Effects of nonsteroidal anti-inflammatory drug therapy on blood pressure and peripheral edema

Etiology of Drug-Induced Edema: A Review of Dihydropyridine, Thiazolidinedione, and Other Medications Causing Edema

Edema is an accumulation of fluid in the body's tissues that affects millions of Americans yearly. It can affect multiple body parts, for example, the brain or eyes, but often occurs in the periphery, including the feet and legs. Medications, such as dihydropyridine and thiazolidinediones (TZDs), can be the etiology of edema. Edema can develop in association with problems in the vasculature or lymphatic flow. In recent years, a better understanding of these drug-induced mechanisms has been appreciated. Specifically, dihydropyridines can increase hydrostatic pressure and cause selective pre-capillary vessel vasodilation. TZDs can cause edema through increased vascular permeability and increased hydrostatic pressure. Specifically, peroxisome proliferator-activated receptor gamma (PPARγ) stimulation increases vascular endothelial permeability, vascular endothelial growth factor (VEGF) secretion, renal sodium, and fluid retention. Other drugs that can cause edema include neuropathic pain agents, dopamine agonists, antipsychotics, nitrates, nonsteroidal anti-inflammatory (NSAIDS), steroids, angiotensin-converting enzyme (ACE) inhibitors, and insulin. There are various clinical presentations of edema. Since multiple mechanisms can induce edema, it is important to understand the basic mechanisms and pathophysiology of drug-induced edema. Edema can even become fatal. For example, angioedema can occur from ACE inhibitor therapy. In this regard, it is considered a medical emergency when there is laryngeal involvement. This review aims to thoroughly appreciate the multiple causes of drug-induced edema and the ways it can be treated or prevented.

Approach to the Patient with Non-cardiac Leg Swelling

One of the most common reasons for patient visits in the outpatient practice is lower extremity swelling. Non-cardiac etiologies are the most frequent reason for these encounters. The approach to this patient population will focus on the 7 key questions to initiate the gathering of historical information on the etiology of leg swelling. Figures and tables will complement the text for diagnosing lower extremity swelling. In this article, the common non-cardiac etiologies will be reviewed which include medications, chronic venous insufficiency, lymphatic disease, lipedema, venous thrombosis, and musculoskeletal etiologies.

Therapeutics in rheumatology and the kidney

The field of rheumatology has advanced significantly in recent years to provide rheumatologists with an extensive array of medications to combat rheumatic joint conditions. In contrast to an older era, when NSAIDs and other nephrotoxic agents were the mainstay of treatment, modern DMARDs vary considerably in their nephrotoxic potential and their use is not always precluded in populations with pre-existing chronic kidney disease (CKD). This review will explore in detail the safety and efficacy profiles of medications used to treat rheumatologic disease, specifically in the setting of CKD. Specifically, we discuss both traditional agents used, i.e. NSAIDs, CSs and conventional synthetic DMARDs, as well as novel biologic DMARDs and targeted synthetic DMARDs. Anti-gout prescribing in CKD is also reviewed. We aim to provide practical guidance to rheumatologists, nephrologists and general physicians when prescribing these medications in the setting of CKD.

Acute kidney injury associated with non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are ones of the commonly prescribed drugs worldwide. They primarily inhibit cyclooxygenase (COX) enzyme which is responsible for conversion of phospholipids to various prostaglandins (PGs). Disruption in PGs production affects the kidneys in several ways, including vasoconstriction that may result in ischemic acute kidney injury (AKI) in at-risk patients. They also impair salt and water excretion, leading to edema and hypertension. Other complications include hyperkalemia, hyponatremia, nephrotic syndrome, acute interstitial nephritis and chronic kidney disease progression. AKI from NSAIDs is usually reversible with favorable prognosis after discontinuation of NSAIDs. Avoidance of NSAIDs exposure is extremely important, especially among high-risk patients.

Edema-like symptoms are common in ultra-distance cyclists and driven by overdrinking, use of analgesics and female sex - a study of 919 athletes

Background

Ultra-endurance cyclists regularly report various extents of bodily decline during long-distance bicycle rides, including potential kidney function-related symptoms such as swelling of body parts and urine changes. This study aimed to assess the prevalence of these symptoms in a representative cohort of ultra-endurance cyclists and shed light on potential predictors related to the ride, the rider and the rider’s behavior.

Methods

Between November 26 and December 14, 2020, 1350 people participated in an online survey investigating potential kidney-related symptoms of ultra-distance cycling. Frequency and severity of edema-like (“swelling”) symptoms and perceived changes in urine output, concentration and quality were associated with ride-related factors, demographic parameters and rider behavior-related variables.

Results

A total of 919 participants met the predefined inclusion criteria. The majority (N = 603, 65.6%) stated that they suffered from at least one potential kidney function-related symptom, out of which 498 (54.2%) stated one or more edema-like (“swelling”) symptoms. In correlational and multiple regression analyses, female sex, intake of analgesics and drinking strategies correlated with swelling symptoms. Further analyses indicated that drinking due to thirst and/or drinking adapted to ambient sweating and temperature negatively correlated with swelling symptoms, whereas “drinking as much as possible” enhanced these. Intake of analgesics was moderately positively correlated with swelling symptoms.

Conclusions

According to our survey, edema-like symptoms occur in the majority of ultra-distance cyclists and female sex, drinking strategy and intake of analgesic drugs are major predictors thereof. Studies are needed to investigate the underlying pathophysiological processes of such symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12970-021-00470-0.

Non-steroidal anti-inflammatory drugs in the pharmacological management of osteoarthritis in the very old: prescribe or proscribe?

Osteoarthritis (OA) is the most common form of arthritis worldwide, and ranges in the top 5–10 most disabling diseases. Contrary to common opinion, this disease is severe, often symptomatic, and may lead to loss of mobility and independence, as well as being responsible for increased frailty and excess mortality [standardized ratio: 1.55 (95% confidence interval, CI: 1.41–1.70)]. The incidence of OA increases dramatically with age in an increasingly ageing world. Therefore, practitioners involved in the management of OA often have to manage very old patients, aged 75–80 years and above, as part of their daily practice. Treatment options are limited. In addition to education and physical treatments, which are at the forefront of all treatment recommendations but require a low level of symptoms to be implemented, many pharmacological options are proposed. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as a second-line treatment but with great caution. However, the precise incidence of cardiovascular, renal, and gastrointestinal adverse events in very elderly patients is unclear. All of these risks are increased in the elderly. The relative risks can be extrapolated from various studies. However, what is the absolute risk according to age categorization? The answer to this question is important because NSAIDs should be used in very elderly patients with OA only if full information has been provided and the decision to prescribe this treatment is shared between the patient and their doctor. This article reviews the risks and currently available recommendations, and proposes practical options and warnings to allow for a responsible and limited use of NSAIDs in the very old.

Drug-induced peripheral oedema: An aetiology-based review

Many drugs are responsible, through different mechanisms, for peripheral oedema. Severity is highly variable, ranging from slight oedema of the lower limbs to anasarca pictures as in the capillary leak syndrome. Although most often noninflammatory and bilateral, some drugs are associated with peripheral oedema that is readily erythematous (eg, pemetrexed) or unilateral (eg, sirolimus). Thus, drug-induced peripheral oedema is underrecognized and misdiagnosed, frequently leading to a prescribing cascade. Four main mechanisms are involved, namely precapillary arteriolar vasodilation (vasodilatory oedema), sodium/water retention (renal oedema), lymphatic insufficiency (lymphedema) and increased capillary permeability (permeability oedema). The underlying mechanism has significant impact on treatment efficacy. The purpose of this review is to provide a comprehensive analysis of the main causative drugs by illustrating each pathophysiological mechanism and their management through an example of a drug.

PGF2α stimulates the 10-pS Cl− channel and thiazide-sensitive Na+-Cl− cotransporter in the distal convoluted tubule

We used patch-clamp and Western blot analysis to test whether PGF2α stimulates the basolateral 10-pS Cl− channel and thiazide-sensitive Na+-Cl− cotransporter (NCC) in the distal convoluted tubule (DCT) via a prostaglandin F receptor (FP-R). Single channel and whole cell recordings demonstrated that PGF2α stimulated the 10-pS Cl− channel in the DCT. The stimulatory effect of PGF2α on the Cl− channel was mimicked by a FP-R agonist, latanoprost, but was abrogated by blocking FP-R with AL8810. Also, the effect of PGF2α on the Cl− channel in the DCT was recapitulated by stimulating PKC but was blocked by inhibiting PKC. Furthermore, inhibition of p38 MAPK but not ERK blocked the effect of PGF2α on the 10-pS Cl− channel. Inhibition of NADPH oxidase also abrogated the stimulatory effect of PGF2α on the 10-pS Cl− channel, while the addition of 10 μM H2O2 mimicked the stimulatory effect of PGF2α on the 10-pS Cl− channel. Moreover, superoxide-related species may mediate the stimulatory effect of PGF2α on the 10-pS Cl− channel because the stimulatory effect of PGF2α and H2O2 was not additive. Western blot analysis showed that infusion of PGF2α in vivo not only increased the expression of FP-R but also increased the expression of total NCC and phosphorylated NCC. We conclude that PGF2α stimulates the basolateral 10-pS Cl− channel in the DCT by activating FP-R through PKC/p38 MAPK and NADPH oxidase-dependent pathways. The stimulatory effects of PGF2α on the Cl− channel and NCC may contribute to PGF2α-induced increases in NaCl reabsorption in the DCT.

Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications.

OBJECTIVE

To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs.

METHODS

Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations.

RESULTS

Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases.

CONCLUSION

NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

Ibuprofen and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of ibuprofen on blood pressure in women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension during the immediate postpartum period.

METHODS

In this double-blind controlled trial, we randomly assigned women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension to receive a postpartum analgesic regimen with either ibuprofen or acetaminophen. The primary outcome was average mean arterial pressure during the postpartum hospital stay. Prespecified secondary outcomes included use of breakthrough opioid pain medications, length of hospital stay, and postpartum diuresis, defined as urine output of at least 200 mL/hour for 4 hours. A sample size of 56 participants was needed to detect a difference of 6 mm Hg in average mean arterial pressure between the study groups.

RESULTS

From January 17, 2017, to February 24, 2018, 61 participants were randomized and completed the trial, 31 participants in the ibuprofen group and 30 in the control group. Baseline characteristics were similar between groups. Postpartum average arterial pressure did not differ between study groups (93±8 mm Hg for those in the ibuprofen group vs 93±7 mm Hg in the control group, P=.93). Breakthrough opioid medications were requested by 24% of the participants in the ibuprofen group compared with 30% in the control group (P=.62). The ibuprofen group did not have a longer length of stay (48 hours vs 43 hours in the control group) or decreased rate of postpartum diuresis (61% in ibuprofen group vs 77% in the control group, P=.2).

CONCLUSION

In women with hypertensive disorders of pregnancy and mild hypertension, ibuprofen did not increase postpartum blood pressure compared with women not receiving nonsteroidal antiinflammatory drugs.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03011567.

A case of bilateral leg edema associated with levofloxacin: A case report

RATIONALE

A number of medicines are associated with edema. However, only 2 cases of edema of both lower legs, associated with levofloxacin, have been reported.

PATIENT

We report the case of levofloxacin-associated bilateral leg edema in an 81-year-old male. The patient was referred to the Division of Nephrology due to edema limited to both lower legs, which had developed 1 day before. He had undergone supraglottic laryngectomy due to supraglottic cancer in our institution 6 months ago. He had been admitted to the Department of Otolaryngology due to persistent aspiration and general weakness 5 days ago.

DIAGNOSIS

The patient had no underlying diseases that could result in edema. No abnormalities were detected in several diagnostic tests. He strongly denied using other medications including herbal or traditional remedies, recreational drugs, or drugs of abuse. The patient had been intravenously administered levofloxacin at 750 mg per day 5 days earlier; on this basis levofloxacin-induced edema was suspected.

INTERVENTIONS AND OUTCOMES

Levofloxacin was immediately withdrawn and conservative management (salt restriction and withdrawal of intravenous fluid) was initiated. His edema was completely restored within 3 weeks after withdrawal of levofloxacin.

OUTCOMES

The patient stopped taking levofloxacin and he did not have any recurrent edema until his death due to uncontrolled pneumonia.

LESSONS

Levofloxacin should be added to the list of drugs associated with the development of bilateral leg edema. This might obviate the need for time-consuming studies for diagnostic purposes and application of ineffective or harmful treatments.

Gender differences in the effect of diabetes mellitus and its treatment on osteoarthritic pain

OBJECTIVE

(1) To investigate differences in pain severity and its distribution between patients with and without diabetes mellitus (DM) in a population with advanced osteoarthritis (OA). (2) To explore the role of medication used for diabetes in these associations.

RESEARCH DESIGN AND METHODS

This is a hospital-based cohort study of patients with advanced OA requiring total joint arthroplasty. Interviews and electronic records included: age, gender, occupation, DM (including medication and duration), analgesics used, anthropometry, joints affected by pain and disease duration. Joint pain was scored by the patients using numerical rating scale. Pain severity score was calculated by adding the number of joints affected by pain and the maximum pain score. All analyses were adjusted and/or stratified by gender, age and body mass index.

RESULTS

In total, 489 patients with painful OA were included. From those, 139 patients had DM (30% males and 28% females, p=0.03). Pain severity, principally the number of joints affected by pain, and analgesic consumption, was higher in males with diabetes compared with males without diabetes (p=0.012 and OR=3.03; 95% CI 1.24 to 7.36, p=0.015, respectively). These associations were not significant in females (p=0.41 and p=0.66). Pain was more severe in males using insulin versus those who did not (p=0.025). Male subjects with diabetes had higher odds of hand pain or knee and hand pain compared with males without diabetes (OR=3.7, 95% CI 1.15 to 12; p=0.028 and OR=5.54; 95% CI 1.43 to 21.5, p=0.013, respectively).

CONCLUSIONS

Males with diabetes, especially those who require insulin, have more severe joint pain and consume more analgesics than males without diabetes or those who have DM and use other DM medication.

Comparison of Efficacy and Safety of Intramuscular Piroxicam and Tramadol for Post-operative Pain in Patients Undergoing Caesarean Delivery

INTRODUCTION

Post-caesarean section pain can be both stressful and unfavourable. Effective and rapid reduction of pain facilitates early ambulation and care of the new born. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and opioids are used for pain relief but they are associated with adverse effects both in the mother and the child.

AIM

To evaluate efficacy and safety of piroxicam and tramadol in post-caesarean section pain.

MATERIALS AND METHODS

Primigravidae who underwent elective caesarean section received either piroxicam 20mg or tramadol 100mg intra-muscularly, following recovery from anaesthesia. Severity of pain was assessed using Visual Analogue Scale (VAS) and side-effects to study drugs were noted. Rescue analgesic butorphanol 2mg was administered if VAS score was more than four. Patient's satisfaction score was assessed at 12 hours post-operatively.

RESULTS

Mean age in piroxicam and tramadol groups were 23.32±3.43 and 22.03±2.0 years respectively. Significant reduction in pain was observed at 2, 4, 8, 12 and 24 hours in both groups (p<0.001). Pain relief was significant at 2, 4 and 8 hours in piroxicam group compared to tramadol. Twenty-one and 12 patients in tramadol and piroxicam groups received rescue analgesic respectively. Sedation and nausea was significantly higher in tramadol group (p<0.001), 46.66% of patients graded their satisfaction score as good and 15% as excellent in piroxicam group.

CONCLUSION

Intra-muscular piroxicam was effective in reducing post-caesarean section pain for 24 hours with minimal side-effects compared to tramadol.

Interaction of the renin angiotensin and cox systems in the kidney

Cyclooxygenase-2 (COX-2) plays an important role in mediating actions of the renin-angiotensin system (RAS). This review sheds light on the recent developments regarding the complex interactions between components of RAS and COX-2; and their implications on renal function and disease. COX-2 is believed to counter regulate the effects of RAS activation and therefore counter balance the vasoconstriction effect of Ang II. In kidney, under normal conditions, these systems are essential for maintaining a balance between vasodilation and vasoconstriction. However, recent studies suggested a pivotal role for this interplay in pathology. COX-2 increases the renin release and Ang II formation leading to increase in blood pressure. COX-2 is also associated with diabetic nephropathy, where its upregulation in the kidney contributes to glomerular injury and albuminuria. Selective inhibition of COX-2 retards the progression of renal injury. COX-2 also mediates the pathologic effects of the (Pro)renin receptor (PRR) in the kidney. In summary, this review discusses the interaction between the RAS and COX-2 in health and disease.

Evaluation of the relationship between effervescent paracetamol and blood pressure: clinical trial

BACKGROUND

Paracetamol's solubility is achieved by adding to the excipient sodium salts, either as bicarbonate, carbonate or citrate. As the relationship between salt and hypertension is well known, due to the sodium content it has raised a hypothesis that may interfere with the control of that risk factor. Therefore, the objective of this study is to evaluate the effect on blood pressure of effervescent paracetamol compared to non-effervescent, in hypertensive patients.

METHODS/DESIGN

This is the protocol of a phase IV multicenter clinical trial, randomized, controlled, crossover, open, which will compare the effect of two different formulations of paracetamol (effervescent or non-effervescent) in the blood pressure of hypertensive patients, with a seven weeks follow up. 49 controlled hypertensive patients will be included (clinical BP lower than 150 and 95 mmHg, and lower than 135 mmHg and 85 mmHg in patients with diabetes or a history of cardiovascular event, and daytime ambulatory measurements lower than 140 and 90 mmHg) and mild to moderate pain (Visual Analog Scale between 1 and 4). The study was approved by the ethics committee of the Fundació Jordi Gol i Gurina and following standards of good clinical practice. The primary endpoint will be the variations in systolic BP in 24 h Ambulatory Blood Pressure Monitoring, considering significant differences 2 or more mmHg among those treated with non-effervescent and effervescent formulations. Intention-to-treat and per-protocol analysis will be held.

DISCUSSION

Despite the broad recommendation not to use effervescent drugs in patients with hypertension, there are relatively little studies that show exactly this pressor effect due to sodium in salt that gives the effervescence of the product. This is the first clinical trial designed to study the effect of effervescence compared to the non-effervescent, in well-controlled hypertensive patients with mild to moderate pain, performed in routine clinical practice.

TRIAL REGISTRATION

NCT 02514538.

Pre-treatment considerations in childhood hypertension due to chronic kidney disease

Hypertension (HTN) develops very early in childhood chronic kidney disease (CKD). It is linked with rapid progression of kidney disease, increased morbidity and mortality hence the imperative to start anti-hypertensive medication when blood pressure (BP) is persistently > 90^th percentile for age, gender, and height in non-dialyzing hypertensive children with CKD. HTN pathomechanism in CKD is multifactorial and complexly interwoven. The patient with CKD-associated HTN needs to be carefully evaluated for co-morbidities that frequently alter the course of the disease as successful treatment of HTN in CKD goes beyond life style modification and anti-hypertensive therapy alone. Chronic anaemia, volume overload, endothelial dysfunction, arterial media calcification, and metabolic derangements like secondary hyperparathyroidism, hyperphosphataemia, and calcitriol deficiency are a few co-morbidities that may cause or worsen HTN in CKD. It is important to know if the HTN is caused or made worse by the toxic effects of medications like erythropoietin, cyclosporine, tacrolimus, corticosteroids and non-steroidal anti-inflammatory drugs. Poor treatment response may be due to any of these co-morbidities and medications. A satisfactory hypertensive CKD outcome, therefore, depends very much on identifying and managing these co-morbid conditions and HTN promoting medications promptly and appropriately. This review attempts to point attention to factors that may affect successful treatment of the hypertensive CKD child and how to attain the desired therapeutic BP target.

Bilateral leg edema in an older woman

Bilateral leg edema is a frequent symptom in older people and an important concern in geriatric medicine. Further evaluation is frequently not performed and simple therapy with diuretics is prescribed. Particularly in older patients, long-term use of diuretics can lead to severe electrolyte imbalances, volume depletion, and falls. In this case report we want to focus the physicians' attention on the necessity to determine the cause and show a correspondingly effective treatment for bilateral leg edema in older people. A thorough approach is required to recognize diseases and to avoid adverse drug events as geriatric patients often show an atypical presentation or minor symptoms. The cause of swollen legs is often multifactorial; therefore, the patient's individual history and an appropriate physical examination are important. Depending on the clinical symptoms, evaluation including basic laboratory tests, urinalysis, chest radiography, and echocardiogram may be indicated. The most probable cause of bilateral edema in older patients is chronic venous insufficiency. Heart failure is also a common cause. Other systemic causes such as renal disease or liver disease are much rarer. Antihypertensive and anti-inflammatory drugs can frequently cause leg edema, but the incidence of drug-induced leg swelling is unknown. With the help of this special case we tried to develop an approach to the diagnosis of symmetric leg edema in older patients, a problem frequently neglected in geriatric medicine.

Safety of Onartuzumab in Patients with Solid Tumors: Experience to Date from the Onartuzumab Clinical Trial Program

BACKGROUND

Onartuzumab, a recombinant humanized monovalent monoclonal antibody directed against MET, the receptor for the hepatocyte growth factor, has been investigated for the treatment of solid tumors. This publication describes the safety profile of onartuzumab in patients with solid tumors using data from the global onartuzumab clinical development program.

METHODS

Adverse event (AE) and laboratory data from onartuzumab phase II/III studies were analyzed and coded into standardized terms according to industry standards. The severity of AEs was assessed using the NCI Common Toxicity Criteria, Version 4. Medical Dictionary for Regulatory Activities (MedDRA) AEs were grouped using the standardized MedDRA queries (SMQs) "gastrointestinal (GI) perforation", "embolic and thrombotic events, venous (VTE)", and "embolic and thrombotic events, arterial (ATE)", and the Adverse Event Group Term (AEGT) "edema." The safety evaluable populations (patients who received at least one dose of study treatment) for each study were included in this analysis.

RESULTS

A total of 773 onartuzumab-treated patients from seven studies (phase II, n = 6; phase III, n = 1) were included. Edema and VTEs were reported in onartuzumab-treated patients in all seven studies. Edema events in onartuzumab arms were generally grade 1-2 in severity, observed more frequently than in control arms and at incidences ranging from 25.4-65.7% for all grades and from 1.2-14.1% for grade 3. Hypoalbuminemia was also more frequent in onartuzumab arms and observed at frequencies between 77.8% and 98.3%. The highest frequencies of all grade and grade ≥3 VTE events were 30.3% and 17.2%, respectively in onartuzumab arms. The cumulative incidence of all grade ATE events ranged from 0-5.6% (grade ≥3, 0-5.1%) in onartuzumab arms. The frequency of GI perforation was below 10% in all studies; the highest estimates were observed in studies with onartuzumab plus bevacizumab for all grades (0-6.2%) and grade ≥3 (0-6.2%).

CONCLUSIONS

The frequencies of VTE, ATE, GI perforation, hypoalbuminemia, and edema in clinical studies were higher in patients receiving onartuzumab than in control arms; these are considered to be expected events in patients receiving onartuzumab.

Role of preferential cyclooxygenase-2 inhibition by meloxicam in ischemia/reperfusion injury of the rat liver

BACKGROUND

Ischemia/reperfusion injury (IRI) is one of the major clinical problems in liver and transplant surgery. Livers subjected to warm ischemia in vivo often show a severe dysfunction and the release of numerous inflammatory cytokines and arachidonic acid metabolites. Cyclooxygenase (COX)-2 is the inducible isoform of an intracellular enzyme that converts arachidonic acid into prostaglandins. The aim of the study was to evaluate the effect of COX-2 inhibition and the role of Kupffer cells in IRI of the liver.

METHODS

Male Wistar rats [250- 280 g body weight (BW)] were anesthetized and subjected to 30-min warm ischemia of the liver (Pringle's maneuver) and 60-min reperfusion after median laparotomy. The I/R group received no additional treatment. In the COX-2 inhibitor (COX-2I) group, the animals received 1 mg/kg BW meloxicam prior to operation. Gadolinium chloride (GdCl3) (10 mg/kg BW) was given 24 h prior to operation in the GdCl3 and GdCl3 + COX-2I groups for the selective depletion of Kupffer cells. The GdCl3 + COX-2I group received both GdCl3 and meloxicam treatment prior to operation. Blood and liver samples were obtained at the end of the experiments for further investigations.

RESULTS

After 30 min of warm ischemia in vivo, severe hepatocellular damage was observed in the I/R group. These impairments could be significantly prevented by the selective COX-2 inhibition and the depletion of Kupffer cells. Alanine aminotransferase was significantly reduced upon meloxicam and GdCl3 treatment compared to the I/R group: I/R, 3,240 ± 1,262 U/l versus COX-2I, 973 ± 649 U/l, p < 0.001; I/R versus GdCl3, 1,611 ± 600 U/l, p < 0.05, and I/R versus GdCl3 + COX-2I, 1,511 ± 575 U/l, p < 0.01. Plasma levels of tumor necrosis factor alpha (TNF-α) were significantly reduced in the COX-2I treatment group compared to I/R (3.5 ± 1.5 vs. 16.3 ± 11.7 pg/ml, respectively; p < 0.05). Similarly, the amount of TxB2, a marker for COX-2 metabolism, was significantly reduced in the meloxicam treatment groups compared to the I/R group: I/R, 22,500 ± 5,210 pg/ml versus COX-2I, 1,822 ± 938 pg/ml, p < 0.001, and I/R versus GdCl3 + COX-2I, 1,530 ± 907 pg/ml, p < 0.001. All values are given as mean ± SD (n = 6).

CONCLUSION

These results suggest that the inhibition of COX-2 suppressed the initiation of an inflammatory cascade by attenuating the release of TNF-α, which is an initiator of the inflammatory reaction in hepatic IRI. Therefore, we conclude that preferential inhibition of COX-2 is a possible therapeutic approach against warm IRI of the liver.

Etoricoxib attenuates effect of antihypertensives in a rodent model of DOCA-salt induced hypertension

While it is known that non-steroidal anti-inflammatory drugs including selective cyclooxygenase-2 (COX-2) inhibitors influence BP, the exact relationship and underlying mechanisms are still unclear. We investigated the effect of etoricoxib, a selective COX-2 inhibitor on the antihypertensive efficacy of atenolol; beta-blocker, ramipril; angiotensin converting enzyme inhibitor and telmisartan; angiotensin receptor blocker in deoxycorticosterone acetate (DOCA)-salt hypertensive rats, a mineralocorticoid volume expansion model. Etoricoxib attenuated the antihypertensive-induced reduction of systolic (atenolol; P < .001, ramipril; P = .011, telmisartan; P = .003) and mean arterial pressure (atenolol; P < .001, ramipril; P = .032, telmisartan; P = .023). These results demonstrate that COX-2 dependent mechanisms play a significant role in blood pressure regulation, and etoricoxib-induced COX-2 inhibition blunts the therapeutic effect of different classes of antihypertensives in this mineralocorticoid volume expansion model of hypertension.

Influence of age on the association between lifestyle factors and risk of hypertension

BACKGROUND

Although hypertension is a highly prevalent disease in older populations, risk factors for developing hypertension have been studied primarily in younger cohorts. We sought to determine whether the strength of traditional hypertensive risk factors varied with age.

METHODS

We analyzed the prospective association between five modifiable risk factors and hypertension incidence among 78,590 initially nonhypertensive women of different ages in the Nurses' Health Study I cohort over 26 years.

RESULTS

Older age attenuated the association between incident hypertension and four of five risk factors associated with hypertension in younger women. Persons aged 50 years and younger who were low risk for all five risk factor behaviors had a hazard ratio (HR) for incident hypertension of 0.13 (95% confidence interval [CI], 0.03-0.52) compared with others in this age group. In women 61 and older, the HR was 0.62 (95% CI, 0.51-0.75). However, the hypothetical number needed to treat (the number of women needed to join the low-risk-factor group for a 10-year period to prevent one hypertension case) was similar between the age groups.

CONCLUSION

The fraction of incident hypertension attributable to modifiable lifestyle factors decreases with age. Because the incidence of hypertension is higher in older persons, however, lifestyle modification would hypothetically prevent similar numbers of hypertension cases in younger and older populations.

National collegiate athletic association division I athletes' use of nonprescription medication

Background:

Athletes are known to use over-the-counter pain medication. However, the frequency of such use among National Collegiate Athletic Association (NCAA) Division I-A football athletes is unknown.

Hypothesis:

NCAA Division I-A football athletes who use nonprescription analgesics for pain misuse these medications.

Study Design:

Cross-sectional study.

Methods:

The football players (N, 144) who met the criteria and agreed to participate were from 8 NCAA Division I-A schools. The participants were administered the Over the Counter Drug Screen for Athletes, which measures attitudes toward the use of a spectrum of substances.

Results:

Among football athletes surveyed who took nonprescription analgesics for football-related pain, 37% reported taking more than the recommended dose. This was slightly higher than the 28% of players who stated they have not taken nonprescription analgesics for football-related pain. Thirty-four percent of all athletes reported using more than the recommended dose of nonprescription analgesics. Athletes who purchased their own nonprescription analgesics communicated poorly regarding nonprescription analgesics use. Those lacking knowledge about nonprescription analgesics and those using nonprescription analgesics in anticipation of pain or to avoid missing a practice or game were most likely to misuse nonprescription analgesics.

Conclusion:

NCAA Division I-A football athletes who use nonprescription analgesics for athletic competition do not misuse nonprescription analgesics.

The assessment and importance of hypertension in the dental setting

Many patients with hypertension have uncontrolled disease. The dental visit presents a unique opportunity to screen patients for undiagnosed and undertreated hypertension, which may lead to improved monitoring and treatment. Although there are no clinical studies, it is generally recommended that nonemergent procedures be avoided in patients with a blood pressure of greater than 180/110 mm Hg. Because of the high prevalence of disease and medication use for hypertension, dentists should be aware of the oral side effects of antihypertensive medications as well as the cardiovascular effects of medications commonly used during dental visits.

[Economic evaluation of tramadol/paracetamol in the management of pain in patients with osteoarthritis in Spain]

OBJECTIVE

To compare the costs of treating osteoarthritis (OA) pain using combination tramadol/paracetamol tablets, Non-Steroidal Anti-Inflammatory Agents (NSAID) alone or NSAID plus proton pump inhibitors (PPI) from the perspective of the Spanish National Health System.

METHODS

A decision-analytical model was constructed to analyze the cost associated with three treatment strategies over 6 months. A cost-minimization approach was used, which considered data related to resource use, medication costs and costs for the treatment of adverse events.

RESULTS

In the base-case analysis, costs for 6 months of treatment of OA pain using tramadol/paracetamol were €232.86, compared with €274.60 for NSAID + PPI and €133.75 for NSAID alone. This provided a savings of €41.74 per patient over 6 months for tramadol/paracetamol compared with NSAID + PPI and a cost increase of €99.11 compared with NSAID alone. When renal adverse events associated with NSAID were considered, tramadol/paracetamol was cost saving compared with all NSAID-based regimens (saving €140.02 vs NSAID alone, €280.86 vs NSAID + PPI).

CONCLUSION

Based on the results of a theoretical decision-analytic model, the data obtained may suggest that tramadol/paracetamol is cost saving compared with NSAID + PPI for the treatment of OA pain over a period of 6 months. Tramadol/paracetamol is also cost saving compared with treatment with NSAID alone if considering renal adverse events.

Resistant hypertension, secondary hypertension, and hypertensive crises: diagnostic evaluation and treatment

Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to those with primary hypertension, there are patients whose hypertension is attributable to secondary causes, those with resistant hypertension, and patients who present with a hypertensive crisis. Secondary causes of hypertension account for less than 10% of cases of elevated blood pressure (BP), and screening for these causes is warranted if clinically indicated. Patients with resistant hypertension, whose BP remains uncontrolled in spite of use of 3 or more antihypertensive agents, are at increased cardiovascular risk compared with the general hypertensive population. After potentially correctible causes of uncontrolled BP (pseudoresistance, secondary causes, and intake of interfering substances) are eliminated, patients with true resistant hypertension are managed by encouraging therapeutic lifestyle changes and optimizing the antihypertensive regimen, whereby the clinician ensures that the medications are prescribed at optimal doses using drugs with complementary mechanisms of action, while adding an appropriate diuretic if there are no contraindications. Mineralocorticoid receptor antagonists are formidable add-on agents to the antihypertensive regimen, usually as a fourth drug, and are effective in reducing BP even in patients without biochemical evidence of aldosterone excess. In the setting of a hypertensive crisis, the BP has to be reduced within hours in the case of a hypertensive emergency (elevated BP with evidence of target organ damage) using parenteral agents, and within a few days if there is hypertensive urgency, using oral antihypertensive agents.

Potential pharmacodynamic drug-drug interaction between concomitantly administered lisinopril and diclofenac sodium: a call for appropriate management in hypertensive osteoarthritic patients

BACKGROUND

The present study was designed as an open label, multiple-dose, randomized, parallel trial to evaluate the pharmacodynamic drug-drug interaction of lisinopril and concomitantly administered diclofenac sodium in non-diabetic and diabetic, mild to moderate hypertensive, osteoarthritic patients.

METHODS

Post-screening and on inclusion, patients were put on a 2-week washout period and then randomly assigned to either only lisinopril 10 mg or combination of lisinopril 10 mg and diclofenac sodium 100 mg treatments for 8-12 weeks in diseased states of hypertension and osteoarthritis with or without type 2 diabetes mellitus.

RESULTS

The blood pressure (BP) control with lisinopril was reduced by concomitantly administered diclofenac sodium in non-diabetic (SBP: p=0.00002; DBP: p=0.000008) and diabetic (SBP: p=0.002; DBP: p=0.001) patients when compared with the patients receiving lisinopril alone. Insulin sensitivity was improved (p=0.00002) and urinary albumin excretion rate was better controlled (p=0.0096) in lisinopril-treated patients when compared with the combination treatment in diabetic pool. Serum creatinine levels increased significantly in non-diabetic patients (p=0.00004) receiving combination treatment. In addition, creatinine clearance (CLCR) and blood urea nitrogen (BUN) were significantly higher in diabetic (CLCR: p<0.00001; BUN: p=0.0098) as well as in non-diabetic (CLCR: p<0.00001; BUN: p=0.03) patients treated with combination treatment. The alterations in serum electrolytes, reduction in % platelet aggregation activity and improvement in lipid profile was more profound with combination treatment in comparison to lisinopril alone.

CONCLUSIONS

The antihypertensive efficacy and insulin sensitivity improving property of lisinopril along with the renal function might get worse in hypertensive osteoarthritic patients receiving concomitant treatment of oral diclofenac sodium with lisinopril. In addition to this, close monitoring of serum electrolytes is also suggested to rule out any long-term detrimental effect.

Hypertension in the elderly

Hypertension is an important risk factor for cardiovascular morbidity and mortality, particularly in the elderly. Blood pressure elevation in the elderly is due to structural and functional changes that occur with aging. Treatment of hypertension reduces the risk of stroke, heart failure, myocardial infarction, all-cause mortality, cognitive impairment, and dementia in elderly patients with hypertension. A healthy lifestyle helps hypertension management, with benefits extending beyond lowering of blood pressure. Several classes of antihypertensive drugs are effective in preventing cardiovascular events. Treatment decisions should be guided by the presence of compelling indications such as diabetes or heart failure and by the tolerability of individual drugs or drug combinations in individual patients. The concomitant intake of certain medications that counter the effects of antihypertensive drugs and the frequent occurrence of orthostatic hypotension complicate treatment in older patients and drive down blood pressure control rates.

The assessment of diastolic function in patients with rheumatoid arthritis

Introduction. Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune chronic disease. In comparison with the overall population, mortality and morbidity of RA patients are increased due to cardiovascular diseases. There is increasing evidence that autoimmunity mechanisms are included in pathogenesis of cardiovascular diseases. Isolated disorder of diastolic function can, even with normal heart contractility, lead to heart failure. The aim of this study was to assess diastolic function in RA patients and determine factors causing diastolic dysfunction. Material and methods. The study included 88 patients with RA treated at Rheumatology Department, Clinical Hospital Centre, Zemun. All the patients were thoroughly examined (clinical findings, laboratory and echocardiographic examination). All parameters of diastolic function (mitral and pulmonary flow) were measured. Results. In RA patients 98,9% had diastolic function disorder. This parameter had been changed prior to clinical signs of heart failure and decrease of ejection fraction. Indicators of diastolic function, velocities E, A and their ratio VE/VA, as well as velocities S, D and their ratio VS/VD were lower in patients with positive rheumatoid factor. The patients' age (p<0.01), duration of the disease (p<0.05), high level of cholesterol (p<0.05), triglycerides (p<0.05) and arterial hypertension (p<0.05) were significant factors considerably affecting diastolic function. Conclusion. These findings suggest subclinical myocardial disorder in a great number of RA patients. Apart from early and aggressive treatment of the chronic inflammatory process, it is also necessary to prevent further heart complications by timely recognition and treatment of 'standard' risk factors for cardiovascular diseases.

A 4-week randomized study of acetaminophen extended-release vs rofecoxib in knee osteoarthritis

OBJECTIVE

To compare the safety and efficacy of acetaminophen extended-release (APAP ER) with rofecoxib for the management of pain associated with knee osteoarthritis (OA).

METHODS

Four hundred and three adult patients with moderate pain secondary to knee OA were randomized to receive APAP ER 1300 mg three times daily, rofecoxib 12.5mg once daily, or rofecoxib 25mg once daily. Primary end point was change from baseline at week 4 in the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale score using a visual analog scale. This 4-week study was conducted at 23 US research sites from October 1999 to October 2000.

RESULTS

APAP ER was noninferior to rofecoxib 12.5mg because the upper 95% confidence limit (CL) for the least squares mean (LSM) change from baseline (35.27 mm at week 4) did not exceed the prespecified noninferiority limit of 50mm. The upper CL (57.39 mm) exceeded the noninferiority limit for APAP ER compared with rofecoxib 25mg at week 4. There were no significant differences among groups in the overall incidence of adverse events.

CONCLUSION

APAP ER 3900 mg daily was noninferior to rofecoxib 12.5mg daily, but noninferiority was not established to rofecoxib 25mg daily. APAP ER was well tolerated and no safety issues were identified. Based on the results of this study, APAP ER 3900 mg daily is an alternative to nonsteroidal anti-inflammatory drugs (NSAIDs), such as rofecoxib, in treating pain associated with knee OA.

Amlodipine reduces the antimigratory effect of diclofenac in spontaneously hypertensive rats

Amlodipine, an antihypertensive drug, and diclofenac, an antiinflammatory drug, may generally be combined, particularly in elderly patients; therefore, the potential for their interaction is high. We aim to determine if amlodipine interferes with the antimigratory effect of diclofenac. For this, male spontaneously hypertensive rats (SHRs) were treated with either diclofenac (1 mg.kg.d, 15 d) alone or combined with amlodipine (10 mg.kg.d, 15 d). Leukocyte rolling, adherence, and migration were studied by intravital microscopy. Diclofenac did not change (180.0 +/- 2.3), whereas amlodipine combined (163.4 +/- 5.1) or not (156.3 +/- 4.3) with diclofenac reduced the blood pressure (BP) levels in SHR (183.1 +/- 4.4). Diclofenac and amlodipine reduced leukocyte adherence, migration, and ICAM-1 expression, whereas only diclofenac reduced rolling leukocytes as well. Combined with amlodipine, the effect of the diclofenac was reduced. Neither treatment tested increased the venular shear rate or modified the venular diameters, number of circulating leukocytes, P-selectin, PECAM-1, L-selectin, or CD-18 expressions. No difference could be found in plasma concentrations of both drugs given alone or in association. In conclusion, amlodipine reduces leukocyte migration in SHR, reducing endothelial cell ICAM-1 expression. Amlodipine reduces the effect of the diclofenac, possibly by the same mechanism. A pharmacokinetic interaction as well as an effect on the other adhesion molecules tested could be discarded.

Anti-inflammatory drugs and the kidney

Non-steroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors (coxibs) enjoy widespread use in clinical practice, leading to a remarkable frequency of unwanted renal side effects. In most cases, NSAID-induced acute renal failure or acute kidney injury is hemodynamically mediated. Clinical syndromes associated with NSAID use include acute renal failure, acute interstitial nephritis, worsening of chronic kidney disease (CKD), salt and water retention and hypertension. Careful monitoring of renal function is advisable in patients at increased risk such as elderly individuals with compromised cardiac reserve, and diabetics.

New risk factors for cardiovascular diseases in patients with rheumatoid arthritis

Introduction In the last three decades numerous epidemiologic studies have shown the correlation between risk factors and cardiovascular diseases. Clinical research has proven that rheumatoid arthritis patients (RA) have higher prevalence of classical risk factors in relation to general population, and over the last few years there has been an emphasis on some new risk factors which can contribute to cardiovascular diseases (CVD). Material and methods This study examined risk factor values for CVD in 88 patients with RA treated at Rheumatology Department, Clinical Hospital Center, Zemun. All patients have been thoroughly examined (clinical findings, laboratory and echocardiographic examination). Apart from classical factors, 'new' risk factors have been examined in all patients: C-reactive proteine (CRP), high-sensitive C-reactive proteine (hs-CRP) and homocystein. Results It has been determined that RA patients have more frequent higher new risk factors in comparison to classical ones. 84.1% of patients had higher CRP values, 97.1% had hsCRP and 39.5% had homocystein. The mean CRP values, especially hsCRP have been higher in patients with positive rheumatoid factor finding. Discussion Rheumatoid arthritis patients may have worse 'background atherosclerosis' than even subjects matched for classical cardiovascular risk factors. Continuous exposure to high grade systemic inflammation may be linked to accelerated atherosclerosis. Conclusions Timely identification of patients with risk factors, particularly with new risk factors, enables adequate approach in prevention of and treatment for CVD in rheumatoid arthritis patients.

New Diagnosis of Hypertension among Celecoxib and Nonselective NSAID Users: A Population-Based Cohort Study

BACKGROUND:

The use of nonsteroidal antiinflammatory drugs (NSAIDs) has been associated with increased blood pressure and hypertension. However, less is known about how the risk of hypertension is associated with cyclooxygenase 2 selective inhibitors (coxibs), especially celecoxib, the only coxib remaining on the market.

OBJECTIVE:

To compare the risk of incident hypertension associated with the use of celecoxib and nonselective (NS) NSAIDs.

METHODS:

A cohort study was conducted using secondary data from the GE Centricity Electronic Medical Record database, which contains millions of patient records seen by thousands of physicians across the US. The index date was defined as the date of the first NSNSAID or celecoxib prescription between January 1, 1999, and June 30, 2004. Patients were included if they were aged 18 years or older and were enrolled for at least 365 days prior to the index date. Excluded were patients who had any prior diagnosis of hypertension or pregnancy-related hypertension during the pre- or postindex date period. Also excluded were patients who had any prior prescription for antihypertensive drugs, coxibs, or NSNSAIDs. After applying inclusion/exclusion criteria, each celecoxib user was matched to 2 NSNSAID users by sex, age (±5 y), propensity score (within 0.2 SD), and number of unique drugs (±20%). Descriptive and survival analyses were conducted.

RESULTS:

The final sample consisted of 51 444 patients, of whom 17 148 were on celecoxib and 34 296 were on NSNSAIDs. Relative to NSNSAID users, patients on celecoxib had a similar rate of postexposure hypertension incidence (HR 1.013; 95% CI 0.862 to 1.190).

CONCLUSIONS:

Results from a population-based cohort analysis of electronic medical records did not show any difference in the hazard rates of incident hypertension between celecoxib and NSNSAID users.

ANTECEDENTES:

El uso de antiinflamatorios no esteroidales (AINEs) ha sido asociado a un incremento en la presión arterial y en el riesgo de hipertensión. Sin embargo, el riesgo de hipertensión asociado al uso de una nueva clase de AINEs conocidos como los inhibidores selectivos de la ciclooxigenasa II ó COX-2, es menos claro.

The effect of non-steroidal anti-inflammatory drugs and other commonly used non-narcotic analgesics on blood pressure level in adults

This review explores the blood pressure effects of three non-narcotic analgesics: non-selective non-steroidal anti-inflammatory drugs (NSAID), paracetamol and aspirin. The current evidence suggests that in normotensive, otherwise healthy adults, short-term use (1-2 weeks) of NSAIDs is not associated with a significant increase in blood pressure. Those with existing hypertension are more likely to see a blood pressure elevation, although the magnitude of the effect is less predictable and may vary with age, baseline blood pressure, type of NSAID and concurrent antihypertensive therapy. The magnitude of the blood pressure increase appears to be similar for both NSAIDs and paracetamol, while low-dose aspirin may have more modest effects. In hypertensive adults who experience deterioration of blood pressure control on NSAIDs, there is some, albeit suboptimal, evidence that the blood pressure-raising effects of NSAIDs are less when used in conjunction with dihydropyridine calcium-channel blockers than angiotensin-converting enzyme inhibitors.

Drug-induced immunomodulation to affect the development and progression of atherosclerosis: a new opportunity?

Inflammation and cytokine pathways are crucial for the development and progression of atherosclerotic lesions. In this review, the hypothesis that immunomodulatory drugs provide a possible therapeutic modality for cardiovascular disease is evaluated. Therefore, after a short overview of the specific inflammatory pathways involved in atherosclerosis, literature on the effect of several immunomodulatory drugs, such as nonsteroidal anti-inflammatory drugs, specific cyclooxygenase inhibitors and immunosuppressive drugs, used currently in the prevention of rejection after organ transplant, on the development and progression of atherosclerosis is reviewed. In addition, the pleiotropic immunomodulatory effect of two established cardiovascular drugs (angiotensin-converting enzyme inhibitors and statins) is discussed.