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Sarvilina IV, Danilov AB. [Comparative analysis of the use of symptomatic slow acting drugs for osteoarthritis containing chondroitin sulfate or affecting its biosynthesis in patients with non-specific low back pain]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:81-96. [PMID: 36719123 DOI: 10.17116/jnevro202312301181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Retrospective comparative analysis of the use of SYSADOA preparations containing chondroitin sulfate (Chondroguard, 2 ml, 25 amp., glycosaminoglycan-peptide complex, 1 ml 25 amp., bioactive concentrate of small marine fish, 2 ml, 10 amp.) in patients with chronic non-specific low back pain (LBP) of lumbar and sacral localization caused by spondylosis and osteochondrosis of the lumbar spine, at the stage of outpatient care. MATERIAL AND METHODS Data of medical records of patients (n=120; men - 32, women - 88, age - 54.1±7.6 years, duration of disease exacerbation 4.0±1.7 months) with nonspecific LBP were systematized according to the inclusion/exclusion criteria. All patients were divided into 4 groups: Group 1 (n=30) received Chondroguard im., 2 ml every other day, the course of treatment was 25 injections, 25 days; Group 2 (n=30) received glycosaminoglycan-peptide complex on the 1st day - 0.3 ml, on the 2nd day - 0.5 ml, and then 3 times a week for 1 ml, course of treatment - 25 injections, 25 days; Group 3 (n=30) received bioactive concentrate of small marine fish, 2 ml im., every other day, the course of treatment was 10 injections; repeated courses of treatment - after 6 months; Group 4 (n=30) received Amelotex (meloxicam) at a dose of 15 mg once a day for 15 days. All patients of the first 3 groups received Amelotex at a dose of 15 mg with the possibility of reducing the dose to 7.5 mg or completely discontinuing the drug if necessary. Retrospectively, dynamic monitoring was performed in the medical records of outpatients after 50 days and 6 months from the start of therapy according to the following parameters: intensity of pain according to VAS, short form of the McGill pain questionnaire, vital signs of patients (Oswestry Disability Index, version 2.1a [Oswestry Disability Index], and Roland-Morris questionnaire), propensity to chronic pain syndrome according to the STarT Back Screening Tool questionnaire, the presence and severity of comorbid fibromyalgia according to the Fibromyalgia Rapid Screening Tool questionnaire, the level of pain catastrophization according to the Pain Catastrophizing Scale, the severity of comorbid anxiety and depression according to the Hospital Anxiety and Depression Scale, the severity comorbid insomnia (Insomnia Severity Index), quality of life according to the SF-36 scale, the effectiveness of drugs according to the patient on a 5-point scale, the need to take NSAIDs and analgesics, tolerability on a 4-point system. The safety of therapy was monitored using the WHO and Naranjo scales. RESULTS In patients with nonspecific LBP, a greater degree of reduction in the intensity of the pain syndrome, a smaller number of exacerbations of the pain syndrome over 6 months of observation, an improvement in the functional status and life activity, a tendency to a decrease in the severity of anxiety and depression, sleep disturbances and comorbid fibromyalgia, limiting the risk of chronicity and catastrophization of pain, the presence of a structure-modifying effect on IVD and degenerative changes in the facet joints, a significant improvement in the physical and mental components of health, high satisfaction and safety of therapy, which included taking Chondroguard with meloxicam, with a decrease in the need to take the latter by the 50th day observation period compared to other regimens. The effects of Chondroguard and meloxicam turned out to be long-term and were recorded by the 6th month in the absence of Chondroguard, which indicated the preservation of the influence of highly purified cholesterol on the pathogenetic mechanisms of the formation of LBP. CONCLUSION The study allows us to recommend the use of a parenteral form of cholesterol (Chondroguard, CJSC «PharmFirma «Sotex», Russia) for the treatment of nonspecific LBP with moderate or severe pain, chronic relapsing or persistent course, in combination with NSAIDs and their subsequent cancellation or administration on demand.
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Affiliation(s)
- I V Sarvilina
- LLC «Medical Center «Novomedicina», Rostov-on-Don, Russia
| | - A B Danilov
- First Moscow State Medical University named after I.M. Sechenov, Moscow, Russia
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Obeid S, Libby P, Husni E, Wang Q, Wisniewski LM, Davey DA, Wolski KE, Xia F, Bao W, Walker C, Ruschitzka F, Nissen SE, Lüscher TF. Cardiorenal risk of celecoxib compared with naproxen or ibuprofen in arthritis patients: insights from the PRECISION trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:611-621. [PMID: 35234840 DOI: 10.1093/ehjcvp/pvac015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/05/2022] [Accepted: 02/26/2022] [Indexed: 06/14/2023]
Abstract
AIMS Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs, both prescribed and over the counter. The long-term cardiovascular safety of NSAIDs in patients with arthritis has engendered controversy. Concerns remain regarding the relative incidence and severity of adverse cardiorenal effects, particularly in arthritis patients with established cardiovascular (CV) disease or risk factors for disease as illustrated by the PRECISION (Prospective Randomized Evaluation of Celecoxib Integrated Safety vs. Ibuprofen Or Naproxen) trial participants (NCT00346216).We further investigated whether the selective COX-2 Inhibitor celecoxib has a superior cardiorenal safety profile compared with ibuprofen or naproxen in the PRECISION population. METHODS AND RESULTS Twenty-four thousand eighty-one patients who required NSAIDs for osteoarthritis or rheumatoid arthritis (RA) and had increased CV risk randomly received celecoxib, ibuprofen, or naproxen. The current pre-specified secondary analysis assessed the incidence, severity, and NSAID-related risk of the pre-specified composite cardiorenal outcome (adjudicated renal event, hospitalization for congestive heart failure, or hospitalization for hypertension) in the intention-to-treat (ITT) population. An on-treatment analysis assessed safety in those taking the study medication. Following a mean treatment duration of 20.3 ± 16.0 months and a mean follow-up of 34.1 ± 13.4 months, the primary cardiorenal composite outcome occurred in 423 patients (1.76%) in the ITT population. Of these 423 patients, 118 (28%) were in the celecoxib, 166 (39%) in the ibuprofen, and 139 (33%) in the naproxen group. In a multivariable Cox regression model adjusted for independent clinical variables, celecoxib showed a significantly lower risk compared with ibuprofen [hazard ratio (HR) 0.67, confidence interval (CI) 0.53-0.85, P = 0.001) and a trend to lower risk compared with naproxen (HR 0.79, CI 0.61-1.00, P = 0.058). In the ITT analysis, clinically significant renal events occurred in 220 patients with events rates of 0.71%, 1.14%, and 0.89% for celecoxib, ibuprofen, and naproxen, respectively (P = 0.052), while in the on-treatment analysis the rates were 0.52%, 0.91%, and 0.78% (P < 0.001). CONCLUSION In the current era, long-term NSAID use was associated with few cardiorenal events in arthritis patients. At the doses studied, celecoxib displayed fewer renal events and hence more favourable cardiovascular safety compared with ibuprofen or naproxen. These results have considerable clinical implications for practitioners managing individuals with chronic arthritis pain and high risk of impaired renal function and/or heart failure.Clinical Trial Registration: NCT00346216.
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Affiliation(s)
- Slayman Obeid
- University Heart Center, Department of Cardiology, University Hospital, CH-8091 Zurich, Switzerland
| | - Peter Libby
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | | | | - Feng Xia
- Pfizer Inc., New York, NY 10017, USA
| | | | | | - Frank Ruschitzka
- University Heart Center, Department of Cardiology, University Hospital, CH-8091 Zurich, Switzerland
| | | | - Thomas F Lüscher
- Cardiology, Royal Brompton & Harefield Hospitals Trust Imperial College, Sidney Street, SW3 5RN London, UK
- Imperial College, SW3 6LY London, UK
- Center for Molecular Cardiology, University of Zurich, CH-8952 Schlieren, Switzerland
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Sharma A, Mahaffey KW, Gibson CM, Hicks KA, Alexander KP, Ali M, Chaitman BR, Held C, Hlatky M, Jones WIS, Mehran R, Menon V, Rockhold FW, Seltzer J, Spitzer E, Wilson M, Lopes RD. Clinical events classification (CEC) in clinical trials: Report on the current landscape and future directions - proceedings from the CEC Summit 2018. Am Heart J 2022; 246:93-104. [PMID: 34973948 DOI: 10.1016/j.ahj.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/26/2022]
Abstract
IMPORTANCE Clinical events adjudication is pivotal for generating consistent and comparable evidence in clinical trials. The methodology of event adjudication is evolving, but research is needed to develop best practices and spur innovation. OBSERVATIONS A meeting of stakeholders from regulatory agencies, academic and contract research organizations, pharmaceutical and device companies, and clinical trialists convened in Chicago, IL, for Clinical Events Classification (CEC) Summit 2018 to discuss key topics and future directions. Formal studies are lacking on strategies to optimize CEC conduct, improve efficiency, minimize cost, and generally increase the speed and accuracy of the event adjudication process. Major challenges to CEC discussed included ensuring rigorous quality of the process, identifying safety events, standardizing event definitions, using uniform strategies for missing information, facilitating interactions between CEC members and other trial leadership, and determining the CEC's role in pragmatic trials or trials using real-world data. Consensus recommendations from the meeting include the following: (1) ensure an adequate adjudication infrastructure; (2) use negatively adjudicated events to identify important safety events reported only outside the scope of the primary endpoint; (3) conduct further research in the use of artificial intelligence and digital/mobile technologies to streamline adjudication processes; and (4) emphasize the importance of standardizing event definitions and quality metrics of CEC programs. CONCLUSIONS AND RELEVANCE As novel strategies for clinical trials emerge to generate evidence for regulatory approval and to guide clinical practice, a greater understanding of the role of the CEC process will be critical to optimize trial conduct and increase confidence in the data generated.
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Shao L, Wu XD, Huang W. Cardiovascular Safety of Denosumab Across Multiple Indications. J Bone Miner Res 2021; 36:617-618. [PMID: 33095450 DOI: 10.1002/jbmr.4189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/12/2020] [Accepted: 10/03/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Long Shao
- Department of Orthopaedic Surgery, Ningbo No.6 Hospital, Ningbo, China
| | - Xiang-Dong Wu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Bao W, Gaffney M, Pressler ML, Fayyad R, Wisemandle W, Beckerman B, Wolski KE, Nissen SE. Strengthening the interpretability of clinical trial results by assessing the effect of informative censoring on the primary estimand in PRECISION. Clin Trials 2020; 17:535-544. [PMID: 32643966 DOI: 10.1177/1740774520934747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The ICH E9(R1) addendum states that the strategy to account for intercurrent events should be included when defining an estimand, the treatment effect to be estimated based on the study objective. The estimator used to assess the treatment effect needs to be aligned with the estimand that accounted for intercurrent events. Regardless of the strategy, missing data resulting from patient premature withdrawal could undermine the robustness of the study results. Informative censoring due to dropouts in an events-based study is one such example. Sensitivity analyses using imputation methods are useful to examine the uncertainty due to informative censoring and address the robustness and strength of the study results. METHODS We assessed the effect of premature patient withdrawal in the PRECISION study, a randomized non-inferiority clinical trial of patients with chronic arthritic pain that compared the cardiovascular safety of three nonsteroidal anti-inflammatory drugs-based treatment policies or paradigms. The protocol-defined use of concomitant or rescue medications was permitted since changes in pain medications due to insufficient analgesia were expected in patients in this long-term study. Anticipating that premature study discontinuations could potentially lead to informative censoring, a supplementary analysis was pre-specified in which censored outcomes due to the premature study discontinuation were imputed based on adverse events that were clinically associated with the primary endpoint (cardiovascular outcome based on the Antiplatelet Trialists Collaboration composite endpoint). Furthermore, tipping point analyses were conducted to test the robustness of the primary analysis results by assuming data censored not at random. The level of increase at which the primary study conclusion would change was estimated. RESULTS For the analysis of time to first primary endpoint event through 30 months, 4065 out of the 24,081 enrolled patients were lost to follow-up, withdrew consent, or were no longer willing to participate in the study. These withdrawals occurred gradually and resulted in a cumulative total of 5893 censored patient-years of observation (10.2%). The rate of discontinuation and the baseline characteristics of the discontinued patients were similar across the three treatment groups. The non-inferiority conclusion from the primary analysis was confirmed in the supplementary analysis incorporating relevant adverse events. Furthermore, tipping point analyses demonstrated that in order to lose non-inferiority in the primary analysis, the risk of primary endpoint events during the censored observation time would have to increase by more than 2.7-fold in the celecoxib group while remaining constant in the other nonsteroidal anti-inflammatory drugs groups, demonstrating that the scenarios where the study results are invalid appear not plausible. CONCLUSIONS Supplementary and sensitivity analyses presented to address informative censoring in PRECISION helped to further interpret and strengthen the study results.
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Kim S, Lee H, Ko JW, Kim JR. Effects of Celecoxib on the QTc Interval: A Thorough QT/QTc Study. Clin Ther 2019; 41:2204-2218. [PMID: 31564512 DOI: 10.1016/j.clinthera.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/01/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Celecoxib is a selective cyclooxygenase-2 inhibitor widely used in patients with osteoarthritis and rheumatoid arthritis. Recently, nonclinical data on the inhibition of human ether-à-go-go-related gene potassium channels by celecoxib were reported, but there is no compelling evidence for this finding in humans. The aim of this study was to assess the potential effects of celecoxib on cardiac repolarization by conducting a thorough QT study, which was designed in compliance with the related guidelines. METHODS This randomized, open-label, positive- and negative-controlled, crossover clinical study was conducted in healthy male and female subjects. Each subject received, in 1 of 4 randomly assigned sequences, all of the following 3 interventions: celecoxib 400 mg once daily for 6 days; a single dose of moxifloxacin 400 mg, which served as a positive control to assess the assay sensitivity; and water without any drug, which served as a negative control. Serial 12-lead ECG and blood samples for pharmacokinetic analysis were collected periodically over 24 h. Individually RR-corrected QT intervals (QTcI) and Fridericia method-corrected QT intervals (QTcF) were calculated and evaluated. FINDINGS Twenty-eight subjects were allocated to 1 of the 4 intervention sequences. The largest time-matched mean effects of celecoxib on the QTcI and QTcF were <5 ms, and the upper bounds of the 1-sided 95% CIs of those values did not exceed 10 ms. Moreover, none of the subjects had an absolute QTcI value of >450 ms or a change from baseline in QTcI of >60 ms after multiple administrations of celecoxib. The QTcI did not show a positive correlation with celecoxib concentrations in the range up to ~2700 μg/L. The overall effects of moxifloxacin on the QTcI and QTcF were enough to establish assay sensitivity. No serious adverse events were reported, with a total of 11 AEs reported in 8 subjects. IMPLICATIONS Celecoxib caused no clinically relevant increase in the QT/QTc interval at the maximum dose level used in current practice settings. ClinicalTrials.gov identifier: NCT03822520.
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Affiliation(s)
- Seokuee Kim
- Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyeryeon Lee
- Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Seoul, Republic of Korea
| | - Jae-Wook Ko
- Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Seoul, Republic of Korea
| | - Jung-Ryul Kim
- Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Seoul, Republic of Korea; Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea.
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Kiehl EL, Menon V, Mandsager KT, Wolski KE, Wisniewski L, Nissen SE, Lincoff AM, Borer JS, Lüscher TF, Cantillon DJ. Effect of Left Ventricular Conduction Delay on All-Cause and Cardiovascular Mortality (from the PRECISION Trial). Am J Cardiol 2019; 124:1049-1055. [PMID: 31395295 DOI: 10.1016/j.amjcard.2019.06.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 10/26/2022]
Abstract
The prognosis associated with prolonged intraventricular conduction on electrocardiogram (ECG) remains uncertain. We aimed to compare clinical outcomes of narrow versus prolonged intraventricular conduction on ECG stratified by QRS morphology and cardiovascular disease (CVD) status. A post-hoc analysis was performed of the randomized-control PRECISION trial. Patients with centrally adjudicated, nonpaced baseline ECGs were included. QRS duration was classified narrow (≤100 ms) versus prolonged (>100 ms) with additional categorization into left (LBBB) or right (RBBB) bundle branch block or nonspecific intraventricular conduction delay (IVCD). IVCD was subclassified if left ventricular conduction delay (LVCD) was present (L-IVCD) or absent (O-IVCD). The primary outcome was adjudicated all-cause and cardiovascular (CV) mortality. Of 24,081 patients randomized, 22,067 (92%) were included with follow-up 34 ± 13 months. Study patients were 63 ± 9 years, 64% female, 75% Caucasian, 23% with established CVD. The prevalence of QRS prolongation was 5.6% (1,240): 760 right bundle branch block (3.4%), 313 LBBB (1.4%), and 161 IVCD (0.7%), 95 subclassified L-IVCD (0.4%). After adjustment, LBBB and L-IVCD were similarly associated with increased all-cause (LBBB: 2.3 [1.4 to 3.8], p = 0.001; L-IVCD: 4.0 [2.1 to 7.9], p <0.001) and CV (LBBB: 3.6 [2.0 to 6.5], p <0.001; L-IVCD 3.6 [1.3 to 9.7], p = 0.001) mortality. The presence of LVCD (LBBB or L-IVCD) was associated with all-cause (2.8 [1.8 to 4.2], p <0.001) and CV (3.6 [2.2 to 6.1], p <0.001) mortality exceeding the observed risks of coronary artery disease, left ventricular hypertrophy, or diabetes. The LVCD hazard persisted across QRS durations (100 to 120 vs >120 ms) and CVD status. In conclusion, LVCD, whether LBBB or L-IVCD, was strongly associated with increased mortality in patients with and at-risk for CVD.
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Yoon SK, Okyere BA, Strasser D. Polypharmacy and Rational Prescribing: Changing the Culture of Medicine One Patient at a Time. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00220-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Barcella CA, Lamberts M, McGettigan P, Fosbøl EL, Lindhardsen J, Torp‐Pedersen C, Gislason GH, Olsen AS. Differences in cardiovascular safety with non‐steroidal anti‐inflammatory drug therapy—A nationwide study in patients with osteoarthritis. Basic Clin Pharmacol Toxicol 2019; 124:629-641. [DOI: 10.1111/bcpt.13182] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Carlo Alberto Barcella
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Copenhagen Denmark
| | - Morten Lamberts
- Department of Cardiology Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Patricia McGettigan
- William Harvey Research Institute Barts and the London School of Medicine and Dentistry London UK
| | - Emil Loldrup Fosbøl
- William Harvey Research Institute Barts and the London School of Medicine and Dentistry London UK
| | - Jesper Lindhardsen
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Copenhagen Denmark
| | - Christian Torp‐Pedersen
- Department of Health Science and Technology Aalborg University Aalborg Denmark
- Department of Cardiology Aalborg University Hospital Aalborg Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology Copenhagen University Hospital Herlev and Gentofte Copenhagen Denmark
- The Danish Heart Foundation Copenhagen Denmark
- The National Institute of Public Health University of Southern Denmark Odense Denmark
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Istomina EV, Shikhkerimov RK. The possibilities of using chondroitin sulfate in patients with chronic back pain. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:12-15. [DOI: 10.17116/jnevro201911903112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Angeli F, Trapasso M, Signorotti S, Verdecchia P, Reboldi G. Amlodipine and celecoxib for treatment of hypertension and osteoarthritis pain. Expert Rev Clin Pharmacol 2018; 11:1073-1084. [PMID: 30362840 DOI: 10.1080/17512433.2018.1540299] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Osteoarthritis constitutes one of the leading causes of pain and disability worldwide with a significant impact on health-care costs. Patients with osteoarthritis are often affected by a number of cardiovascular comorbidities, including hypertension, which is present in about 40% of cases. Just recently, a single tablet combination of amlodipine besylate, a calcium channel blocker, and celecoxib, a nonsteroidal anti-inflammatory drug, indicated for patients for whom treatment with amlodipine for hypertension and celecoxib for osteoarthritis are appropriate, has been recently approved. Areas covered: We reviewed data from clinical studies that investigated safety and efficacy of the combination of amlodipine and celecoxib in hypertensive patients with osteoarthritis published before 31 August 2018. The literature search was conducted using research Methodology Filters. Expert commentary: The advantages of this single formulation over sequential administration include increased compliance, possibly reduced cost, and less likelihood of dosage-related issues. Moreover, this single tablet formulation combines the anti-inflammatory activity of the celecoxib with the systemic vasodilatation induced by the amlodipine. It is a promising treatment for patients with osteoarthritis and hypertension. Nevertheless, celecoxib may cause a variable degree of blood pressure increase and only a small clinical trial has been conducted before approval to assess interactions related to blood pressure effect between these two molecules.
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Affiliation(s)
- Fabio Angeli
- a Division of Cardiology and Cardiovascular Pathophysiology , Hospital and University of Perugia , Perugia , Italy
| | - Monica Trapasso
- b Department of Medicine , University of Perugia , Perugia , Italy
| | - Sara Signorotti
- b Department of Medicine , University of Perugia , Perugia , Italy
| | - Paolo Verdecchia
- c Fondazione Umbra Cuore e Ipertensione-ONLUS and Department of Cardiology , Perugia , Italy
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Drug partitioning in individual and mixed micelles and interaction with protein upon delivery form micellar media. J Mol Liq 2018. [DOI: 10.1016/j.molliq.2018.05.107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Araújo AC, Wheelock CE, Haeggström JZ. The Eicosanoids, Redox-Regulated Lipid Mediators in Immunometabolic Disorders. Antioxid Redox Signal 2018; 29:275-296. [PMID: 28978222 DOI: 10.1089/ars.2017.7332] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
SIGNIFICANCE The oxidation of arachidonic acid via cyclooxygenase (COX) and lipoxygenase (LOX) activity to produce eicosanoids during inflammation is a well-known biosynthetic pathway. These lipid mediators are involved in fever, pain, and thrombosis and are produced from multiple cells as well as cell/cell interactions, for example, immune cells and epithelial/endothelial cells. Metabolic disorders, including hyperlipidemia, hypertension, and diabetes, are linked with chronic low-grade inflammation, impacting the immune system and promoting a variety of chronic diseases. Recent Advances: Multiple studies have corroborated the important function of eicosanoids and their receptors in (non)-inflammatory cells in immunometabolic disorders (e.g., insulin resistance, obesity, and cardiovascular and nonalcoholic fatty liver diseases). In this context, LOX and COX products are involved in both pro- and anti-inflammatory responses. In addition, recent work has elucidated the potent function of specialized proresolving mediators (i.e., lipoxins and resolvins) in resolving inflammation, protecting organs, and stimulating tissue repair and remodeling. CRITICAL ISSUES Inhibiting/stimulating selected eicosanoid pathways may result in anti-inflammatory and proresolution responses leading to multiple beneficial effects, including the abrogation of reactive oxygen species production, increased speed of resolution, and overall improvement of diseases related to immunometabolic perturbations. FUTURE DIRECTIONS Despite many achievements, it is crucial to understand the molecular and cellular mechanisms underlying immunological/metabolic cross talk to offer substantial therapeutic promise. Antioxid. Redox Signal. 29, 275-296.
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Affiliation(s)
- Ana Carolina Araújo
- Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics, Karolinska Institutet , Stockholm, Sweden
| | - Craig E Wheelock
- Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics, Karolinska Institutet , Stockholm, Sweden
| | - Jesper Z Haeggström
- Division of Physiological Chemistry II, Department of Medical Biochemistry and Biophysics, Karolinska Institutet , Stockholm, Sweden
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Ruschitzka F, Borer JS, Krum H, Flammer AJ, Yeomans ND, Libby P, Lüscher TF, Solomon DH, Husni ME, Graham DY, Davey DA, Wisniewski LM, Menon V, Fayyad R, Beckerman B, Iorga D, Lincoff AM, Nissen SE. Differential blood pressure effects of ibuprofen, naproxen, and celecoxib in patients with arthritis: the PRECISION-ABPM (Prospective Randomized Evaluation of Celecoxib Integrated Safety Versus Ibuprofen or Naproxen Ambulatory Blood Pressure Measurement) Trial. Eur Heart J 2018; 38:3282-3292. [PMID: 29020251 DOI: 10.1093/eurheartj/ehx508] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/21/2017] [Indexed: 12/24/2022] Open
Abstract
Aims Non-steroidal anti-inflammatory drugs (NSAIDs), both non-selective and selective cyclooxygenase-2 (COX-2) inhibitors, are among the most widely prescribed drugs worldwide, but associate with increased blood pressure (BP) and adverse cardiovascular (CV) events. PRECISION-ABPM, a substudy of PRECISION was conducted at 60 sites, to determine BP effects of the selective COX-2 inhibitor celecoxib vs. the non-selective NSAIDs naproxen and ibuprofen. Methods and results In this double-blind, randomized, multicentre non-inferiority CV-safety trial, 444 patients (mean age 62 ± 10 years, 54% female) with osteoarthritis (92%) or rheumatoid arthritis (8%) and evidence of or at increased risk for coronary artery disease received celecoxib (100-200 mg bid), ibuprofen (600-800 mg tid), or naproxen (375-500 mg bid) with matching placebos in a 1: 1: 1 allocation, to assess the effect on 24-h ambulatory BP after 4 months. The change in mean 24-h systolic BP (SBP) in celecoxib, ibuprofen and naproxen-treated patients was -0.3 mmHg [95% confidence interval (CI), -2.25, 1.74], 3.7 (95% CI, 1.72, 5.58) and 1.6 mmHg (95% CI, -0.40, 3.57), respectively. These changes resulted in a difference of - 3.9 mmHg (P = 0.0009) between celecoxib and ibuprofen, of - 1.8 mmHg (P = 0.12) between celecoxib and naproxen, and of - 2.1 mmHg (P = 0.08) between naproxen and ibuprofen. The percentage of patients with normal baseline BP who developed hypertension (mean 24-h SBP ≥ 130 and/or diastolic BP ≥ 80 mmHg) was 23.2% for ibuprofen, 19.0% for naproxen, and 10.3% for celecoxib (odds ratio 0.39, P = 0.004 and odds ratio 0.49, P = 0.03 vs. ibuprofen and naproxen, respectively). Conclusions In PRECISION-ABPM, allocation to the non-selective NSAID ibuprofen, compared with the COX-2 selective inhibitor celecoxib was associated with a significant increase of SBP, and a higher incidence of new-onset hypertension. ClinicalTrials gov number NCT00346216.
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Affiliation(s)
- Frank Ruschitzka
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Jeffrey S Borer
- Cardiovascular Medicine, Schiavone Cardiovascular Translational Research Institute, State University of New York, Downstate College of Medicine, New York, NY, USA
| | | | - Andreas J Flammer
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Neville D Yeomans
- Cardiovascular Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Peter Libby
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas F Lüscher
- Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Daniel H Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Elaine Husni
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - David Y Graham
- Cardiovascular Medicine, Baylor College of Medicine, Veterans Affairs Medical Center, Houston, TX, USA
| | - Deborah A Davey
- Department for Cleveland Clinic, Cleveland Clinic, Cleveland, OH, USA
| | - Lisa M Wisniewski
- Department for Cleveland Clinic, Cleveland Clinic, Cleveland, OH, USA
| | - Venu Menon
- Department for Cleveland Clinic, Cleveland Clinic, Cleveland, OH, USA
| | - Rana Fayyad
- Cardiovascular Medicine, Pfizer, New York, NY, USA
| | | | - Dinu Iorga
- Cardiovascular Medicine, Pfizer, New York, NY, USA
| | - A Michael Lincoff
- Cardiovascular Medicine, Baylor College of Medicine, Veterans Affairs Medical Center, Houston, TX, USA
| | - Steven E Nissen
- Cardiovascular Medicine, Baylor College of Medicine, Veterans Affairs Medical Center, Houston, TX, USA
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15
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Yeomans ND, Graham DY, Husni ME, Solomon DH, Stevens T, Vargo J, Wang Q, Wisniewski LM, Wolski KE, Borer JS, Libby P, Lincoff AM, Lüscher TF, Bao W, Walker C, Nissen SE. Randomised clinical trial: gastrointestinal events in arthritis patients treated with celecoxib, ibuprofen or naproxen in the PRECISION trial. Aliment Pharmacol Ther 2018; 47:1453-1463. [PMID: 29667211 DOI: 10.1111/apt.14610] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/09/2017] [Accepted: 02/21/2018] [Indexed: 12/18/2022]
Abstract
AIM To evaluate GI safety of celecoxib compared with 2 nonselective (ns) NSAIDs, as a secondary objective of a large trial examining multiorgan safety. METHODS This randomised, double-blind controlled trial analysed 24 081 patients. Osteoarthritis or rheumatoid arthritis patients, needing ongoing NSAID treatment, were randomised to receive celecoxib 100-200 mg b.d., ibuprofen 600-800 mg t.d.s. or naproxen 375-500 mg b.d. plus esomeprazole, and low-dose aspirin or corticosteroids if already prescribed. Clinically significant GI events (CSGIE-bleeding, obstruction, perforation events from stomach downwards or symptomatic ulcers) and iron deficiency anaemia (IDA) were adjudicated blindly. RESULTS Mean treatment and follow-up durations were 20.3 and 34.1 months. While on treatment or 30 days after, CSGIE occurred in 0.34%, 0.74% and 0.66% taking celecoxib, ibuprofen and naproxen. Hazard ratios (HR) were 0.43 (95% CI 0.27-0.68, P = 0.0003) celecoxib vs ibuprofen and 0.51 (0.32-0.81, P = 0.004) vs naproxen. There was also less IDA on celecoxib: HR 0.43 (0.27-0.68, P = 0.0003) vs ibuprofen; 0.40 (0.25-0.62, P < 0.0001) vs naproxen. Even taken with low-dose aspirin, fewer CSGIE occurred on celecoxib than ibuprofen (HR 0.52 [0.29-0.94], P = 0.03), and less IDA vs naproxen (0.42 [0.23-0.77, P = 0.005]). Corticosteroid use increased total GI events and CSGIE. H. pylori serological status had no influence. CONCLUSIONS Arthritis patients taking NSAIDs plus esomeprazole have infrequent clinically significant gastrointestinal events. Co-prescribed with esomeprazole, celecoxib has better overall GI safety than ibuprofen or naproxen at these doses, despite treatment with low-dose aspirin or corticosteroids.
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Affiliation(s)
- N D Yeomans
- Department of Medicine, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Western Sydney University, Campbelltown, NSW, Australia
| | - D Y Graham
- Baylor College of Medicine, Veterans Affairs Medical Center, Houston, TX, USA
| | - M E Husni
- Cleveland Clinic, Cleveland, OH, USA
| | - D H Solomon
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - T Stevens
- Cleveland Clinic, Cleveland, OH, USA
| | - J Vargo
- Cleveland Clinic, Cleveland, OH, USA
| | - Q Wang
- Cleveland Clinic, Cleveland, OH, USA
| | | | | | - J S Borer
- Downstate College of Medicine, State University of New York, New York, NY, USA
| | - P Libby
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - T F Lüscher
- Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - W Bao
- Pfizer, New York, NY, USA
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16
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Shelbaya A, Solem CT, Walker C, Wan Y, Johnson C, Cappelleri JC. The economic and clinical burden of early versus late initiation of celecoxib among patients with osteoarthritis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:213-222. [PMID: 29670383 PMCID: PMC5896655 DOI: 10.2147/ceor.s140208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to evaluate the characteristics associated with early versus late initiation of celecoxib treatment after osteoarthritis (OA) diagnosis and whether economic and safety outcomes differ between patients with early versus late initiation of celecoxib. Methods Adults (≥18 years) with a confirmed OA diagnosis (International Classification of Diseases, 9th Edition, Clinical Modifications code: 715.XX), ≥12 months of continuous pre- and post-index enrollment, and ≥1 post-index claim for celecoxib were included from the MarketScan® Commercial Claims and Encounter Database (2009-2013). Index date was defined as initial OA diagnosis. Patients were categorized as initiating celecoxib early (within 6 months of index date) or late (≥6 months after index date). Logistic regressions were used to assess characteristics associated with early versus late celecoxib initiation. Key outcomes included health care resource utilization (HCRU) and costs post-index, and adverse event incidence post-celecoxib initiation. Unadjusted and adjusted comparisons (using generalized linear models with a gamma distribution for costs and Poisson distribution for event and resource utilization) were made between early and late celecoxib initiators. Results Of the 62,434 OA patients identified, 27,402 were early and 35,032 were late initiators. Post-index hospital admissions and length of stay did not differ statistically between early versus late initiators after controlling for pre-index event rates and covariates, but early patients had significantly fewer outpatient (incidence rate ratio [IRR]: 0.96; 95% confidence interval [CI]: 0.95, 0.97) and emergency room visits (IRR: 0.89; 95% CI: 0.84, 0.95). After adjustment for key covariates, early initiators (versus late initiators) had lower all-cause (US$12,909 versus US$13,781, P<0.001) and OA-related (US$4,988 versus US$5,178, P=0.015) costs per person-year. Early initiators had no statistically significant difference in the incidence of post-celecoxib cardiovascular (IRR: 0.92; 95% CI: 0.73, 1.14), gastrointestinal (IRR: 1.25; 95% CI: 0.81, 1.92), or renal (IRR: 1.19; 95% CI: 0.65, 2.18) events, controlling for pre-index event rates and covariates when compared to late initiators. Conclusion In this real-world cohort, patients initiated on celecoxib early (versus late) had significantly lower costs and HCRU; this may warrant consideration when making treatment decisions for OA patients.
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Affiliation(s)
- Ahmed Shelbaya
- Pfizer Inc., New York, NY.,Columbia School of Public Health, New York, NY
| | | | | | - Yin Wan
- Pharmerit International, Bethesda, MD, USA
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17
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Effect of Aspirin Coadministration on the Safety of Celecoxib, Naproxen, or Ibuprofen. J Am Coll Cardiol 2018; 71:1741-1751. [DOI: 10.1016/j.jacc.2018.02.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/06/2018] [Indexed: 11/21/2022]
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18
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Solomon DH, Husni ME, Wolski KE, Wisniewski LM, Borer JS, Graham DY, Libby P, Lincoff AM, Lüscher TF, Menon V, Yeomans ND, Wang Q, Bao W, Berger MF, Nissen SE. Differences in Safety of Nonsteroidal Antiinflammatory Drugs in Patients With Osteoarthritis and Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2018; 70:537-546. [DOI: 10.1002/art.40400] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/12/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel H. Solomon
- Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts
| | | | | | | | - Jeffrey S. Borer
- State University of New York; Downstate College of Medicine; Brooklyn New York
| | - David Y. Graham
- Baylor College of Medicine; Veterans Affairs Medical Center; Houston Texas
| | - Peter Libby
- Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts
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19
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Kamchatnov PR, Chugunov AV, Khanmurzaeva SB. [New possibilities of treatment of low back pain]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:162-167. [PMID: 29377000 DOI: 10.17116/jnevro2017117121162-167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low back pain (LBP) is a syndrome caused by degenerative spine diseases and a common reason for referral for medical care. LBP is mostly often caused by osteoarthritis (OA) that needs long-term treatment with nonsteroidal anti-inflammatory drugs. The treatment is associated with a risk of side-effects. The authors consider the possibility of using slow-acting drugs for symptomatic treatment of OA (SYSADOA) in patients with LBP and present the data on anti-inflammatory effects of chondroitin sulfate on the chondral tissue in OA. The results of the studies on the use of SYSADOA in LBP are analyzed.
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Affiliation(s)
- P R Kamchatnov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Chugunov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S B Khanmurzaeva
- Dagestan State Medical University, Makhachkala, Dagestan, Russia
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20
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Walker C, Biasucci LM. Cardiovascular safety of non-steroidal anti-inflammatory drugs revisited. Postgrad Med 2017; 130:55-71. [DOI: 10.1080/00325481.2018.1412799] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Chris Walker
- Global Product Director, Pfizer, Walton Oaks, UK
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21
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Solomon DH, Husni ME, Libby PA, Yeomans ND, Lincoff AM, Lϋscher TF, Menon V, Brennan DM, Wisniewski LM, Nissen SE, Borer JS. The Risk of Major NSAID Toxicity with Celecoxib, Ibuprofen, or Naproxen: A Secondary Analysis of the PRECISION Trial. Am J Med 2017; 130:1415-1422.e4. [PMID: 28756267 DOI: 10.1016/j.amjmed.2017.06.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND The relative safety of long-term use of nonsteroidal anti-inflammatory drugs is unclear. Patients and providers are interested in an integrated view of risk . We examined the risk of major nonsteroidal anti-inflammatory drug toxicity in the PRECISION trial. METHODS We conducted a post hoc analysis of a double-blind, randomized, controlled, multicenter trial enrolling 24,081 patients with osteoarthritis or rheumatoid arthritis at moderate or high cardiovascular risk. Patients were randomized to receive celecoxib 100 to 200 mg twice daily, ibuprofen 600 to 800 mg thrice daily, or naproxen 375 to 500 mg twice daily. All patients were provided with a proton pump inhibitor. The outcome was major nonsteroidal anti-inflammatory drug toxicity, including time to first occurrence of major adverse cardiovascular events, important gastrointestinal events, renal events, and all-cause mortality. RESULTS During follow-up, 4.1% of subjects sustained any major toxicity in the celecoxib arm, 4.8% in the naproxen arm, and 5.3% in the ibuprofen arm. Analyses adjusted for aspirin use and geographic region found that subjects in the naproxen arm had a 20% (95% CI 4-39) higher risk of major toxicity than celecoxib users and that 38% (95% CI 19-59) higher risk. These risks translate into numbers needed to harm of 135 (95% CI, 72-971) for naproxen and 82 (95% CI, 53-173) for ibuprofen, both compared with celecoxib. CONCLUSIONS Among patients with symptomatic arthritis who had moderate to high risk of cardiovascular events, approximately 1 in 20 experienced a major toxicity over 1 to 2 years. Patients using naproxen or ibuprofen experienced significantly higher risk of major toxicity than those using celecoxib.
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Affiliation(s)
| | | | | | - Neville D Yeomans
- Western Sydney University, Sydney, NSW, Australia; University of Melbourne, Melbourne, Australia
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22
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Grosser T, Theken KN, FitzGerald GA. Cyclooxygenase Inhibition: Pain, Inflammation, and the Cardiovascular System. Clin Pharmacol Ther 2017; 102:611-622. [PMID: 28710775 DOI: 10.1002/cpt.794] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 07/11/2017] [Indexed: 12/26/2022]
Abstract
Inhibitors of the cyclooxygenases (COXs), the nonsteroidal antiinflammatory drugs (NSAIDs), relieve inflammatory pain, but are associated with gastrointestinal and cardiovascular complications. Given the widespread use of NSAIDs, there has been a longstanding interest in optimizing their risk-benefit ratio, for example by reducing their gastrointestinal risk. More recently, the focus has shifted toward the cardiovascular complications of NSAIDs and very large prospective studies have been performed to compare cardiovascular risk across distinct NSAIDs. Surprisingly, much less attention has been paid to the efficacy side of the risk-benefit ratio. There is marked variability in the degree of pain relief by NSAIDs due to the complex interplay of molecular mechanisms contributing to the pain sensation, variability in the disposition of NSAIDs, and imprecision in the quantification of human pain. Here we discuss how NSAIDs relieve pain, how molecular mechanisms relate to clinical efficacy, and how this may inform our interpretation of clinical trials.
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Affiliation(s)
- Tilo Grosser
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine N Theken
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Garret A FitzGerald
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Abstract
Some drugs used to treat noncardiovascular conditions may adversely impact the cardiovascular status of individuals both with and without known cardiovascular disease. When the US Food and Drug Administration judges the potential cardiovascular safety signal to be of sufficient concern, it may require the pharmaceutical manufacturer of the drug in question to conduct a postmarketing (phase 4) randomized controlled trial (RCT). Although historically many phase 4 RCTs focused on efficacy (using a superiority design), contemporary phase 4 RCTs often are focused on safety and use a noninferiority design. The choices made by investigators during the planning stage of a postmarketing phase 4 RCT dedicated to the evaluation of cardiovascular safety can influence the ability to compare the standard and test agents. Multiple factors reflecting the conduct of a phase 4 RCT for a general medical condition may influence interpretation of a cardiovascular safety signal. The higher the rates of failure to adhere to the protocol and dropout from the study, the greater the risk of bias. Trials evaluating the cardiovascular safety of nonsteroidal anti-inflammatory drugs (NSAIDs) when used for arthritis are difficult to conduct and even more challenging to interpret. Concerns include the comparison of drug regimens that do not provide comparable analgesic efficacy and problems with adherence to the protocol and retention in the study. On the basis of phase 4 RCTs of NSAIDs to date, it appears that a comparatively low dose of celecoxib administered to low-risk subjects is associated with approximately the same cardiovascular risk as NSAIDs with less cyclooxygenase-2 inhibitory activity, but at the cost of not controlling arthritic pain as effectively.
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Affiliation(s)
- Elliott M Antman
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA; and Clinical and Translational Science Center, Harvard Medical School, Boston, MA.
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24
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Grosser T, Ricciotti E, FitzGerald GA. The Cardiovascular Pharmacology of Nonsteroidal Anti-Inflammatory Drugs. Trends Pharmacol Sci 2017; 38:733-748. [PMID: 28651847 DOI: 10.1016/j.tips.2017.05.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 12/27/2022]
Abstract
The principal molecular mechanisms underlying the cardiovascular (CV) and renal adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs), such as myocardial infarction and hypertension, are understood in more detail than most side effects of drugs. Less is known, however, about differences in the CV safety profile between chemically distinct NSAIDs and their relative predisposition to complications. In review article, we discuss how heterogeneity in the pharmacokinetics and pharmacodynamics of distinct NSAIDs may be expected to affect their CV risk profile. We consider evidence afforded by studies in model systems, mechanistic clinical trials, a meta-analysis of randomized controlled trials, and two recent large clinical trials, Standard Care vs. Celecoxib Outcome Trial (SCOT) and Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen (PRECISION), designed specifically to compare the CV safety of the cyclooxygenase-2-selective NSAID, celecoxib, with traditional NSAIDs. We conclude that SCOT and PRECISION have apparently not compared equipotent doses and have other limitations that bias them toward underestimation of the relative risk of celecoxib.
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Affiliation(s)
- Tilo Grosser
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emanuela Ricciotti
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Garret A FitzGerald
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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25
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Affiliation(s)
- Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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26
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Alvarez PA, Nguyen DT, Schutt R, Ganduglia C, Estep JD, Graviss EA, Putney D. In-hospital use of non-steroidal anti-inflammatory drugs in patients with heart failure in academic centers in the United States. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2017; 28:181-188. [DOI: 10.3233/jrs-170736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paulino A. Alvarez
- Department of Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Duc T. Nguyen
- Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Robert Schutt
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jerry D. Estep
- Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA
| | | | - David Putney
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
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Gordo AC, Walker C, Armada B, Zhou D. Efficacy of celecoxib versus ibuprofen for the treatment of patients with osteoarthritis of the knee: A randomized double-blind, non-inferiority trial. J Int Med Res 2017; 45:59-74. [PMID: 28222627 PMCID: PMC5536610 DOI: 10.1177/0300060516673707] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective To compare the efficacy and tolerability of celecoxib and ibuprofen for the treatment of knee osteoarthritis symptoms. Method In this 6-week, multicentre, double-blind, non-inferiority trial, patients were randomized to 200 mg celecoxib once daily, 800 mg ibuprofen three times daily or placebo. The primary outcome was non-inferiority of celecoxib to ibuprofen in Patient’s Assessment of Arthritis Pain (scored 0–100). Secondary outcomes included the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, Pain Satisfaction Scale, and upper gastrointestinal tolerability. Results A total of 388 patients were treated (celecoxib n = 153; ibuprofen n = 156; placebo n = 79). Mean difference (95% confidence interval) between celecoxib and ibuprofen in the Patient’s Assessment of Arthritis Pain was 2.76 (−3.38, 8.90). As the lower bound was greater than −10, celecoxib was non-inferior to ibuprofen. The WOMAC total score was significantly improved with celecoxib and ibuprofen, versus placebo. Patients receiving celecoxib were significantly more satisfied (versus placebo) in 10 of 11 measures on the Pain Satisfaction Scale versus three measures with ibuprofen. Upper gastrointestinal events were less frequent with celecoxib (1.3%) than ibuprofen (5.1%) or placebo (2.5%). Conclusion Celecoxib was well tolerated and as effective as ibuprofen for symptoms associated with knee osteoarthritis. ClinicalTrials.gov identifier NCT00630929
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Affiliation(s)
| | | | - Beatriz Armada
- 3 Medical Department, Pfizer SLU, Alcobendas, Madrid, Spain
| | - Duo Zhou
- 4 Pfizer Inc., New York, NY, USA
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28
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Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME, Graham DY, Borer JS, Wisniewski LM, Wolski KE, Wang Q, Menon V, Ruschitzka F, Gaffney M, Beckerman B, Berger MF, Bao W, Lincoff AM. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. N Engl J Med 2016; 375:2519-29. [PMID: 27959716 DOI: 10.1056/nejmoa1611593] [Citation(s) in RCA: 466] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The cardiovascular safety of celecoxib, as compared with nonselective nonsteroidal antiinflammatory drugs (NSAIDs), remains uncertain. METHODS Patients who required NSAIDs for osteoarthritis or rheumatoid arthritis and were at increased cardiovascular risk were randomly assigned to receive celecoxib, ibuprofen, or naproxen. The goal of the trial was to assess the noninferiority of celecoxib with regard to the primary composite outcome of cardiovascular death (including hemorrhagic death), nonfatal myocardial infarction, or nonfatal stroke. Noninferiority required a hazard ratio of 1.12 or lower, as well as an upper 97.5% confidence limit of 1.33 or lower in the intention-to-treat population and of 1.40 or lower in the on-treatment population. Gastrointestinal and renal outcomes were also adjudicated. RESULTS A total of 24,081 patients were randomly assigned to the celecoxib group (mean [±SD] daily dose, 209±37 mg), the naproxen group (852±103 mg), or the ibuprofen group (2045±246 mg) for a mean treatment duration of 20.3±16.0 months and a mean follow-up period of 34.1±13.4 months. During the trial, 68.8% of the patients stopped taking the study drug, and 27.4% of the patients discontinued follow-up. In the intention-to-treat analyses, a primary outcome event occurred in 188 patients in the celecoxib group (2.3%), 201 patients in the naproxen group (2.5%), and 218 patients in the ibuprofen group (2.7%) (hazard ratio for celecoxib vs. naproxen, 0.93; 95% confidence interval [CI], 0.76 to 1.13; hazard ratio for celecoxib vs. ibuprofen, 0.85; 95% CI, 0.70 to 1.04; P<0.001 for noninferiority in both comparisons). In the on-treatment analysis, a primary outcome event occurred in 134 patients in the celecoxib group (1.7%), 144 patients in the naproxen group (1.8%), and 155 patients in the ibuprofen group (1.9%) (hazard ratio for celecoxib vs. naproxen, 0.90; 95% CI, 0.71 to 1.15; hazard ratio for celecoxib vs. ibuprofen, 0.81; 95% CI, 0.65 to 1.02; P<0.001 for noninferiority in both comparisons). The risk of gastrointestinal events was significantly lower with celecoxib than with naproxen (P=0.01) or ibuprofen (P=0.002); the risk of renal events was significantly lower with celecoxib than with ibuprofen (P=0.004) but was not significantly lower with celecoxib than with naproxen (P=0.19). CONCLUSIONS At moderate doses, celecoxib was found to be noninferior to ibuprofen or naproxen with regard to cardiovascular safety. (Funded by Pfizer; ClinicalTrials.gov number, NCT00346216 .).
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Affiliation(s)
- Steven E Nissen
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Neville D Yeomans
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Daniel H Solomon
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Thomas F Lüscher
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Peter Libby
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - M Elaine Husni
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - David Y Graham
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Jeffrey S Borer
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Lisa M Wisniewski
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Katherine E Wolski
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Qiuqing Wang
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Venu Menon
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Frank Ruschitzka
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Michael Gaffney
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Bruce Beckerman
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Manuela F Berger
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - Weihang Bao
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
| | - A Michael Lincoff
- From the Cleveland Clinic, Cleveland (S.E.N., M.E.H., L.M.W., K.E.W., Q.W., V.M., A.M.L.); Western Sydney University, Campbelltown, NSW, Australia (N.D.Y.); Brigham and Women's Hospital, Harvard Medical School, Boston (D.H.S., P.L.); University Hospital Zurich, Zurich, Switzerland (T.F.L., F.R.); Baylor College of Medicine, Veterans Affairs Medical Center, Houston (D.Y.G.); and State University of New York, Downstate Health Sciences Center (J.S.B.) and Pfizer (M.G., B.B., M.F.B., W.B.), New York
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Amaki M, Konagai N, Fujino M, Kawakami S, Nakao K, Hasegawa T, Sugano Y, Tahara Y, Yasuda S. Report of the American Heart Association (AHA) Scientific Sessions 2016, New Orleans. Circ J 2016; 81:22-27. [PMID: 27941303 DOI: 10.1253/circj.cj-16-1222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The American Heart Association (AHA) Scientific Sessions 2016 were held on November 12-16 at the Ernest N. Morial Convention Center, New Orleans, LA. This 5-day event featured cardiovascular clinical practice covering all aspects of basic, clinical, population, and translational content. One of the hot topics at AHA 2016 was precision medicine. The key presentations and highlights from the AHA Scientific Sessions 2016, including "precision medicine" as one of the hot topics, are herein reported.
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Affiliation(s)
- Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Affiliation(s)
- Garret A FitzGerald
- From Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
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Patrono C. Cardiovascular effects of cyclooxygenase-2 inhibitors: a mechanistic and clinical perspective. Br J Clin Pharmacol 2016; 82:957-64. [PMID: 27317138 PMCID: PMC5137820 DOI: 10.1111/bcp.13048] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/26/2016] [Accepted: 06/05/2016] [Indexed: 12/14/2022] Open
Abstract
LINKED ARTICLES This article is part of a joint Themed section with the British Journal of Pharmacology on Targeting Inflammation to Reduce Cardiovascular Disease Risk: a Realistic Clinical Prospect? The rest of the Themed section will appear in a future issue of BJP and will be available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1476-5381 Prostaglandin (PG) H synthase 2 [also referred to colloquially as cyclooxygenase (COX) 2] represents a key enzyme in arachidonic acid metabolism in health and disease. It is both constitutively expressed in several human tissues (e.g. kidney and brain) and induced in various cell types (including monocytes/macrophages, vascular endothelial cells and colorectal cancer cells) in response to inflammatory cytokines, laminar shear stress and growth factors. Products of COX-2 activity (e.g. PGE2 and prostacyclin) are involved in diverse physiological and pathophysiological processes, including renal haemodynamics and the control of blood pressure, endothelial thromboresistance, pain and inflammation, and colorectal tumorigenesis. Therefore, it is not surprising that COX-2 inhibitors display multifaceted clinical effects, ranging from reduced pain and inflammation to increased blood pressure, an increased risk of atherothrombotic events and a decreased risk of colorectal cancer. The aim of the present article was to review the cardiovascular effects of COX-2 inhibitors [traditional nonsteroidal anti-inflammatory drugs (tNSAIDs) and coxibs alike], with a focus on the mechanisms contributing to the clinical readouts of COX-2 inhibition.
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Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy.
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Twarock S, Bagheri S, Bagheri S, Hohlfeld T. Platelet-vessel wall interactions and drug effects. Pharmacol Ther 2016; 167:74-84. [PMID: 27492900 DOI: 10.1016/j.pharmthera.2016.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/16/2016] [Indexed: 01/07/2023]
Affiliation(s)
- Sören Twarock
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Saghar Bagheri
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Sayeh Bagheri
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Thomas Hohlfeld
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.
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Gaffney M. Statistical issues in the design, conduct and analysis of two large safety studies. Clin Trials 2016; 13:513-8. [PMID: 27365014 DOI: 10.1177/1740774516657336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/AIMS The emergence, post approval, of serious medical events, which may be associated with the use of a particular drug or class of drugs, is an important public health and regulatory issue. The best method to address this issue is through a large, rigorously designed safety study. Therefore, it is important to elucidate the statistical issues involved in these large safety studies. METHODS Two such studies are PRECISION and EAGLES. PRECISION is the primary focus of this article. PRECISION is a non-inferiority design with a clinically relevant non-inferiority margin. Statistical issues in the design, conduct and analysis of PRECISION are discussed. RESULTS Quantitative and clinical aspects of the selection of the composite primary endpoint, the determination and role of the non-inferiority margin in a large safety study and the intent-to-treat and modified intent-to-treat analyses in a non-inferiority safety study are shown. Protocol changes that were necessary during the conduct of PRECISION are discussed from a statistical perspective. Issues regarding the complex analysis and interpretation of the results of PRECISION are outlined. EAGLES is presented as a large, rigorously designed safety study when a non-inferiority margin was not able to be determined by a strong clinical/scientific method. In general, when a non-inferiority margin is not able to be determined, the width of the 95% confidence interval is a way to size the study and to assess the cost-benefit of relative trial size. CONCLUSION A non-inferiority margin, when able to be determined by a strong scientific method, should be included in a large safety study. Although these studies could not be called "pragmatic," they are examples of best real-world designs to address safety and regulatory concerns.
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The Coxib case: Are EP receptors really guilty? Atherosclerosis 2016; 249:164-73. [DOI: 10.1016/j.atherosclerosis.2016.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/21/2016] [Accepted: 04/05/2016] [Indexed: 01/08/2023]
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Boulakh L, Gislason GH. Treatment with non-steroidal anti-inflammatory drugs in patients after myocardial infarction - a systematic review. Expert Opin Pharmacother 2016; 17:1387-94. [PMID: 27148768 DOI: 10.1080/14656566.2016.1186648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Studies over the past decade have shown that NSAIDs are associated with increased cardiovascular risk and may predispose to myocardial infarction in healthy individuals. Despite this knowledge patients with established cardiovascular disease are frequently treated with NSAIDs. The benefits versus potential harm of treatment need careful assessment. AREAS COVERED Observational studies and clinical trials providing information about outcome of NSAID treatment in post MI patients were retrieved; fourteen articles in total: two case-control studies, two randomized double-blind trials and ten cohort studies. The studies had a follow-up time between 30 days and 15 years. Two studies reported of risk of atrial fibrillation, and only one addressed antithrombotic treatment. EXPERT OPINION The risk of death and reinfarction in this group of patients is well established. Further studies are needed to investigate factors increasing the risk of atrial fibrillation. The correlation between recommended pharmaceutical treatment post MI and NSAIDs needs to be further examined. None of the studies examined correlated their results to dosages available over the counter.
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Affiliation(s)
- Lena Boulakh
- a Department of Cardiology , Herlev and Gentofte Hospital, University of Copenhagen , Hellerup , Denmark
| | - Gunnar H Gislason
- a Department of Cardiology , Herlev and Gentofte Hospital, University of Copenhagen , Hellerup , Denmark.,b The Danish Heart Foundation , Copenhagen , Denmark.,c The National Institute of Public Health , University of Southern Denmark , Copenhagen , Denmark
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Papageorgiou N, Zacharia E, Briasoulis A, Charakida M, Tousoulis D. Celecoxib for the treatment of atherosclerosis. Expert Opin Investig Drugs 2016; 25:619-33. [DOI: 10.1517/13543784.2016.1161756] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lindhardsen J, Kristensen SL, Ahlehoff O. Management of Cardiovascular Risk in Patients with Chronic Inflammatory Diseases: Current Evidence and Future Perspectives. Am J Cardiovasc Drugs 2016; 16:1-8. [PMID: 26293235 DOI: 10.1007/s40256-015-0141-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An increased risk of cardiovascular disease (CVD) has been observed in a range of chronic inflammatory diseases (CID), including rheumatoid arthritis (RA), psoriasis, inflammatory bowel diseases (IBD), and systemic lupus erythematosus (SLE). The increased risk of CVDs and reduced life expectancy in these conditions has stimulated considerable research and started an ongoing discussion on the need for a multidisciplinary approach and dedicated guidelines on CVD prevention in these patients. In addition, the possibility of inhibiting inflammation as a means to preventing CVD in these patients has gained considerable interest in recent years. We briefly summarize the current level of evidence of the association between CIDs and CVD and cardiovascular risk management recommendations. Perspectives of ongoing and planned trials are discussed in consideration of potential ways to improve primary and secondary CVD prevention in patients with CID.
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Affiliation(s)
- Jesper Lindhardsen
- Department of Internal Medicine, Copenhagen University Hospital Slagelse, 4200, Slagelse, Denmark
| | - Søren Lund Kristensen
- Department of Cardiology, Copenhagen University Hospital Gentofte, 2900, Hellerup, Denmark
| | - Ole Ahlehoff
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 7, 2100, Copenhagen, Denmark.
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Ghosh R, Alajbegovic A, Gomes AV. NSAIDs and Cardiovascular Diseases: Role of Reactive Oxygen Species. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2015; 2015:536962. [PMID: 26457127 PMCID: PMC4592725 DOI: 10.1155/2015/536962] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/03/2015] [Accepted: 03/03/2015] [Indexed: 12/24/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs worldwide. NSAIDs are used for a variety of conditions including pain, rheumatoid arthritis, and musculoskeletal disorders. The beneficial effects of NSAIDs in reducing or relieving pain are well established, and other benefits such as reducing inflammation and anticancer effects are also documented. The undesirable side effects of NSAIDs include ulcers, internal bleeding, kidney failure, and increased risk of heart attack and stroke. Some of these side effects may be due to the oxidative stress induced by NSAIDs in different tissues. NSAIDs have been shown to induce reactive oxygen species (ROS) in different cell types including cardiac and cardiovascular related cells. Increases in ROS result in increased levels of oxidized proteins which alters key intracellular signaling pathways. One of these key pathways is apoptosis which causes cell death when significantly activated. This review discusses the relationship between NSAIDs and cardiovascular diseases (CVD) and the role of NSAID-induced ROS in CVD.
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Affiliation(s)
- Rajeshwary Ghosh
- Department of Neurobiology, Physiology, and Behavior, University of California, Davis, CA 95616, USA
| | - Azra Alajbegovic
- Department of Neurobiology, Physiology, and Behavior, University of California, Davis, CA 95616, USA
| | - Aldrin V. Gomes
- Department of Neurobiology, Physiology, and Behavior, University of California, Davis, CA 95616, USA
- Department of Physiology and Membrane Biology, University of California, Davis, CA 95616, USA
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Abstract
In February 2014, the US Food and Drug Administration (FDA) convened an advisory committee meeting to discuss the accumulated data relating to the cardiovascular risk of non-steroidal anti-inflammatory drugs (NSAIDs) and the potential implications on the class prescription labeling. The committee recommended, though not unanimously, that (1) the current data does not support the conclusion that naproxen has a lower risk of thrombotic events than other NSAIDs; (2) there is no latency period for the risk of cardiovascular thrombotic events; (3) there are some patient populations at increased risk for events; and (4) equipoise remains in the major ongoing trial designed to address these issues further. The clinical implications of the FDA deliberations as well as the recently published meta-analyses and observational studies are discussed. With the information available today, there is insufficient evidence to conclude that there are significant differences between the approved NSAIDs with regard to the potential for cardiovascular events. An approach for balancing the major risks associated with NSAIDs is suggested. Clinicians should continue to use the current FDA NSAID labeling language to guide their decision making for individual patients until such time as the FDA makes changes.
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Danelich IM, Wright SS, Lose JM, Tefft BJ, Cicci JD, Reed BN. Safety of Nonsteroidal Antiinflammatory Drugs in Patients with Cardiovascular Disease. Pharmacotherapy 2015; 35:520-35. [DOI: 10.1002/phar.1584] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | | | - Jonathan D. Cicci
- Department of Pharmacy; University of North Carolina Hospitals; Chapel Hill North Carolina
| | - Brent N. Reed
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
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Sager PT, Seltzer J, Turner JR, Anderson JL, Hiatt WR, Kowey P, Prochaska JJ, Stockbridge N, White WB. Cardiovascular Safety Outcome Trials: A meeting report from the Cardiac Safety Research Consortium. Am Heart J 2015; 169:486-95. [PMID: 25819855 DOI: 10.1016/j.ahj.2015.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/13/2015] [Indexed: 01/21/2023]
Abstract
This White Paper provides a summary of presentations and discussions at a Cardiovascular Safety Outcome Trials Think Tank cosponsored by the Cardiac Safety Research Consortium, the US Food and Drug Administration, and the American College of Cardiology, held at American College of Cardiology's Heart House, Washington, DC, on February 19, 2014. Studies to assess cardiovascular (CV) risk of a new drug are sometimes requested by regulators to resolve ambiguous safety signals seen during its development or among other members of its class. Think Tank participants thought that important considerations in undertaking such studies were as follows: (1) plausibility-how likely it is that a possible signal indicating risk is real, based on strength of evidence, and/or whether a plausible mechanism of action for potential CV harm has been identified; (2) relevance-what relative and absolute CV risk would need to be excluded to determine that the drug had an acceptable benefit-to-risk balance for its use in the intended patient population; and (3) how plausibility and relevance influence the timing and approach to further safety assessment.
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Affiliation(s)
| | | | | | | | - William R Hiatt
- Division of Cardiology/CPC Clinical Research, University of Colorado School of Medicine, Aurora, CO
| | | | | | | | - William B White
- Cardiology Center, University of Connecticut School of Medicine, Farmington, CT.
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Yeomans ND. Consensus about managing gastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugs? BMC Med 2015; 13:56. [PMID: 25858463 PMCID: PMC4365530 DOI: 10.1186/s12916-015-0291-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
In a recently published article in BMC Medicine, Scarpignato and colleagues present the results of a consensus conference that addressed several aspects of the management of pain in patients with osteoarthritis. The main areas covered include the relative safety in regard to gastrointestinal and cardiovascular adverse events of non-selective 'traditional' non-steroidal anti-inflammatory drugs (NSAIDs) versus cyclooxygenase-2 selective NSAIDs. The role of co-therapy with proton pump inhibitors in enhancing gastrointestinal safety is also reviewed. This commentary focuses on two areas that the consensus conference addressed, i) the whole length of gastrointestinal tract risk profile of the various NSAIDs (not just the ulcer risks in stomach and duodenum); ii) more recent information, but still some uncertainties, about the cardiovascular risks associated with the two classes of NSAID in general, and naproxen in particular. Please see related article: http://dx.doi.org/10.1186/s12916-015-0285-8.
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Scarpignato C, Lanas A, Blandizzi C, Lems WF, Hermann M, Hunt RH. Safe prescribing of non-steroidal anti-inflammatory drugs in patients with osteoarthritis--an expert consensus addressing benefits as well as gastrointestinal and cardiovascular risks. BMC Med 2015; 13:55. [PMID: 25857826 PMCID: PMC4365808 DOI: 10.1186/s12916-015-0285-8] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 01/29/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There are several guidelines addressing the issues around the use of NSAIDs. However, none has specifically addressed the upper versus lower gastrointestinal (GI) risk of COX-2 selective and non-selective compounds nor the interaction at both the GI and cardiovascular (CV) level of either class of drugs with low-dose aspirin. This Consensus paper aims to develop statements and guidance devoted to these specific issues through a review of current evidence by a multidisciplinary group of experts. METHODS A modified Delphi consensus process was adopted to determine the level of agreement with each statement and to determine the level of agreement with the strength of evidence to be assigned to the statement. RESULTS For patients with both low GI and CV risks, any non-selective NSAID (ns-NSAID) alone may be acceptable. For those with low GI and high CV risk, naproxen may be preferred because of its potential lower CV risk compared with other ns-NSAIDs or COX-2 selective inhibitors, but celecoxib at the lowest approved dose (200 mg once daily) may be acceptable. In patients with high GI risk, if CV risk is low, a COX-2 selective inhibitor alone or ns-NSAID with a proton pump inhibitor appears to offer similar protection from upper GI events. However, only celecoxib will reduce mucosal harm throughout the entire GI tract. When both GI and CV risks are high, the optimal strategy is to avoid NSAID therapy, if at all possible. CONCLUSIONS Time is now ripe for offering patients with osteoarthritis the safest and most cost-effective therapeutic option, thus preventing serious adverse events which could have important quality of life and resource use implications. Please see related article: http://dx.doi.org/10.1186/s12916-015-0291-x.
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Affiliation(s)
- Carmelo Scarpignato
- grid.10383.390000000417580937Department of Clinical & Experimental Medicine, Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125 Parma, Italy
| | - Angel Lanas
- grid.11205.370000000121528769Service of Digestive Diseases, Clinic Hospital Lozano Blesa, Aragón Institute for Health Research (IIS Aragón), CIBERehd, University of Zaragoza, Zaragoza, Spain
| | - Corrado Blandizzi
- grid.5395.a0000000417573729Department of Clinical & Experimental Medicine, Division of Pharmacology & Chemotherapy, University of Pisa, Pisa, Italy
| | - Willem F Lems
- grid.16872.3a000000040435165XDepartment of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Matthias Hermann
- grid.412004.30000000404789977Department of Cardiology, University Hospital, Zurich, Switzerland
| | - Richard H Hunt
- grid.25073.330000000419368227Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON Canada
| | - For the International NSAID Consensus Group
- grid.10383.390000000417580937Department of Clinical & Experimental Medicine, Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125 Parma, Italy
- grid.11205.370000000121528769Service of Digestive Diseases, Clinic Hospital Lozano Blesa, Aragón Institute for Health Research (IIS Aragón), CIBERehd, University of Zaragoza, Zaragoza, Spain
- grid.5395.a0000000417573729Department of Clinical & Experimental Medicine, Division of Pharmacology & Chemotherapy, University of Pisa, Pisa, Italy
- grid.16872.3a000000040435165XDepartment of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
- grid.412004.30000000404789977Department of Cardiology, University Hospital, Zurich, Switzerland
- grid.25073.330000000419368227Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON Canada
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Roth SH, Fuller P. Diclofenac Sodium Topical Solution 1.5% w/w with Dimethyl Sulfoxide Compared with Placebo for the Treatment of Osteoarthritis: Pooled Safety Results. Postgrad Med 2015; 123:180-8. [DOI: 10.3810/pgm.2011.11.2507] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Anwar A, Anwar IJ, Delafontaine P. Elevation of cardiovascular risk by non-steroidal anti-inflammatory drugs. Trends Cardiovasc Med 2015; 25:726-35. [PMID: 25956433 DOI: 10.1016/j.tcm.2015.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 02/13/2015] [Accepted: 03/06/2015] [Indexed: 12/27/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most frequently used medications. NSAIDs profoundly modify prostaglandin homeostasis through inhibition of the enzyme, cyclooxygenase (COX), especially COX-2. COX-2 inhibition is associated with adverse cardiovascular outcomes as demonstrated by recent trials using this type of drug. This review explores the latest available data, including recent, randomized, clinical trials, controversies, and pathophysiology of the adverse effects of COX-inhibition.
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Affiliation(s)
- Asif Anwar
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA.
| | - Imran John Anwar
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA
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Mason JC, Libby P. Cardiovascular disease in patients with chronic inflammation: mechanisms underlying premature cardiovascular events in rheumatologic conditions. Eur Heart J 2015; 36:482-9c. [PMID: 25433021 PMCID: PMC4340364 DOI: 10.1093/eurheartj/ehu403] [Citation(s) in RCA: 262] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A variety of systemic inflammatory rheumatic diseases associate with an increased risk of atherosclerotic events and premature cardiovascular (CV) disease. Although this recognition has stimulated intense basic science and clinical research, the precise nature of the relationship between local and systemic inflammation, their interactions with traditional CV risk factors, and their role in accelerating atherogenesis remains unresolved. The individual rheumatic diseases have both shared and unique attributes that might impact CV events. Understanding of the positive and negative influences of individual anti-inflammatory therapies remains rudimentary. Clinicians need to adopt an evidence-based approach to develop diagnostic techniques to identify those rheumatologic patients most at risk of CV disease and to develop effective treatment protocols. Development of optimal preventative and disease-modifying approaches for atherosclerosis in these patients will require close collaboration between basic scientists, CV specialists, and rheumatologists. This interface presents a complex, important, and exciting challenge.
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Affiliation(s)
- Justin C Mason
- Vascular Sciences Unit and Rheumatology Section, Imperial Centre for Translational and Experimental Medicine, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Peter Libby
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Differential impairment of aspirin-dependent platelet cyclooxygenase acetylation by nonsteroidal antiinflammatory drugs. Proc Natl Acad Sci U S A 2014; 111:16830-5. [PMID: 25385584 DOI: 10.1073/pnas.1406997111] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The cardiovascular safety of nonsteroidal antiinflammatory drugs (NSAIDs) may be influenced by interactions with antiplatelet doses of aspirin. We sought to quantitate precisely the propensity of commonly consumed NSAIDs—ibuprofen, naproxen, and celecoxib—to cause a drug-drug interaction with aspirin in vivo by measuring the target engagement of aspirin directly by MS. We developed a novel assay of cyclooxygenase-1 (COX-1) acetylation in platelets isolated from volunteers who were administered aspirin and used conventional and microfluidic assays to evaluate platelet function. Although ibuprofen, naproxen, and celecoxib all had the potential to compete with the access of aspirin to the substrate binding channel of COX-1 in vitro, exposure of volunteers to a single therapeutic dose of each NSAID followed by 325 mg aspirin revealed a potent drug-drug interaction between ibuprofen and aspirin and between naproxen and aspirin but not between celecoxib and aspirin. The imprecision of estimates of aspirin consumption and the differential impact on the ability of aspirin to inactivate platelet COX-1 will confound head-to-head comparisons of distinct NSAIDs in ongoing clinical studies designed to measure their cardiovascular risk.
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Fabule J, Adebajo A. Comparative evaluation of cardiovascular outcomes in patients with osteoarthritis and rheumatoid arthritis on recommended doses of nonsteroidal anti-inflammatory drugs. Ther Adv Musculoskelet Dis 2014; 6:111-30. [PMID: 25342992 DOI: 10.1177/1759720x14541668] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AIMS AND OBJECTIVES We conducted an analysis to explore whether the cardiovascular outcomes associated with nonsteroidal anti-inflammatory drugs (NSAIDs), when used in licensed doses by patients with osteoarthritis or rheumatoid arthritis, was class or compound dependent. METHODS Using the Ovid technology search engine, we conducted a search of the literature for relevant studies published between 1995 and 2011. We also retrieved further studies following manual searches. The primary endpoint was major vascular events and the secondary endpoints were stroke, hypertension and congestive heart failure. A total of 19 studies were analysed. Studies conducted in the osteoarthritis and rheumatoid arthritis patients' population that reported on cardiovascular events were included in the analysis. The analysis was conducted using the software Review Manager 5.1 and Cochrane methodology. RESULTS Using the primary endpoint of major vascular events (MVE) and a prespecified cutoff point of 1.30, diclofenac (versus 1 comparator) and rofecoxib (versus 2 comparators) had increased risk for MVE [odds ratio (OR) >1.30]. Using the same criteria, diclofenac (versus 1 comparator) had an increased risk of myocardial infarction (MI). Although celecoxib had a slightly increased risk for MI (OR 1.33, versus 1 comparator), the confidence interval included 1 and was not significant. For the secondary endpoints, etoricoxib and rofecoxib were significantly worse off for HT (versus 1 comparator each) and naproxen was significantly worse off for stroke (versus 1 comparator). Although ibuprofen was worse off for HT (versus 1 comparator) the increased risk was not significant. CONCLUSION From the analysis conducted, it appears that the risk for cardiovascular events in arthritis patients on licensed doses of NSAIDs varies considerably and is likely to depend on the individual compound.
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Affiliation(s)
- John Fabule
- Astrazeneca - Global Medical Affairs, 2 Kingdom Street, London W2 6BD, UK
| | - Ade Adebajo
- Academic Rheumatology Group, Faculty of Medicine, University of Sheffield and Barnsley Hospital NHS Foundation Trust, Barnsley, UK
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2066] [Impact Index Per Article: 206.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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