Gastrointestinal disease associated with nonsteroidal anti-inflammatory drugs: new insights from observational studies and functional status questionnaires

Ginger extract components suppress induction of chemokine expression in human synoviocytes

INTRODUCTION

Ginger has a long history of medicinal use, particularly as an anti-inflammatory agent for a wide variety of diseases such as arthritis. Suppression of inflammation in arthritis is attributed to suppression of proinflammatory cytokines and chemokines produced by synoviocytes, chondrocytes, and leukocytes.

OBJECTIVE

This study aimed to elucidate the effect of a combination ginger extract and its individual components on chemokine expression in human synoviocytes.

METHODS

Human synoviocytes were incubated with 100 microg/mL combination ginger extract (GE) of Alpinia galanga (AG) and Zingiber officinale (ZO); AG extract alone; ZO extract alone; or control media, for 1 hour at 37 degrees C, 5% CO2. Cells were next activated with 1 ng/mL of tumor necrosis factor alpha (TNF-alpha) for 1 hour to determine macrophage chemotactic factor (MCP-1) and interferon-gamma activated protein (IP-10) mRNA levels using reverse transcriptase polymerase chain reaction (RT-PCR). Secreted MCP-1 and IP-10 were quantified by enzyme-linked immunosorbent assay (ELISA) following a 24 hour incubation period.

RESULTS

The GE combination was consistently more effective in decreasing chemokine mRNA and chemokine secreted protein levels than its individual components ZO or AG. In comparison, ZO was more effective than AG in suppressing chemokine expression.

CONCLUSION

The present study demonstrates that GE inhibits chemokine expression, and that the combination of ZO and AG components acts synergistically. This ginger formulation may be useful for suppressing inflammation due to arthritis.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: a randomized controlled trial

CONTENT

The risk for serious gastrointestinal complications due to nonsteroidal anti-inflammatory drugs (NSAIDs) is high in the elderly. Acetaminophen-based regimens are safer and may be as effective as NSAIDs for the treatment of osteoarthritis in many patients.

OBJECTIVE

To determine the effects of an educational program on NSAID use and clinical outcomes in nursing homes.

DESIGN AND SETTING

Randomized controlled study. Ten pairs of Tennessee nursing homes with > or = 8% of residents receiving NSAIDs were randomized to intervention or control.

SUBJECTS

Nursing home residents (intervention n = 76 and control n = 71) aged 65 years and older taking NSAIDs regularly.

INTERVENTIONS

An educational program for physicians and nursing home staff that included the risks and benefits of NSAIDs in the elderly and an algorithm that substituted acetaminophen, topical agents, and nonpharmacologic measures for the treatment of noninflammatory musculoskeletal pain. Intervention and control subjects were assessed at baseline and 3 months later.

MAIN OUTCOME MEASURES

Differences in NSAID and acetaminophen use, and pain, function, and disability scores in intervention and control nursing home subjects.

RESULTS

The intervention was effective resulting in markedly decreased NSAID use and increased acetaminophen use. Mean number of days of NSAID use in the 7 day periods before the baseline and 3 month assessments decreased from 7.0 to 1.9 days in intervention home subjects compared with a decrease from 7.0 to 6.2 days in control homes (P = 0.0001). Acetaminophen use in the 7 days immediately before the 3 month assessment increased by 3.1 days in intervention home subjects compared with 0.31 days in control homes (P = 0.0001). A similar proportion of subjects in control (32.5%) and intervention (35.4%) groups had worsening of their arthritis pain score (P = 0.81).

CONCLUSIONS

An educational intervention effectively reduced NSAID use in nursing homes without worsening of arthritis pain.

Tolerability and efficacy of nabumetone and naproxen in the treatment of rheumatoid arthritis

OBJECTIVE

The purpose of this study was to compare the tolerability and efficacy of nabumetone and naproxen in the treatment of patients with rheumatoid arthritis (RA). The occurrence of gastrointestinal (GI) adverse events was compared.

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) have similar efficacy at equipotent doses, but the therapeutic response to various NSAIDs often differs in individual patients.

METHODS

This was a 3-month, randomized, double-blind, multicenter, parallel-group study conducted in adult patients with RA. The study had 2 phases: a 3- to 14-day washout period and a 12-week treatment period. During the treatment phase, the tolerability and efficacy of nabumetone 2000 mg/d were compared with those of naproxen 1000 mg/d. The change from baseline in efficacy variables, including global assessments, number of tender or swollen joints, and pain, was evaluated. The study was sized to provide an 80% power to detect a 15% difference in the percentage improvement on the physician's global assessment (alpha = 0.05). GI safety was assessed by monitoring the occurrence of clinically important adverse GI events.

RESULTS

A total of 346 RA patients at 31 US rheumatology centers were randomly assigned to treatment (173 patients per group). The study population was predominantly white (87.0%) and female (70.5%), with a mean age of 54 years. Both treatments improved the signs and symptoms of RA, with no statistically significant differences between groups for any efficacy variables. No serious GI adverse events occurred with either NSAID. The most frequent treatment-related adverse events in both groups were predominantly GI in origin, as were those that resulted in withdrawal from the study. Diarrhea with lower abdominal pain was the most common adverse event in the nabumetone group; upper abdominal pain was the most common adverse event in the naproxen group. The only significant difference between the 2 groups was a higher incidence of diarrhea (P < 0.01) in patients receiving nabumetone.

CONCLUSIONS

Nabumetone 2000 mg/d was as effective as naproxen 1000 mg/d in relieving the signs and symptoms of RA. In this study, no serious GI adverse events were observed with either NSAID, but nabumetone was associated with a higher incidence of diarrhea.

Slowing the titration rate of tramadol HCl reduces the incidence of discontinuation due to nausea and/or vomiting: a double-blind randomized trial

BACKGROUND

Ultram [tramadol hydrochloride (HCl)] is a centrally acting analgesic that is widely prescribed for the treatment of moderate to moderately severe chronic pain. Although tramadol is generally well tolerated, some patients discontinue use early in the course of treatment because of nausea and vomiting.

OBJECTIVE

To investigate the effect of three initial titration rates of tramadol HCl on the incidence of discontinuation due to nausea and/or vomiting in patients who previously did not tolerate tramadol HCl.

METHOD

A multicentre, outpatient, randomized double-blind study was conducted, comprised of two phases: a 14-day open-label run-in phase and a 28-day double-blind phase. In the run-in phase the dose of tramadol was titrated over 4 days to the target of 200 mg/day. Patients who discontinued tramadol HCl due to nausea and/or vomiting in the open-label phase were eligible to enter the 28-day double-blind phase after a 10-day wash-out. Patients were randomized to one of three groups using a 10-, 16- or a 13-day titration schedule in order to achieve a target dosage of either 200 mg/day (10- and 16-day titration groups) or 150 mg/day (13-day titration group). The number of discontinuations due to nausea and/or vomiting in each group were compared.

RESULTS

Significantly fewer patients (22%) discontinued because of nausea and/or vomiting in the 13- and 16-day titration groups compared to the 10-day group (P=0.008 and P=0.006, respectively). The time to discontinuation was also significantly delayed in the 13- and 16-day groups compared to the 10-day group (P=0.006 and P=0.007, respectively). The outcome of the 13-day titration to 150 mg/day was essentially the same as that of the 16-day titration to 200 mg/day, suggesting that this is a true rate effect rather than being dose related.

CONCLUSION

This study demonstrated that a slower titration rate of tramadol HCl improves tolerability in patients who previously discontinued therapy due to nausea and/or vomiting. This study also demonstrates that the rate of titration of tramadol HCl rather than the target dose is the major determinant of tolerability.

Slowing the initial titration rate of tramadol improves tolerability

STUDY OBJECTIVES

To examine the effect of three titration schedules on the tolerability of tramadol, and to determine whether slow titration would reduce the frequency of drug discontinuation due to adverse events.

DESIGN

Multicenter, outpatient, double-blind, parallel study.

SETTING

Twenty-eight outpatient study centers.

SUBJECTS

Four hundred sixty-five patients with chronic joint pain Interventions. Patients were randomized into one of four treatment groups for 14 days: placebo, or tramadol dosage titrated at 1, 4, or 10 days to achieve the study target dosage of 200 mg/day. They continued taking their dosage of nonsteroidal antiinflammatory drug during the study. Each group was examined to determine if slower titration resulted in a statistically significant trend toward fewer discontinuations due to nausea and/or vomiting and dizziness and/or vertigo. Discontinuation due to any adverse event was similarly analyzed. If the trend was statistically significant, pairwise comparisons were performed to determine the statistical significance among titration rates.

MEASUREMENTS AND MAIN RESULTS

A statistically significant trend was seen toward fewer discontinuations as a result of nausea/vomiting, dizziness/vertigo, and any adverse event as the titration rate decreased. Patients with 10-day titration rate required the fewest discontinuations, and this rate was statistically significantly different from both the 1- and 4-day rates for discontinuations.

CONCLUSION

A slower rate of initiating tramadol therapy (50-mg increments every 3 days) improved tolerability with significantly fewer discontinuations due to dizziness or vertigo.

Management of pain in patients with multiple health problems: a guide for the practicing physician

Chronic pain is a universal problem that is especially prevalent in the elderly population. Current drug therapy for pain management is limited to acetaminophen, centrally acting analgesics (opioids), and nonsteroidal anti-inflammatory drugs (NSAIDs). Although NSAIDs are the most commonly used drugs for the treatment of chronic pain, their use is associated with a high degree of gastrointestinal (GI) and renal morbidity. Furthermore, practicing physicians are faced with the dual challenge of controlling chronic pain, as well as controlling the side effects of pain medication, in patients with multiple health problems. Polypharmacy and the use of over-the-counter (OTC) medications are important considerations in this cohort of patients. A comprehensive pharmacologic treatment strategy includes NSAIDs and, when NSAIDs are deemed inappropriate, other suitable pain medications.

[Risk of ulcer and its prophylaxis in therapy with non-steroidal antirheumatic drugs]

Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most frequently prescribed drugs in western countries. The high incidence of adverse gastrointestinal effects which are potentially life-threatening require steps for prevention. The use of NSAIDs should be restricted to patients with inflammatory rheumatic diseases. If NSAIDs are indicated it is important to identify patients who are at high risk to develop serious gastrointestinal side effects. These patients should receive Misoprostol at a dose of 2 to 3 x 200 micrograms per day. Up to date Misoprostol is the only drug with proven efficacy with respect to the prevention of gastroduodenal ulcer and its complications. NSAIDs inhibit the key enzyme of prostaglandin synthesis, the cyclooxygenase. Recently published data show that 2 isoenzymes of the cyclooxygenase exists. Cyclooxygenase-1 is primarily involved in the maintenance of organ function whereas cyclooxygenase-2 is expressed in inflamed tissue. Specific cyclooxygease-2 inhibitors have been developed. Clinical trials have to prove if the concept of a selective cyclooxygenase-2 inhibition with high antiinflammatory potency but lack of gastrointestinal side effects holds true in humans.

Meta-analysis of risk factors for peptic ulcer. Nonsteroidal antiinflammatory drugs, Helicobacter pylori, and smoking

Attributable risk models describe the role of three risk factors for peptic ulcer and related serious upper gastrointestinal (GI) events. The factors-nonsteroidal antiinflammatory drugs (NSAIDs), Helicobacter pylori, and cigarette smoking-have been identified as major risk factors for peptic ulcer in numerous clinical and epidemiologic studies. Overall risk ratios for each risk factor were based on meta-analyses of English-language studies of risk for peptic ulcer-related GI events. Exposure estimates for factors used data from North American populations. Summary risk and exposure values were computed for the general population, males and females separately, and the elderly. Hypothetical models of multiple factor attributable risks were developed using population attributable risk percent calculated from these summary values. General population attributable risk percent were as follows: 24%, NSAIDs; 48%, H. pylori; and 23%, cigarette smoking. Based on these numbers, the "no interaction" attributable risk model estimates that 95% of total peptic ulcer related risk is attributable to these factors in the general population. The "interaction" model attributes 89% of cases to these risk factors: 24%, NSAIDs alone; 31%, H. pylori alone; 34%, H. pylori/smoking combined. Between 89% and 95% of peptic ulcer-related serious upper GI events may be attributed to NSAID use, H. pylori infection, and cigarette smoking.

Nonsteroidal anti-inflammatory drug-induced gastrointestinal injury

Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are the most commonly used medications worldwide. They are effective analgesic and anti-inflammatory agents. A major drawback to their use is a high frequency of adverse gastrointestinal (GI) effects that cause significant morbidity, occasional mortality, and substantial increases in cost of therapy. In this review, mechanisms of NSAID-induced GI injury are presented, and a clinical approach to diagnosis, treatment, and prevention of these adverse GI effects is provided.

Adverse Gastrointestinal Effects of Nonsteroidal Anti-Inflammatory Drugs

There are a substantial number of adverse reactions attributable to nonsteroidal anti-inflammatory drug (NSAID) therapy, particularly of the gastrointestinal (GI) tract. The stomach is most commonly affected, although injury may occur from esophagus to colon. The incidence of developing serious GI toxicity seems to be three times as great in users compared with nonusers of NSAIDs. Age greater than 60 years, history of GI problems, previous corticosteroid use, and recency of NSAID use seem to increase the risk of toxicity. Short-term studies have found differences in ulceration or bleeding caused by various NSAIDs. However, there are insufficient long-term clinical trials involving adequate numbers of patients to demonstrate substantial advantages for any particular NSAID based on its toxicity profile. Prostaglandin inhibition seems to be one mechanism responsible for the GI toxicity of NSAIDs, but it is probably not the only mechanism. When serious GI bleeding occurs, the NSAID use must be stopped, although omeprazole and misoprostol have been used successfully to treat gastroduodenal ulcerations in patients while continuing NSAID therapy. Misoprostol and possibly omeprazole have effectively prevented GI ulceration associated with NSAID therapy, but questions remain regarding patient selection, length of therapy, and their utility in preventing serious GI bleeding. At this time, routine prophylaxis for patients receiving long-term NSAID therapy cannot be recommended.

Extra-articular manifestations of rheumatoid arthritis: risk factors for serious gastrointestinal events

OBJECTIVES

Serious upper gastrointestinal events are an important threat to patients with arthritis who are treated with non-steroidal anti-inflammatory drugs (NSAIDs). In this study risk factors for serious upper gastrointestinal events are identified in patients with possible or definite rheumatoid arthritis (RA).

METHODS

A retrospective analysis of factors that might contribute to the risk of serious upper gastrointestinal events was performed in a cohort of 2315 consecutive patients with possible or definite RA. The relative influences of disease severity, drug treatment, particularly with corticosteroids, and history of peptic ulceration were analysed with a conditional logistic regression model for the 106 patients with serious upper gastrointestinal intestinal events and for an equal number of control patients who were matched for age, gender, number of criteria for RA, and disease duration.

RESULTS

The incidence rate for serious upper gastrointestinal events was 4.0/1000 patients in each year. The study reconfirmed that age over 60 years, history of peptic ulceration, and use of corticosteroids are risk factors. The presence of extra-articular manifestations of RA was associated with a two to 11-fold increase in the risk for serious upper gastrointestinal events. This risk was independent of the use of corticosteroids.

CONCLUSION

Disease severity, in particular the presence of extra-articular features, may be an important factor in the pathogenesis of upper gastrointestinal ulceration in patients with RA who are treated with NSAIDs.