach the statistical significance level (p = 0.09). No serious adverse event was reported.

CONCLUSIONS

Celecoxib may be an effective adjuvant therapy in treatment of manic episodes (without psychotic features) of adolescents with bipolar mood disorder. The mood-stabilizing role of this drug might be mediated through its action on inflammatory cascades.

Use of ginger versus stretching exercises for the treatment of primary dysmenorrhea: a randomized controlled trial

BACKGROUND

Dysmenorrhea is a common gynecologic problem. In some cases, non-medical treatments are considered to be more effective, with fewer side effects. Ginger and exercise are alternative treatments for dysmenorrhea, but in the present study they were not combined.

OBJECTIVE

In this study, the effects of ginger and exercise on primary dysmenorrhea were compared.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This randomized controlled trial was performed in Mazandaran University of Medical Sciences, Iran. Two groups of female students were recruited by simple random allocation. In each group, 61 students with moderate to severe primary dysmenorrhea with regular menstrual cycles and without a history of regular exercise were assessed. The ginger group received 250 mg ginger capsules from the onset of menstruation. In the exercise group, belly and pelvic stretching exercises were performed for 10 min, 3 times per week.

MAIN OUTCOME MEASURES

Intensity of pain was assessed according to a visual analogue scale after the first and the second month.

RESULTS

Exercise was significantly more effective than ginger for pain relief (31.57 ± 16.03 vs 38.19 ± 20.47, P = 0.02), severity of dysmenorrhea (63.9% vs 44.3% mild dysmenorrhea, P = 0.02) and decrease in menstrual duration (6.08 ± 1.22 vs 6.67 ± 1.24, P = 0.006), in the second cycle.

CONCLUSION

Stretching exercises, as a safe and low-cost treatment, are more effective than ginger for pain relief in primary dysmenorrhea.

TRIAL REGISTRATION

The trial was registered in www.IRCT.ir with No. 201203118822N2.

Cyclooxygenase-2 inhibitors differentially attenuate pentylenetetrazol-induced seizures and increase of pro- and anti-inflammatory cytokine levels in the cerebral cortex and hippocampus of mice

Seizures increase prostaglandin and cytokine levels in the brain. However, it remains to be determined whether cyclooxygenase-2 (COX-2) derived metabolites play a role in seizure-induced cytokine increase in the brain and whether anticonvulsant activity is shared by all COX-2 inhibitors. In this study we investigated whether three different COX-2 inhibitors alter pentylenetetrazol (PTZ)-induced seizures and increase of interleukin-1β (IL-1β), interleukin-6 (IL-6), interferon-γ (INF-γ), tumor necrosis factor-α (TNF-α) and interleukin-10 (IL-10) levels in the hippocampus and cerebral cortex of mice. Adult male albino Swiss mice received nimesulide, celecoxib or etoricoxib (0.2, 2 or 20mg/kg in 0.1% carboxymethylcellulose (CMC) in 5% Tween 80, p.o.). Sixty minutes thereafter the animals were injected with PTZ (50mg/kg, i.p.) and the latency to myoclonic jerks and to generalized tonic-clonic seizures were recorded. Twenty minutes after PTZ injection animals were killed and cytokine levels were measured. PTZ increased cytokine levels in the cerebral cortex and hippocampus. While celecoxib and nimesulide attenuated PTZ -induced increase of proinflammatory cytokines in the cerebral cortex, etoricoxib did not. Nimesulide was the only COX-2 inhibitors that attenuated PTZ-induced seizures. This effect coincided with an increase of IL-10 levels in the cerebral cortex and hippocampus, constituting circumstantial evidence that IL-10 increase may be involved in the anticonvulsant effect of nimesulide.

Structure-activity relationships for the synthesis of selective cyclooxygenase 2 inhibitors: an overview (2009-2016)

Most drugs used to treat pain and inflammation act through inhibition of the enzymes prostaglandin G/H synthase, commonly known as cyclooxygenase (COX). Among these, the simultaneous inhibition of cyclooxygenase 1 (COX-1) would explain the unwanted side effects in the gastrointestinal tract and many adverse cardiovascular effects, such as high blood pressure, myocardial infarction and thrombosis. These side effects led in time to the development of NSAIDs that behave as selective COX-2 inhibitors. This manuscript highlights the structure-activity relationships which characterize the chemical scaffolds endowed with selective COX-2 inhibition. Additionally, the role of COX-2 inhibitors in the pain phenomenon and cancer is discussed.

Comparison of the Effect of Stretching Exercises and Mefenamic Acid on the Reduction of Pain and Menstruation Characteristics in Primary Dysmenorrhea: A Randomized Clinical Trial

OBJECTIVES

Dysmenorrhea is a common gynecologic disorder. Although non-steroidal anti-inflammatory drugs are commonly used, due to their side effects and lack of response in some individuals, other approaches such as exercise have been considered. This study compared the effect of stretching exercises and mefenamic acid on the reduction of pain and menstruation characteristics in primary dysmenorrhea.

METHODS

In this randomized clinical trial, 122 female students with moderate to severe dysmenorrhea were assessed and were placed in either the exercise or mefenamic acid group. The exercise program was performed for 15 minutes, three times a week and included a five-minute warm up and six belly and pelvic stretching exercises for 10 minutes. The mefenamic acid group received 250 mg capsules every eight hours from the onset of menstruation until pain relief. Both interventions were performed during two consecutive menstrual cycles. Pain intensity was measured using a 10 cm visual analog scale.

RESULTS

The mean pain intensity was significantly higher in the exercise group only in the first cycle (p = 0.058). In the second cycle, the mean difference in pain reduction in the exercise group was higher than the mefenamic group compared to the start of the study (p = 0.056) and the first cycle (p = 0.007). There was no significant difference in the severity and duration of pain between the groups (p > 0.050).

CONCLUSIONS

Stretching exercises were as effective as mefenamic acid in the treatment of primary dysmenorrhea. Our results suggest that the effect of exercise on relieving menstruation pain increases over time.

Discovery of synthetic small molecules that enhance the number of stomata: C–H functionalization chemistry for plant biology

The first-in-class synthetic small molecules enhancing the number of stomata in Arabidopsis thaliana have been discovered.

Lumiracoxib metabolism in male C57bl/6J mice: characterisation of novel in vivo metabolites

1. The pharmacokinetics and metabolism of lumiracoxib in male C57bl/6J mice were investigated following a single oral dose of 10 mg/kg. 2. Lumiracoxib achieved peak observed concentrations in the blood of 1.26 + 0.51 μg/mL 0.5 h (0.5-1.0) post-dose with an AUC_inf of 3.48 + 1.09 μg h/mL. Concentrations of lumiracoxib then declined with a terminal half-life of 1.54 + 0.31 h. 3. Metabolic profiling showed only the presence of unchanged lumiracoxib in blood by 24 h, while urine, bile and faecal extracts contained, in addition to the unchanged parent drug, large amounts of hydroxylated and conjugated metabolites. 4. No evidence was obtained in the mouse for the production of the downstream products of glutathione conjugation such as mercapturates, suggesting that the metabolism of the drug via quinone-imine generating pathways is not a major route of biotransformation in this species. Acyl glucuronidation appeared absent or a very minor route. 5. While there was significant overlap with reported human metabolites, a number of unique mouse metabolites were detected, particularly taurine conjugates of lumiracoxib and its oxidative metabolites.

PET imaging of cyclooxygenase-2 (COX-2) in a pre-clinical colorectal cancer model

Background

Cyclooxygenase-2 (COX-2) is the inducible isoform of the cyclooxygenase enzyme family. COX-2 is involved in tumor development and progression, and frequent overexpression of COX-2 in a variety of human cancers has made COX-2 an important drug target for cancer treatment. Non-invasive imaging of COX-2 expression in cancer would be useful for assessing COX-2-mediated effects on chemoprevention and radiosensitization using COX-2 inhibitors as an emerging class of anti-cancer drugs, especially for colorectal cancer. Herein, we describe the radiopharmacological analysis of [¹⁸F]Pyricoxib, a novel radiolabeled COX-2 inhibitor, for specific PET imaging of COX-2 in colorectal cancer.

Methods

Uptake of [¹⁸F]Pyricoxib was assessed in human colorectal cancer cell lines HCA-7 (COX-2 positive) and HCT-116 (COX-2 negative). Standard COX-2 inhibitors were used to test for specificity of [¹⁸F]Pyricoxib for COX-2 binding in vitro and in vivo. PET imaging, biodistribution, and radiometabolite analyses were included into radiopharmacological evaluation of [¹⁸F]Pyricoxib.

Results

Radiotracer uptake in COX-2 positive HCA-7 cells was significantly higher than in COX-2 negative HCT-116 cells (P < 0.05). COX-2 inhibitors, celecoxib, rofecoxib, and SC58125, blocked uptake of [¹⁸F]Pyricoxib in HCA-7 cells in a concentration-dependent manner. The radiotracer was slowly metabolized in mice, with approximately 60 % of intact compound after 2 h post-injection. Selective COX-2-mediated tumor uptake of [¹⁸F]Pyricoxib in HCA-7 xenografts was confirmed in vivo. Celecoxib (100 mg/kg) selectively blocked tumor uptake by 16 % (PET image analysis; P < 0.05) and by 51 % (biodistribution studies; P < 0.01).

Conclusions

The novel PET radiotracer [¹⁸F]Pyricoxib displays a promising radiopharmacological profile to study COX-2 expression in cancer in vivo.

Electronic supplementary material

The online version of this article (doi:10.1186/s13550-016-0192-9) contains supplementary material, which is available to authorized users.

Pre-emptive 8 mg dexamethasone and 120 mg etoricoxib for pain prevention after periodontal surgery: A randomised controlled clinical trial

Several anti-inflammatory drugs have been used to reduce pain and discomfort after periodontal surgeries. This study evaluates the efficacy of using etoricoxib and dexamethasone for pain prevention after open-flap debridement surgery. In this study, 60 patients who were undergoing open flap debridment surgery were randomly assigned to receive a single dose preoperative medication 1 hour prior to surgery. The patients were divided into three groups. In Group 1, 20 patients were given placebo drug orally. In Group 2, 20 patients were given 8 mg Dexamethasone orally and in Group 3, 20 patients were given 120 mg Etoricoxib orally. Patients were instructed to complete a pain diary hourly for the first 8 hours after each surgery and three times a day on the following 3 days. The four point verbal rating scale (VRS 4) and Numerical rate scale were used to assess discomfort. Post-operative Assessment of Pain and Discomfort showed that persistent discomfort and pain were found to be more in the placebo group compared to dexamethasone and etoricoxib group. The adoption of a preemptive medication protocol using either etoricoxib or dexamethasone may be considered effective for pain and discomfort prevention after open-flap debridement surgeries.

Toward a Better Understanding of the Physical Stability of Amorphous Anti-Inflammatory Agents: The Roles of Molecular Mobility and Molecular Interaction Patterns

The aim of this article is to examine the crystallization tendencies of three chemically related amorphous anti-inflammatory agents, etoricoxib, celecoxib, and rofecoxib. Since the molecular mobility is considered as one of the factors affecting the crystallization behavior of a given material, broadband dielectric spectroscopy was used to gain insight into the molecular dynamics of the selected active pharmaceutical ingredients. Interestingly, our experiments did not reveal any significant differences in their relaxation behavior either in the supercooled liquid or in the glassy state. Hence, as a possible explanation for the enhanced physical stability of etoricoxib, its ability to undergo a tautomerization reaction was recognized. The occurrence of intramolecular proton transfer in the disordered etoricoxib was proven experimentally by time-dependent dielectric and infrared (IR) measurements. Additionally, IR spectroscopy combined with density functional theory calculations pointed out that in the etoricoxib drug, being in fact a binary mixture of tautomers, the individual isomers may interact with each other through a hydrogen bonding network. A possible explanation of this issue was achieved by performing dielectric experiments at elevated pressure. Since compression results in etoricoxib recrystallization, the possible influence of pressure on the observed stabilization effect is also carefully discussed.

Celecoxib adjunctive therapy for acute bipolar mania: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

Recent research has focused on the inflammatory cascade as a key culprit in the etiology of bipolar disorder. We hypothesized that celecoxib, via its anti-inflammatory properties, may have a therapeutic role in mood disorder.

METHODS

Forty-six inpatients with the diagnosis of acute bipolar mania without psychotic features participated in a parallel, randomized, double-blind, placebo-controlled trial, and underwent six weeks of treatment with either celecoxib (400 mg daily) or placebo as an adjunctive treatment to sodium valproate. Patients were evaluated using the Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS). The primary outcome measure with respect to efficacy was the mean decrease in YMRS score from baseline to the study endpoint, which was compared between the two groups.

RESULTS

A significant difference was observed in the change in YMRS scores on Day 42 compared to baseline in the two groups (p < 0.001). The changes at the endpoint compared to baseline were -29.78 ± 21.78 (mean ± standard deviation) and -21.78 ± 7.16 for the celecoxib and placebo groups, respectively. A significantly higher remission rate was observed in the celecoxib group (87.0%) than the placebo group (43.5%) at Week 6 (p = 0.005). General linear model repeated measures demonstrated a significant effect for the time × treatment interaction on the YMRS scores [F(2.27,99.98) = 6.67, p = 0.001].

CONCLUSIONS

Celecoxib is an effective adjuvant therapy in the treatment of manic episodes (without psychotic features) of bipolar mood disorder. The mood-stabilizing role of the drug might be mediated via its action on the inflammatory cascade.

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that act by blocking prostaglandin production. They inhibit the action of cyclooxygenase (COX), an enzyme responsible for the formation of prostaglandins. The COX enzyme exists in two forms, COX-1 and COX-2. Traditional NSAIDs are considered 'non-selective' because they inhibit both COX-1 and COX-2 enzymes. More selective NSAIDs that solely target COX-2 enzymes (COX-2-specific inhibitors) were launched in 1999 with the aim of reducing side effects commonly reported in association with NSAIDs, such as indigestion, headaches and drowsiness.

OBJECTIVES

To determine the effectiveness and safety of NSAIDs in the treatment of primary dysmenorrhoea.

SEARCH METHODS

We searched the following databases in January 2015: Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, November 2014 issue), MEDLINE, EMBASE and Web of Science. We also searched clinical trials registers (ClinicalTrials.gov and ICTRP). We checked the abstracts of major scientific meetings and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trial (RCT) comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed their risk of bias and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). We used inverse variance methods to combine data. We assessed the overall quality of the evidence using GRADE methods.

MAIN RESULTS

We included 80 randomised controlled trials (5820 women). They compared 20 different NSAIDs (18 non-selective and two COX-2-specific) versus placebo, paracetamol or each other. NSAIDs versus placeboAmong women with primary dysmenorrhoea, NSAIDs were more effective for pain relief than placebo (OR 4.37, 95% CI 3.76 to 5.09; 35 RCTs, I(2) = 53%, low quality evidence). This suggests that if 18% of women taking placebo achieve moderate or excellent pain relief, between 45% and 53% taking NSAIDs will do so.However, NSAIDs were associated with more adverse effects (overall adverse effects: OR 1.29, 95% CI 1.11 to 1.51, 25 RCTs, I(2) = 0%, low quality evidence; gastrointestinal adverse effects: OR 1.58, 95% CI 1.12 to 2.23, 14 RCTs, I(2) = 30%; neurological adverse effects: OR 2.74, 95% CI 1.66 to 4.53, seven RCTs, I(2) = 0%, low quality evidence). The evidence suggests that if 10% of women taking placebo experience side effects, between 11% and 14% of women taking NSAIDs will do so. NSAIDs versus other NSAIDsWhen NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain relief or safety. However, the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials. Non-selective NSAIDs versus COX-2-specific selectorsOnly two of the included studies utilised COX-2-specific inhibitors (etoricoxib and celecoxib). There was no evidence that COX-2-specific inhibitors were more effective or tolerable for the treatment of dysmenorrhoea than traditional NSAIDs; however data were very scanty. NSAIDs versus paracetamolNSAIDs appeared to be more effective for pain relief than paracetamol (OR 1.89, 95% CI 1.05 to 3.43, three RCTs, I(2) = 0%, low quality evidence). There was no evidence of a difference with regard to adverse effects, though data were very scanty.Most of the studies were commercially funded (59%); a further 31% failed to state their source of funding.

AUTHORS' CONCLUSIONS

NSAIDs appear to be a very effective treatment for dysmenorrhoea, though women using them need to be aware of the substantial risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea. We rated the quality of the evidence as low for most comparisons, mainly due to poor reporting of study methods.

A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars

Pain after third molar extraction has been considered the most suitable pharmaceutical model to evaluate acute pain. This study aimed to evaluate the pre-emptive analgesic/anti-inflammatory efficacy of etoricoxib 120 mg following mandibular third molar surgery. A split-mouth, randomized, triple-blind, placebo-controlled study was conducted with patients undergoing the surgical removal of mandibular third molars. All volunteers were allocated randomly to receive either etoricoxib 120 mg or placebo 1h preoperatively, and inflammatory events were evaluated. An estimated sample of 18 surgical units per group was required based on a pilot study (95% confidence level and 80% statistical power). Rescue medication was analyzed by Kaplan-Meier method through log-rank Mantel-Cox test and Pearson linear correlation (P<0.05). Pre-emptive etoricoxib reduced postoperative pain scores significantly in comparison to placebo (P<0.001), with a pain score peak at 6h after surgery (P<0.001). The mean rescue medication consumption was lower in the etoricoxib group compared to the placebo group over the study period (P<0.05). There was no statistically significant difference between groups related to swelling and trismus. The pre-emptive administration of etoricoxib 120 mg significantly reduced the postoperative pain intensity and the need for rescue medication, but did not reduce swelling or trismus.

Efficacy of celecoxib for acute pain management following total hip arthroplasty in elderly patients: A prospective, randomized, placebo-control trial

The aim of the present study was to determine whether celecoxib is able to ameliorate pain intensity, provide a narcotic-sparing effect, achieve early ambulation and improve rehabilitation following total hip arthroplasty (THA) in elderly patients. Peri- and post-operative oral celecoxib was administered to verify the efficacy of celecoxib for acute pain management in a multimodal analgesic strategy. All 64 eligible patients were randomly allocated to either the celecoxib group, who took an oral 400 mg capsule of celecoxib peri-operatively and 200 mg per 12 h post-operatively for the first 5 days, or the control group, who were orally treated with a placebo capsule having the same appearance. A multimodal analgesic technique was used in which oral celecoxib or placebo capsule was combined with intravenous patient-controlled analgesia (PCA) morphine pump for peri- and post-operative pain management. Pain assessments were recorded at 6, 12, 24, 48 and 72 h, and 7 and 14 days after THA using the visual analog scale (VAS). PCA morphine consumption; 6, 12, 24 and 48-h post-operative Harris hip score (HHS); time interval until initial ambulation; rates of urinary retention and post-operative nausea and vomiting (PONV) within 72 h; and intra- and post-operative blood loss were also documented. The celecoxib and control groups comprised 34 and 30 patients, respectively. Baseline demographics were comparable between the two groups. The post-operative VAS in the celecoxib group was significantly lower than that in the control group at 12, 24, 48 and 72 h after THA. The post-operative HHS had no significant difference between the two groups, while the time interval until initial ambulation in the celecoxib group (4.5±1.2 days) was significantly less than that in the control group (5.83±2.04 days; P<0.05). Morphine consumption was significantly decreased in the celecoxib group when compared with the control group at 6, 12, 24 and 24 h. Although the 72-h post-operative rates of urinary retention and PONV were lower in the celecoxib group than in the control group, there were no significant differences in these rates between the two groups. The intra- or post-operative blood loss was not significantly different between groups. In conclusion, pre-and post-operative oral celecoxib in a multimodal analgesic strategy can achieve favorable pain relief, reduce opioid consumption, and provide earlier ambulation and improved rehabilitation when compared with PCA morphine alone following THA in elderly patients.

Celecoxib Inhibits the Lytic Activation of Kaposi's Sarcoma-Associated Herpesvirus through Down-Regulation of RTA Expression by Inhibiting the Activation of p38 MAPK

Kaposi’s sarcoma associated herpesvirus (KSHV) is the etiologic agent of Kaposi’s sarcoma (KS), primary effusion lymphoma (PEL), and multicentric Castleman’s disease (MCD). KSHV’s lytic replication cycle is critical for the pathogenesis of KSHV-associated diseases. Despite recent progress in the development of treatments for KSHV associated malignancies, these therapies are not completely efficacious and cause side effects. Therefore, more effective therapies with antiviral agents against KSHV are urgently needed. In this study, we identified celecoxib as an antiviral agent against KSHV. Our data suggest that celecoxib inhibits the lytic activation of KSHV through the down-regulation of the expression of the lytic switch protein, replication and transcription activator (RTA), by inhibiting the activation of p38 MAPK. Therefore, celecoxib may provide a candidate inhibitor for the therapeutic research of KSHV-related malignancies.

Evidence of different mediators of central inflammation in dysfunctional and inflammatory pain--interleukin-8 in fibromyalgia and interleukin-1 β in rheumatoid arthritis

The purpose of this study was to relate central inflammation to autonomic activity (heart rate variability (HRV)) in patients with rheumatoid arthritis (RA) and fibromyalgia (FM). RA patients had reduced parasympathetic activity and FM patients had increased sympathetic activity compared to healthy controls. Comparisons between RA and FM showed higher cerebrospinal fluid (CSF) interleukin (IL)-1β inversely correlated to parasympathetic activity in RA. The FM patients had higher concentrations of CSF IL-8, IL-1Ra, IL-4 and IL-10, but none of these cytokines correlated with HRV. In conclusion, we found different profiles of central cytokines, i.e., elevated IL-1β in inflammatory pain (RA) and elevated IL-8 in dysfunctional pain (FM).

Intraarticular platelet-rich plasma injection in the treatment of knee osteoarthritis: review and recommendations

Intraarticular platelet-rich plasma (PRP) injection has emerged as a promising treatment for knee osteoarthritis. Studies to date, including multiple randomized controlled trials, have shown that PRP is a safe and effective treatment option for knee osteoarthritis. Intraarticular PRP is similar in efficacy to hyaluronic acid, and seems to be more effective than hyaluronic acid in younger, active patients with low-grade osteoarthritis. Treatment benefits seem to wane after 6-9 mos. There are numerous PRP treatment variables that may be of importance, and the optimal PRP protocol remains unclear. Future investigations should control and analyze the effects of these variables in PRP treatment. High-quality randomized controlled trials are needed to optimize PRP treatment methods and better define the role of PRP in osteoarthritis management in the knee and, potentially, in other joints.