Open experience with a new myorelaxant agent for low back pain

Effects of Eperisone Hydrochloride and Non-Steroid Anti-Inflammatory Drugs (NSAIDs) for Acute Non-Specific Back Pain with Muscle Spasm: A Prospective, Open-Label Study

Background

Low back pain (LBP) occurs as a common condition and may harm the patient’s quality-of-life. Non-steroid anti-inflammatory drugs (NSAIDs) and eperisone form a drug regiment that has been reported as effective in improving low back pain, yet the evidence for its efficacy and safety is lacking.

Objective

The aim of this study was to evaluate the effect of eperisone hydrochloride and ibuprofen compared with ibuprofen alone in reducing symptoms of patients with acute non-specific back pain with a muscle spasm.

Methods

This was an open-label, prospective study involving 100 subjects with symptoms of back pain and muscle spasm. Eligible participants were randomly allocated to an experimental group (54 patients) and a control group (46 patients). The experimental group received eperisone 50 mg three times daily + ibuprofen 400 mg twice daily, and the control group received ibuprofen 400 mg twice daily over a 4-week duration. The primary outcomes were measured with the visual analog scale (VAS), and finger-to-floor (FTF) distance at baseline, week 2, and week 4.

Results

After 4 weeks of follow-up, results from 59 subjects were collected. In both groups, VAS and FTF were decreased compared to baseline. Clinically significant pain reduction (>50% than baseline) was observed to be higher in the experimental group compared with the control group in the fourth week (72.4% vs 46.7%, P<0.05). At the end of the study, pain reduction in the experimental group was more significant compared to the control group (28.13±24.72 vs 34.42±28.47) and participants mobility (FTF distance <10 cm) improved in both groups, especially in the experimental group (75.9% vs 70%). There was no difference in adverse events between groups (P>0.05).

Conclusion

The combination of eperisone hydrochloride and ibuprofen effectively reduces pain and improves functional outcomes over ibuprofen alone with a similar safety profile in these patients with acute non-specific back pain with muscle spasm.

Comparative pharmacokinetics of osmotic-controlled and immediate-release Eperisone tablet formulation in healthy human subjects using a sensitive plasma LC-ESI-MS/MS method

To evaluate and compare the pharmacokinetic (PK) characteristics of a newly developed oral osmotically controlled drug delivery system of Eperisone 150 mg tablets with Eperisone immediate release (IR) marketed tablet brand as a reference formulation. It was a single dose, two treatment, two sequence, randomized, crossover study, involving 12 healthy human subjects. A modified, sensitive LC-ESI-MS/MS method was developed and validated as per FDA guidelines for estimation of Eperisone in plasma using a simple extraction and quick protein precipitation method. Non-compartmental pharmacokinetic model was used for PK analysis. Results were statistically compared using logarithmically transformed data, where p > 0.05 was considered as non-significant with 90% CI limit of 0.8–1.25. The bio-analytical method used for estimating drug plasma concentration was found to be simple, selective, linear, accurate and precise with 0.01 ng/ml as limit of detection. The comparative PK analysis revealed an insignificant difference in AUC_0-∞, AUC_0-t, V_z/F, Cl/F and t_1/2λz, whereas a significant difference in C_max, T_max and MTTs were found. The relative bioavailability of Eperisone osmotic tablet was 109.7%. The osmotic controlled release drug formulation was found to release Eperisone for an extended period with less inter individual fluctuation in pharmacokinetic variables.

Eperisone-Induced Anaphylaxis: Pharmacovigilance Data and Results of Allergy Testing

PURPOSE

Eperisone is an oral muscle relaxant used in musculoskeletal disorders causing muscle spasm and pain. For more effective pain control, eperisone is usually prescribed together with nonsteroidal anti-inflammatory drugs (NSAIDs). As such, eperisone may have been overlooked as the cause of anaphylaxis compared with NSAIDs. This study aimed to analyze the adverse drug reaction (ADR) reported in Korea and suggest an appropriate diagnostic approach for eperisone-induced anaphylaxis.

METHODS

We reviewed eperisone-related pharmacovigilance data (Korea Institute of Drug Safety-Korea Adverse Event Reporting System [KIDS-KAERS]) reported in Korea from 2010 to 2015. ADRs with causal relationship were selected. Clinical manifestations, severity, outcomes, and re-exposure information were analyzed. For further investigation, 7-year ADR data reported in a single center were also reviewed. Oral provocation test (OPT), skin prick test (SPT) and basophil activation test (BAT) were performed in this center.

RESULTS

During the study period, 207 patients had adverse reactions to eperisone. The most common ADRs were cutaneous hypersensitive reactions (30.4%) such as urticaria, itchiness or angioedema. Fifth common reported ADR was anaphylaxis. There were 35 patients with anaphylaxis, comprising 16.9% of the eperisone-related ADRs. In the single center study, there were 11 patients with eperisone-induced anaphylaxis. All the patients underwent OPT and all the provoked patients showed a positive reaction. Four of the 11 patients with anaphylaxis also underwent SPT and BAT, which were all negative.

CONCLUSIONS

Incidence of eperisone-induced anaphylaxis calculated from the KIDS-KAERS database was 0.001%. Eperisone can cause hypersensitive reactions, including anaphylaxis, possibly by inducing non-immunoglobulin E-mediated immediate hypersensitivity.

Pharmacokinetic Interactions Between Pelubiprofen and Eperisone Hydrochloride: A Randomized, Open-label, Crossover Study of Healthy Korean Men

PURPOSE

Pelubiprofen is a novel nonsteroidal anti-inflammatory, analgesic, and antipyretic drug with at least similar efficacy and better tolerability compared with other nonsteroidal anti-inflammatory, analgesic, and antipyretic drugs such as naproxen and aceclofenac. Eperisone hydrochloride is a centrally acting muscle relaxant that performs by blocking calcium channels. The combined use of pelubiprofen and eperisone hydrochloride is increasingly anticipated to promote the clinical effectiveness of pelubiprofen in relieving musculoskeletal symptoms of osteoarthritis, rheumatoid arthritis, and low back pain. No published data are yet available, however, regarding the pharmacokinetic interactions between these 2 drugs when administered concurrently. The objective of this study was to evaluate any pharmacokinetic interactions between pelubiprofen and eperisone hydrochloride in healthy Korean male volunteers.

METHODS

This was a randomized, open-label, crossover study. Each participant was randomly assigned to 1 of 6 treatment sequences and orally received either 45-mg sustained-release pelubiprofen, 75-mg sustained-release eperisone hydrochloride, or both as a single dose in each treatment period, with a 7-day washout period between each treatment. Serial blood samples were collected over 24 hours after dosing, and plasma concentrations of each drug and the major active metabolite of pelubiprofen (trans-alcohol pelubiprofen) were determined by using a validated HPLC-MS/MS system. Pharmacokinetic analyses were conducted by using noncompartmental methods.

FINDINGS

A total of 24 men (mean ± standard deviation of: age, 29 ± 4 years; weight, 72.5 ± 7.8 kg; body mass index, 23.4 ± 1.9 kg/m²) were enrolled, and 23 participants completed the study. For pelubiprofen, the geometric mean ratios (90% CIs) of C_max and AUC_0-∞ were 1.02 (0.87-1.19) and 0.97 (0.88-1.07), respectively. For the major active metabolite of pelubiprofen (trans-alcohol pelubiprofen), the geometric mean ratios (90% CIs) of C_max and AUC_0-∞ were 1.05 (0.98-1.13) and 1.04 (1.01-1.07). For eperisone, the geometric mean ratios (90% CIs) of C_max and AUC_0-∞ were 0.87 (0.67-1.15) and 1.05 (0.85-1.30). None of the study participants experienced serious adverse events during the study.

IMPLICATIONS

No clinically significant changes were noted in the pharmacokinetic interactions of pelubiprofen, the major active metabolite of pelubiprofen (trans-alcohol pelubiprofen), and eperisone hydrochloride between monotherapy and combination therapy with 45-mg sustained-release pelubiprofen and 75-mg sustained-release eperisone hydrochloride.

Clinical efficacy and safety of eperisone for low back pain: A systematic literature review

Eperisone, an analgesic and centrally acting muscle relaxant has been in use for the treatment of low back pain (LBP). The present systematic review evaluates the efficacy and safety of eperisone in patients with LBP. Cochrane Back and Neck (CBN) Group and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were adopted to perform this systematic review. For risk of bias assessment CBN Group and Moga tools were used. Seven (5 randomized controlled trials [RCTs] and 2 uncontrolled studies) studies involving 801 participants were included. Eperisone intervention may be effective in acute LBP patients with less adverse effects (relative risk, 0.25; 95% confidence interval, 0.15-0.41; p<0.0001). Eperisone also improved paraspinal blood flow and was found to have efficacy similar to tizanidine in chronic LBP patients. The included studies in this review are of smaller sample size and short duration to support eperisone use in LBP. However, we recommend well-designed RCTs of high quality with larger sample size and longer follow-up to confirm the clinical benefits of eperisone in the treatment of acute or chronic LBP.

Substantive review of the literature of medication treatment of chronic low back pain among adults

PURPOSE

Pain can be debilitating, and it is often inadequately treated, particularly among patients with chronic low back pain (CLBP). CLBP has a substantial economic impact, as it affects an individual's ability to perform activities of daily living and maintain employment. This study aims to review original studies related to the evidence-based management of patients with CLBP to develop an algorithm for prescribing medications and recommending other treatment modalities for patients with CLBP.

DATA SOURCES

An electronic search of PubMed, CINAHL, and the Cochrane Database was conducted to identify studies related to the evidence-based management of CLBP that were performed between 2003 and 2012. The following keywords were used: low back pain, back pain, chronic back pain, medication management, and adjunct therapy. The selected articles were specific to CLBP, medication-based management, and additional treatment options, such as adjunct therapies.

CONCLUSIONS

The collected data revealed that there are a number of approaches to the management of CLBP. Medication regimens are frequently used and widely available, but alternative treatment modalities can also be effective.

IMPLICATIONS FOR PRACTICE

Providers should encourage patients to explore a variety of treatment modalities that can provide pain relief and improve functionality and overall well-being.

Pharmacokinetic interactions between eperisone hydrochloride and aceclofenac: a randomized, open-label, crossover study of healthy Korean men

BACKGROUND

Eperisone hydrochloride, a centrally acting muscle relaxant, is a calcium antagonist that causes vasodilation and antispastic actions. Aceclofenac, an anti-inflammatory analgesic and antipyretic drug, has similar efficacy and improved gastrointestinal tolerance compared with other nonsteroidal anti-inflammatory drugs, such as diclofenac. Although eperisone hydrochloride and aceclofenac are frequently coadministered, no published studies have reported on the pharmacokinetic interactions between these 2 drugs.

OBJECTIVE

The aim of this study was to investigate any pharmacokinetic interactions between eperisone hydrochloride and aceclofenac in healthy Korean men.

METHODS

This was a randomized, open-label, crossover study. Each participant was randomly assigned to 1 of 6 treatment sequences and received eperisone hydrochloride (3 doses of 50 mg each), aceclofenac (2 doses of 100 mg each), or both as a single dose with a 7-day washout period between each dose. Blood samples were collected ≤ 24 hours after dosing, and plasma eperisone hydrochloride and aceclofenac concentrations were determined using validated LC/MS-MS. Pharmacokinetic analyses were conducted using noncompartmental methods. A safety profile was determined using the measurement of vital signs, ECG, and clinical laboratory tests.

RESULTS

A total 24 of men were enrolled, and all completed the study. The geometric mean ratios (90% CIs) of the Cmax and AUC0-∞ values for eperisone were 1.18 (0.828-1.673) and 1.12 (0.836-1.507), respectively. The geometric mean ratios (90% CIs) of the Cmax and AUC0-∞ for aceclofenac were 0.93 (0.847-1.022) and 1.01 (0.979-1.036), respectively. A total of 7 adverse events were reported in 7 men. All adverse events were mild, and no significant differences were found between treatment groups.

CONCLUSION

No clinically significant pharmacokinetic differences exist between 150 mg eperisone hydrochloride and 200 mg aceclofenac when administrated as a monotherapy or in combination.

Effects of combined application of muscle relaxants and celecoxib administration after total knee arthroplasty (TKA) on early recovery: a randomized, double-blind, controlled study

The purpose of this study was to evaluate the effectiveness of application of muscle relaxants and celecoxib in early recovery after total knee arthroplasty (TKA). One hundred and fifty patients were randomized 1:1:1 to receive either both of muscle relaxants and celecoxib or muscle relaxants alone or placebo for 2 weeks (50 patients in each group). VAS pain scores as primary efficacy, active range of motion, morphine consumption, blood loss, and postoperative complications including postoperative nausea and vomiting (PONV), extremities myasthenia and deep vein thrombosis (DVT) were determined postoperatively. Group A improved better with reduced VAS pain scores compared with another two groups. These results demonstrated that application of muscle relaxants and celecoxib into patients undergoing TKA for 2 weeks postoperative consequently improved their convalescence.

Efficacy and tolerability of eperisone and baclofen in spastic palsy: a double-blind randomized trial

INTRODUCTION

Few trials have compared different central muscle relaxants in the treatment of spastic palsy. This head-to-head phase 3 trial compares oral eperisone, a central muscle relaxant with a promising activity in spasticity therapy, and oral baclofen.

METHODS

Patients (>18 years) with moderate to severe spastic palsy were eligible in this double-blind, randomized study; they received eperisone 300 mg/ day or baclofen 60 mg/day for 6 weeks. The efficacy evaluations included: functional analysis (Pedersen's scale, muscular tone, joint range of motion, 10-meter walking time); physiological and pathological reflexes; and electromyography (Hmax/Mmax amplitude ratio and the Wartenberg test). Physicians and patients globally assessed treatment efficacy.

RESULTS

Both eperisone (n=40) and baclofen (n=40) significantly improved functionality of lower limbs versus baseline (eperisone: -9.1%, P<0.01; baclofen: -8.3%, P<0.05), but only eperisone improved this parameter in the upper limbs (-7.8%, P<0.01 vs. -6.3%, P=NS). Both drugs reduced muscular tone from week 2. Only eperisone improved the joint range of motion (-32.5%, P<0.01 vs. -14.6%, P=NS). Both treatments reduced the 10-meter walking time (eperisone: -20.2%, P<0.01; baclofen: -24.0%, P<0.01); this effect was evident at week 2 with eperisone only. Both drugs improved reflexes. Eperisone and baclofen decreased the Hmax/Mmax amplitude ratio (eperisone: -30.0%, baclofen: -18.6%; P<0.01 for both). Eperisone increased the number of leg oscillations at the Wartenberg test (P<0.05) while baclofen increased the velocity of leg falling (P<0.01). For tolerability, no differences were observed between eperisone and baclofen in any parameters. Eperisone was judged as "good" by a higher number of physicians and patients than baclofen. Eighteen adverse events, most of mild intensity, were reported with eperisone and 27 with baclofen.

CONCLUSION

Eperisone 300 mg/day and baclofen 60 mg/day, administered orally, are effective and well-tolerated drugs in the treatment of spastic palsy. However, eperisone might be associated with some additional clinical benefits when compared with baclofen.