Cyclooxygenase-2 specificity and its clinical implications

Celecoxib Decreases the Need for Rescue Analgesics after Total Knee Arthroplasty: A Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the analgesic efficacy and adverse effects of celecoxib after total knee arthroplasty. Keywords in the PubMed and Scopus databases were used to find article abstracts. Each included clinical trial was assessed using the Cochrane Collaboration risk of bias tool, and we extracted data on postoperative pain assessment using the Visual Analogue Scale (VAS) at rest, ambulation, and active range of motion, rescue analgesic intake, and adverse effects. Inverse variance tests with mean differences were used to analyze the numerical variables. The Mantel-Haenszel statistical method and the odds ratio were used to evaluate the dichotomous data. According to this qualitative assessment (n = 482), two studies presented conclusions in favor of celecoxib (n = 187), one showed similar results between celecoxib and the placebo (n = 44), and three clinical trials did not draw conclusions as to the effectiveness of celecoxib versus the placebo (n = 251). Moreover, the evaluation of the rescue analgesic intake showed that the patients receiving celecoxib had a lower intake compared to patients receiving a placebo (n = 278, I2 = 82%, p = 0.006, mean difference = -6.89, 95% IC = -11.76 to -2.02). In conclusion, the pooled analysis shows that administration of celecoxib alone results in a decrease in rescue analgesic consumption compared to a placebo after total knee surgery.

Plumbagin alleviates temporomandibular joint osteoarthritis progression by inhibiting chondrocyte ferroptosis via the MAPK signaling pathways

AIMS

The acceleration of osteoarthritis (OA) development by chondrocytes undergoing ferroptosis has been observed. Plumbagin (PLB), known for its potent antioxidant and anti-inflammatory properties, has demonstrated promising potential in the treatment of OA. However, it remains unclear whether PLB can impede the progression of temporomandibular joint osteoarthritis (TMJOA) through the regulation of ferroptosis. The study aims to investigate the impact of ferroptosis on TMJOA and assess the ability of PLB to modulate the inhibitory effects of ferroptosis on TMJOA.

MATERIALS AND METHODS

The study utilized an in vivo rat model of unilateral anterior crossbite (UAC)-induced TMJOA and an in vitro study of chondrocytes exposed to H2O2 to create an OA microenvironment. Various experiments including cell viability assessment, quantitative RT-PCR, western blot analysis, histology, and immunofluorescence were conducted to examine the impact of ferroptosis on TMJOA and evaluate the potential of PLB to mitigate the inhibitory effects of ferroptosis on TMJOA. Additionally, RNA-seq and bioinformatics analysis were performed to investigate the underlying mechanism by which PLB regulates ferroptosis in TMJOA.

RESULTS

Fer-1 demonstrated its potential in mitigating the advancement of TMJOA through its inhibitory effects on ferroptosis and matrix degradation in chondrocytes, thereby substantiating the role of ferroptosis in the pathogenesis of TMJOA. Furthermore, the observed protective impact of PLB on cartilage implied that PLB can modulate the inhibition of ferroptosis in TMJOA by regulating the MAPK signaling pathways.

CONCLUSIONS

PLB alleviates TMJOA progression by suppressing chondrocyte ferroptosis via MAPK pathways, indicating PLB to be a potential therapeutic strategy for TMJOA.

Chemotherapy-induced gastrointestinal toxicity: Pathogenesis and current management

Chemotherapy is the most common treatment for malignant tumors. However, chemotherapy-induced gastrointestinal toxicity (CIGT) has been a major concern for cancer patients, which reduces their quality of life and leads to treatment intolerance and even cessation. Nevertheless, prevention and treatment for CIGT are challenging, due to the prevalence and complexity of the condition. Chemotherapeutic drugs directly damage gastrointestinal mucosa to induce CIGT, including nausea, vomiting, anorexia, gastrointestinal mucositis, and diarrhea, etc. The pathogenesis of CIGT involves multiple factors, such as gut microbiota disorders, inflammatory responses and abnormal neurotransmitter levels, that synergistically contribute to its occurrence and development. In particular, the dysbiosis of gut microbiota is usually linked to abnormal immune responses that increases inflammatory cytokines' expression, which is a common characteristic of many types of CIGT. Chemotherapy-induced intestinal neurotoxicity is also a vital concern in CIGT. Currently, modern medicine is the dominant treatment of CIGT, however, traditional Chinese medicine (TCM) has attracted interest as a complementary and alternative therapy that can greatly alleviate CIGT. Accordingly, this review aimed to comprehensively summarize the pathogenesis and current management of CIGT using PubMed and Google Scholar databases, and proposed that future research for CIGT should focus on the gut microbiota, intestinal neurotoxicity, and promising TCM therapies, which may help to develop more effective interventions and optimize managements of CIGT.

Anti-myocardial ischemia effect of Syringa pinnatifolia Hemsl. by inhibiting expression of cyclooxygenase-1 and -2 in myocardial tissues of mice

ETHNOPHARMACOLOGICAL RELEVANCE

The peeled stem of Syringa pinnatifolia Hemsl. (SP) is a traditional medicine in Inner Mongolia, China. The powder form of SP has been widely used for hundreds of years to relieve "He-Yi" related myocardial ischemia independently or in a traditional Chinese medicine preparation.

MATERIALS AND METHODS

SP was extracted with 95% and 80% ethanol. Chemical profiling was performed using HPLC-DAD and IT-TOF-ESI-MS analyses. Myocardial ischemia was produced by ligation of the left anterior descending (LAD) coronary artery to evaluate the anti-myocardial ischemia effect of SP. Male C57BL/6 mice were randomly divided into six groups (n=10 per group): a sham group, a model group, groups pretreated with SP at three dosages (20mg/kg, 40mg/kg, and 80mg/kg, intragastrically), and a positive control group (acetylsalicylic acid, ASA, 53mg/kg, intragastrically). Echocardiography was performed to determine heart function by measuring ejection fraction and fractional shortening. The levels of creatine kinase-MB (CK-MB) and lactate dehydrogenase (LDH) in serum, and 6-keto-PGF1α and TXB2 both in plasma and in protein homogenate of myocardial tissue were also measured. The levels of cyclooxygenase (COX)-1 and -2 in the heart tissue and their expressions in mouse myocardial tissue were determined using Western blot and an immunofluorescence assay, respectively. Inflammatory cell infiltration and collagen deposition changes in the myocardial ischemic tissue were observed by pathological examination.

RESULTS

Intragastric pretreatment with SP produced a dose-dependent increase in cardiac function. SP at 80mg/kg significantly improved the EF (p<0.001) and FS (p<0.01) compared with the model group, as well as the levels of serum CK-MB and LDH decreased obviously (p<0.001), approaching those in the sham group. Besides, an obvious reduction in inflammatory cells infiltration and collagen deposition in the infarcted myocardial tissue was shown in each SP treatment group. In addition, SP increased 6-keto-PGF1α and decreased TXB2 levels in the plasma, whereas the opposite pattern was observed in the protein homogenate from the myocardial tissues at the infarction edge, but keeping balance the ratio of 6-keto-PGF1α and TXB2, which is better than ASA in plasma. The mechanisms is associated with the downregulated expressions of COX-1 (p<0.05) and COX-2 (p<0.001).

CONCLUSIONS

Ethanol extract of SP has a protective effect against myocardial ischemia via down regulation of COX-1 and COX-2 expression and by adjusting the ischemia-induced imbalance between 6-keto-PGF1α and TXB2. This study shows substantial evidence to support the clinical application of SP and indicates that such medicine has great potential for treating ischemia-induced heart disease.

Efficacy and safety of celecoxib versus diclofenac and omeprazole in elderly arthritis patients: a subgroup analysis of the CONDOR trial

OBJECTIVE

To compare the safety and efficacy of celecoxib versus diclofenac slow release (SR) plus omeprazole in elderly arthritis patients.

RESEARCH DESIGN AND METHODS

Patients aged≥65 years, with osteoarthritis and/or rheumatoid arthritis, at high gastrointestinal (GI) risk who participated in the CONDOR trial (Celecoxib vs. Omeprazole and Diclofenac in Patients With Osteoarthritis and Rheumatoid Arthritis) were included in this subanalysis. CONDOR was a 6-month prospective, double-blind, randomized, parallel-group, multicenter, international study comparing treatment with celecoxib 200 mg twice daily (BID) versus diclofenac SR 75 mg BID plus omeprazole 20 mg daily.

MAIN OUTCOME MEASURES

The primary end point was a composite of Clinically Significant Upper and Lower GI Events adjudicated by an independent blinded expert committee. Efficacy was determined by the Patient's Global Assessment of Arthritis.

RESULTS

A total of 2446 patients aged≥65 years were included in the intent-to-treat (ITT) population (n=1219 celecoxib; n=1227 diclofenac). Eight patients in the celecoxib group and 52 in the diclofenac group were adjudicated as having Clinically Significant Upper and Lower GI events (adjusted odds ratio: 6.27; p<0.0001). Clinically significant reductions in hemoglobin (≥2 g/dL) and/or hematocrit (≥10%) were observed in 23 patients in the celecoxib group and in 76 in the diclofenac group (relative risk: 3.22 [95% confidence interval: 2.04-5.07]; p<0.0001). Incidence of moderate-to-severe abdominal symptoms and discontinuation of treatment due to GI adverse events (AEs) were lower in the celecoxib group. The Patient's Global Assessment of Arthritis score least squares mean change from baseline to final visit and percentage of patients rating treatment efficacy as good/very good at baseline and final visit were similar in both groups.

LIMITATIONS

The dose of celecoxib used is consistent with the European label for the management of osteoarthritis and may not reflect what is commonly prescribed in current clinical practice in the United States. The data were obtained in a clinical trial setting where patients were enrolled based on specific inclusion and exclusion criteria; as such, the patients may not be broadly representative of the patient population in a general practice setting.

CONCLUSIONS

Efficacy was comparable in the two treatment groups. There were fewer endpoints as well as fewer GI AEs reported in patients treated with celecoxib compared with diclofenac. These data may help physicians in their treatment decisions for elderly patients with arthritis.

Glycosylation of human cyclooxygenase-2 (COX-2) decreases the efficacy of certain COX-2 inhibitors

Prostanoids play an important role in a variety of physiological and pathophysiological processes including inflammation and cancer. The rate-limiting step in the prostanoid biosynthesis pathway is catalyzed by cyclooxygenase-2 (COX-2). COX-2 exists as two glycoforms, 72 and 74 kDa, the latter resulting from an additional glycosylation at Asn(580). In this study, Asn(580) was mutated, and the mutant and wild-type COX-2 genes were expressed in COS-1 cells to determine how glycosylation affects the inhibition of COX-2 activity by aspirin, flurbiprofen, ibuprofen, celecoxib, and etoricoxib. Results indicate that certain inhibitors were 2-5 times more effective at inhibiting COX-2 activity when the glycosylation site was eliminated, indicating that glycosylation of COX-2 at Asn(580) decreases the efficacy of some inhibitors.

Heme oxygenase/carbon monoxide-biliverdin pathway may be involved in the antinociceptive activity of etoricoxib, a selective COX-2 inhibitor

The aim of this study was to assess the interaction between the heme oxygenase-1/ biliverdin/carbon monoxide (HO-1/BVD/CO) and cyclooxygenase-2 (COX-2) pathways in the writhing test. Mice were pretreated with 0.1, 1 or 10 mg/kg, ip etoricoxib, a selective COX-2 inhibitor, or with one of the following HO-1/BVD/CO pathway modulators: 1, 3 or 9 mg/kg, sc ZnPP IX, a specific HO-1 inhibitor, 0.3, 1 or 3 mg/kg, sc hemin, a substrate of the HO-1/BVD/CO pathway; or 0.00025, 0.025 or 2.5 μmol/kg, sc DMDC, a CO donor. Mice pretreated with etoricoxib or one of the HO-1/BVD/CO pathway modulators received an injection of acetic acid (ip) after 30 and 60 min, respectively. Next, the number of writhes was quantified between 0 and 30 min after stimulus injection. In another series of experiments, ineffective doses of etoricoxib were co-administered with hemin or DMDC and an effective dose of etoricoxib with ZnPP IX, followed by an acetic acid injection. Four hours after the acetic acid injection, levels of bilirubin, which is a product of BVD conversion by the BVD reductase enzyme, in the peritoneal lavage were determined. Hemin or DMDC reduced (p<0.05) the number of writhes, but ZnPP IX potentiated (p<0.05) the effect of acetic acid by increasing (p < 0.05) the number of writhes. The co-administration of etoricoxib with hemin or DMDC reduced (p<0.05) the number of writhes. However, the analgesic effect of etoricoxib was not observed in the presence of ZnPP IX. Pretreatment with ZnPP IX reduced bilirubin levels, but etoricoxib pretreatment significantly increased the bilirubin concentration in peritoneal exudates. The data obtained from these experiments showed that the HO-1/BVD/CO pathway was activated in the acetic acid-induced abdominal writhing model. The analgesic effect of etoricoxib was at least partially dependent on the participation of the HO-1/BVD/CO pathway.

Screening for gastrointestinal, hepatic/biliary, and renal/urologic disease

NARRATIVE REVIEW: Many organ systems in the body can demonstrate signs and symptoms of impairment that mimic integumentary, musculoskeletal, and/or neuromuscular conditions commonly evaluated and treated by the hand therapist. In this review, diseases and disorders affecting the gastrointestinal (GI), hepatic/biliary, and renal/urologic systems capable of referring pain and other symptoms to the upper quadrant are presented. Specifically, these organ systems can refer pain to the sternum, neck, shoulder, scapulae, and subscapular and interscapular regions. Symptom referral from the viscera to the elbow and hand is extremely rare. Symptoms of carpal tunnel syndrome/paresthesias can occur in renal disorders and with hepatic/biliary problems. Following the screening model proposed by Goodman and Snyder, potential origins from the GI, hepatic/biliary, and renal/urologic systems are discussed. The goal is to identify patients with referred pain patterns and associated signs and symptoms of conditions that require referral to a physician or other appropriate health care professional. The alert hand therapist will recognize red flag histories, clinical presentation, and risk factors suggesting the need for a more thorough examination to ensure that the patient/client has a condition requiring intervention that is within the scope of the therapist's practice. Screening principles and tips for physician referral are offered.

LEVEL OF EVIDENCE

5.

A critical appraisal of COX-2 selective inhibition and analgesia: how good so far?

The development of COX-2 selective inhibitors has opened a new era of clinical investigation in NSAIDs. Discussion of the established concepts of inflammation and therapeutical uses of these drugs has changed the rationale for its clinical use and therapeutic labeling of these drugs. A comprehensive discussion across basic science and clinical areas involved in each of these concepts is presented. This led to a remarkable re-evaluation of our insights on their traditionally proposed mechanisms of analgesia, their side-effects, and the clinical indication of NSAIDs as "over the counter" pain killers. This may shift physicians toward a more rational use of this drug class.

Anti-inflammatory effects of an ethanolic extract from Clematis mandshurica Rupr

Clematis mandshurica Rupr (Ranunculaceae) roots are used in traditional Korean medicine to treat inflammation-related diseases. Therefore, we undertook to investigate their inhibitory effect on inflammation under non-cytotoxic conditions. The ethanolic extract of Clematis mandshurica at 100 microg/ml was found to significantly block the production of the pro-inflammatory mediators, nitric oxide (NO) and prostaglandin E(2) (PGE(2)), in lipopolysaccharide (LPS)/interferon(IFN)-gamma-stimulated mouse peritoneal macrophages, by up to 77% and 59%, respectively. In addition, it significantly inhibited cell proliferation and cytokine production (interleukin (IL)-2 and IFN-gamma) in splenocytes stimulated with Con A (concanavalin A; 5 microg/ml). Furthermore, when splenocytes from extract fed mice (200 mg/kg for 2 weeks) were activated with Con A, cell proliferation and the production of IL-2 and IFN-gamma were significantly inhibited. In addition, the extract reduced in vivo inflammation in oxazolone-induced delayed type hypersensitivity (DTH) model mice. Taken together, these data suggest that Clematis mandshurica is able to ameliorate inflammatory disease by exerting an anti-inflammatory effect in cases of proinflammatory and cell-mediated inflammation.

Potent inhibition of the inductions of inducible nitric oxide synthase and cyclooxygenase-2 by taiwaniaflavone

The improper productions of nitric oxide and prostaglandins following the inductions of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) are involved in the pathogenesis of chronic inflammation. Selaginella tamariscina is used as an oriental medicine for its anti-inflammatory effects. Here, we isolated taiwaniaflavone from S. tamariscina and investigated whether taiwaniaflavone affects the induction of iNOS and COX-2 in RAW264.7 macrophages stimulated with lipopolysaccharide. We found that taiwaniaflavone blocks the transactivations of iNOS and COX-2 genes by blocking the nuclear translocation of p65 and subsequent nuclear factor-kappaB inactivation. It is known that NF-kappaB activation is controlled by the phosphorylation and subsequent degradation of I-kappaBalpha, and in the present study, we found that the phosphorylation and degradation of I-kappaBalpha were also inhibited by taiwaniaflavone. Our findings indicate that taiwaniaflavone may provide a developmental basis for an agent against inflammatory diseases.

7,7'-Dihydroxy bursehernin inhibits the expression of inducible nitric oxide synthase through NF-kappaB DNA binding suppression

This study isolated a lignan, 7,7'-dihydroxy bursehernin, from Geranium thunbergii and investigated whether or not the lignan affects the induction of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in RAW264.7 macrophages stimulated with lipopolysaccharide (LPS). The gel shift analysis and luciferase reporter gene assays using the iNOS promoter and nuclear factor-kappaB (NF-kappaB) minimal promoter showed that a treatment with 7,7'-dihydroxy bursehernin reduced the reporter activities and binding of NF-kappaB to the NF-kappaB consensus sequence, while it had no effect on the nuclear translocation of p65 and the phosphorylation/degradation of I-kappaBalpha. It was reported that a few natural compounds directly suppressed the binding activity of the NF-kappaB components to DNA. The NF-kappaB binding activity was not reversed by the in vitro exposure of the nuclear extracts to 7,7'-dihydroxy bursehernin, which suggest that a metabolite(s) of 7,7'-dihydroxy bursehernin might target the binding of the NF-kappaB complex to the DNA binding domain region in the promoter region of the iNOS gene. After incubation of RAW264.7 cells with 7,7-dihydroxy bursehernin for 18h, the levels of parent compound were negligible; while a main metabolite, 4-[4-(n-hydroxy-phenyl)-2,3-dimethyl-buta-1,3-dienyl]-benzene-1,2-diol was detected in cell lysates and culture medium.

Effects of selective cyclooxygenase-2 inhibitor and omega-3 fatty acid on serum interleukin-1beta, osteocalcin, and C-reactive protein levels in rats

BACKGROUND

The aim of this study was to evaluate the effects of selective cyclooxygenase-2 inhibitor, celecoxib, and omega-3 fatty acid on serum levels of interleukin 1-beta (IL-1beta), osteocalcin (OC), and C-reactive protein (CRP) in experimental periodontitis.

METHODS

Experimental periodontitis in rats was induced by repeated injection of purified lipopolysaccharide (LPS) derived from Escherichia coli endotoxin. Forty-seven adult male Sprague-Dawley rats were divided into five study groups as follows: saline control, LPS, LPS + celecoxib, LPS + omega-3 fatty acid, and LPS + celecoxib + omega-3 fatty acid. Celecoxib and omega-3 fatty acid were given alone or in combination during 14 days of the experimental study period. At the end of the 2-week protocol, serum samples were obtained, and the rats were sacrificed. Serum samples were analyzed for IL-1beta, OC, and CRP concentrations by enzyme-linked immunosorbent assay. Defleshed jaws were analyzed morphometrically for alveolar bone loss. Data were evaluated statistically by non-parametric tests.

RESULTS

According to the morphometric measurements, the LPS and drug treatment groups showed significantly higher bone loss than the saline control group (P <0.05). Omega-3 fatty acid, both alone and in combination with celecoxib, revealed significantly higher IL-1beta levels than LPS and celecoxib groups (P <0.05). Individual and combined administration of celecoxib and omega-3 fatty acid significantly increased OC levels compared to the LPS group (P <0.05). There were no significant differences in serum CRP levels.

CONCLUSIONS

Celecoxib and/or omega-3 fatty acid administration does not significantly influence circulating levels of CRP. The significantly increased serum OC level observed after individual and combination administration suggests that celecoxib and omega-3 fatty acid may influence bone remodeling and thereby inhibit the progression of alveolar bone resorption. However, the failure to observe any significant inhibition of bone loss in celecoxib- and/or omega-3 fatty acid-treated rats compared to the LPS group suggests that their therapeutic effect may be reduced by other factors, such as increases in serum IL-1beta promoting osteoclast activity.

Perioperative Pain Control: A Strategy for Management

A thorough understanding of the anatomy and neurophysiology of the pain response is necessary for the effective treatment of perioperative pain. This article describes the mechanisms that produce pain,including those related to inflammation. Other topics include the pharmacologies of nonopioid and opioid analgesics. Nonopioid analgesics can be separated into two categories: nonsteroidal anti-inflammatory drugs, such as salicylates, and acetaminophen. Opioids include morphine, fentanyl, and meperidine. The pharmacology of local anesthesia is discussed. The six major adverse reactions to local anesthetics are cardiac arrhythmias, hypertension, direct tissue toxicity, central nervous system toxicity, methemoglobinemia and allergic reactions. Methods for measuring pain are described.

Clinical implications of cyclo-oxygenase-2 inhibitors for acute dental pain management: benefits and risks

BACKGROUND; Cyclo-oxygenase-2 inhibitors (COX-2i) demonstrate analgesic efficacy for patients who require gastrointestinal safety. The authors discuss the potential benefits and risks of these novel, but expensive, analgesics when used in dentistry.

METHODS

The authors conducted a MEDLINE search focused on the subject headings of common analgesic drugs and COX-2i, using peer-reviewed journals limited to the English language. They selected for review 127 articles that met the criteria. They also tried to identify any randomized controlled trials pertinent to dentistry and indicative of evidence-based medicine. RESULTS. When comparing COX isoforms (COX-1 and COX-2), the authors found that overlapping and mutually exclusively properties coexist. COX-2i originally were developed to minimize interference with the gastroprotective properties of the COX-1 isoform, while selectively preventing prostanoid synthesis expressed solely at sites of bodily trauma or other inflammation. COX-2i were found to provide pain relief equal to or slightly exceeding that offered by many mild narcotics. They may avoid some of the serious side effects that can occur with even short-term use of nonselective nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

The pharmacodynamics of COX-2i reveal an agent that includes analgesic, anti-inflammatory and gastroprotective properties but also allows for an undesirable disruption of the delicate hemodynamic balance.

CLINICAL IMPLICATIONS

Symptomatic and asymptomatic gastroparietic patients who do not have severe cardiovascular, cerebral or renal ischemic disease benefit from use of COX-2i. Long-term use of these agents in medically compromised patients may prove disastrous.

Effects of the celecoxib on the acute necrotizing pancreatitis in rats

The investigation of the effects of the celecoxib as a cylooxygenase-2 (COX-2) inhibitor on the course of the acute necrotising pancreatitis (ANP) in rats. ANP was induced in 72 rats by standardized intraductal glycodeoxycholic acid infusion and intravenous cerulein infusion. The rats were divided into four groups (six rats in each group): Sham + saline, sham + celecoxib, ANP + saline, ANP + celecoxib. Six hours later after the ANP induction, celecoxib (10 mg/kg) or saline was given i.p. In the 12th hour, routine cardiorespiratuar, renal parameters were monitored to assess the organ function. The serum amylase, alanine amino transferase (ALT), interleukin 6 (IL-6), lactate dehydrogenase (LDH) in bronchoalveolar lavage (BAL) fluid, the serum concentration of the urea, the tissue activity of myeloperoxidase (MPO) and malondialdehyde (MDA) in pancreas and lungs were measured. The pancreas histology was examined. In the second part of the study, 48 rats were studied in four groups similar to the first part. Survival of all the rats after the induction of ANP was observed for 24 h. The induction of the pancreatitis increased the mortality from 0/12, in the sham groups to 4/12 (30%) in the acute pancreatitis with saline group, 5/12 (42%) in the acute pancreatitis with celecoxib group respectively, heart rate, the serum activities of amylase, ALT, the tissue activities of MPO, MDA in the pancreas and lung, and LDH in BAL fluid, the serum concentration of the urea and IL-6, the degree of the pancreatic damage and decreased the blood pressure, the urine production, pO(2) and the serum concentration of calcium. The use of celecoxib did not alter these changes except the serum IL-6 concentration, urine production and MPO, MDA activities in the tissue of the lungs and pancreas. Serum urea concentration and pancreatic damage in ANP + celecoxib group were insignificantly lesser than ANP + saline group. Whereas treatment with celecoxib improves lung and renal functions, the degree of pancreatic damage partially and the serum IL-6 level completely, it does not improve the cardiovascular and liver functions, the mortality rate and the calcium level. Celecoxib may be useful for the support of some organ functions during ANP in rats.

Preparation of celecoxib-dimethyl-β-cyclodextrin inclusion complex: characterization and in vitro permeation study

The ability of 2,6-di-O-methyl-beta-cyclodextrin (DM-beta-Cyd) to include the anti-inflammatory drug celecoxib (CCB) was evaluated. The complex was prepared by kneading and freeze-drying methods and was characterized in the solid state and in aqueous solution. Water solubility and dissolution rate of CCB, in a medium simulating gastric fluid, significantly increased after complexation, with complete dissolution obtained after 30 and 180 min for the freeze-dried and kneaded complexes respectively. Phase solubility studies showed Ap-type diagrams. Stability constants for the 1:1 and 1:2 CCB-DM-beta-Cyd complexes and (1)H-NMR studies suggested a probable 1:1 inclusion complex and only an external interaction for the second Cyd molecule. Thermodynamic parameters of the binding process showed the existence of van der Waals forces between CCB and DM-beta-Cyd. DM-beta-Cyd influenced the permeation of CCB through the CaCo-2 cells monolayer. The increase of permeation observed was due to the fast dissolution rate of the included drug and to a destabilizing action exerted by the macrocycle on the biomembrane.

Individual and combined effects of selective cyclooxygenase-2 inhibitor and omega-3 fatty acid on endotoxin-induced periodontitis in rats

BACKGROUND

The present study was planned to evaluate the individual and combined effects of selective cyclooxygenase-2 (COX-2) inhibitor, celecoxib, and omega-3 fatty acid on the gingival tissue levels of prostaglandin E2 (PGE2), prostaglandin F2alpha (PGF2alpha), leukotriene B4 (LTB4), and platelet activating factor (PAF) in endotoxin-induced periodontitis in rats.

METHODS

Experimental periodontitis was induced by repeated injection of Escherichia coli endotoxin (LPS). Forty-four adult male Sprague-Dawley rats were divided into five study groups: saline control, LPS, celecoxib, omega-3 fatty acid, and combination celecoxib and omega-3 fatty acid. Celecoxib and omega-3 fatty acid were given either as a single agent or as a combination therapy during 14 days of the study period. At the end of the 2-week protocol, the rats were sacrificed, the gingival tissues were dissected and extracted, and the extracts were analyzed for PGE2, PGF2alpha, and LTB4 levels by enzyme immunoassay and for PAF levels by radioimmunoassay. The defleshed jaws were analyzed morphometrically for alveolar bone loss. Data were evaluated statistically by using parametric tests.

RESULTS

LPS injection resulted in significantly more bone loss than the saline controls (P<0.05) and significant elevations in the gingival tissue levels of all the analyzed mediators except PGF2alpha. Individual administration of celecoxib revealed significant reductions in PGE2 and PAF levels (P <0.05), while omega-3 fatty acid provided significant reduction in PGE2, PGF2alpha, and LTB4 levels compared to the LPS group (P <0.05). Combined administration of celecoxib and omega-3 fatty acid exhibited significantly lower values than those of the LPS group in all the analyzed membrane phospholipid mediators (P <0.05), which approximated the levels in the saline control group (P>0.05).

CONCLUSIONS

The results of the present study indicate that celecoxib and omega-3 fatty acid, when used individually, show a rather partial effect on the control of the analyzed mediators, but when combined they show a synergic effect and provide significant reductions in the gingival tissue levels of PGE2, PGF2alpha, LTB4, and PAF in LPS-induced experimental periodontitis. These findings may pioneer further clinical human studies investigating the possible place of celecoxib and omega-3 fatty acid in periodontal treatment.

Survivin: a novel target for indomethacin-induced gastric injury

BACKGROUND & AIMS

Nonsteroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal erosions and ulcers. Apoptosis is one of the mechanisms. The role of survivin, an antiapoptosis protein, in NSAID-induced gastric injury is unknown. We examined the role of survivin in NSAID-induced gastric mucosal and gastric cell injury.

METHODS

We examined: (1) the effects of indomethacin (nonselective NSAID), celecoxib and NS-398 (cyclooxygenase [COX]-2-selective NSAIDs), SC-560 (a COX-1-selective NSAID), and SC-560 plus celecoxib on survivin expression and extent of injury in rat gastric mucosa; (2) the effects of indomethacin, NS-398, SC-560, and SC-560 plus NS-398 on survivin expression and injury in gastric epithelial (RGM-1) cells; and (3) the effects of survivin suppression with small interfering RNA (siRNA) on RGM-1 cell integrity at baseline and following indomethacin injury.

RESULTS

Indomethacin treatment dose-dependently reduced survivin protein levels and caused severe injury of gastric mucosa and RGM-1 cells. Suppression of survivin expression with siRNA in RGM-1 cells caused cell damage and increased susceptibility to injury by indomethacin. Celecoxib treatment caused exfoliation of the mucosal surface epithelium, but neither caused deep erosions or altered survivin expression. Neither NS-398 nor SC-560 treatment altered survivin levels or produced injury in vivo or in vitro. COX-1 and COX-2 inhibitor combination caused injury in vivo and in vitro but did not decrease survivin expression.

CONCLUSIONS

(1) Indomethacin, but not selective COX-1 or COX-2 inhibitors alone or in combination, reduces survivin expression in gastric mucosal cells and (2) significant reduction of survivin precedes greater severity of gastric injury.

Cyclooxygenase Isozymes: The Biology of Prostaglandin Synthesis and Inhibition

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent one of the most highly utilized classes of pharmaceutical agents in medicine. All NSAIDs act through inhibiting prostaglandin synthesis, a catalytic activity possessed by two distinct cyclooxygenase (COX) isozymes encoded by separate genes. The discovery of COX-2 launched a new era in NSAID pharmacology, resulting in the synthesis, marketing, and widespread use of COX-2 selective drugs. These pharmaceutical agents have quickly become established as important therapeutic medications with potentially fewer side effects than traditional NSAIDs. Additionally, characterization of the two COX isozymes is allowing the discrimination of the roles each play in physiological processes such as homeostatic maintenance of the gastrointestinal tract, renal function, blood clotting, embryonic implantation, parturition, pain, and fever. Of particular importance has been the investigation of COX-1 and -2 isozymic functions in cancer, dysregulation of inflammation, and Alzheimer's disease. More recently, additional heterogeneity in COX-related proteins has been described, with the finding of variants of COX-1 and COX-2 enzymes. These variants may function in tissue-specific physiological and pathophysiological processes and may represent important new targets for drug therapy.

Analgesic efficacy of a single dose of lumiracoxib compared with rofecoxib, celecoxib and placebo in the treatment of post-operative dental pain

This randomised, double-blind, placebo-controlled, parallel-group study compared the efficacy and tolerability of lumiracoxib (a novel COX-2 selective inhibitor) with rofecoxib, celecoxib and placebo in patients with moderate-to-severe post-operative dental pain. Following third molar extraction, patients received single oral doses of lumiracoxib 400 mg, rofecoxib 50 mg, celecoxib 200 mg or placebo (n = 355). Additional patients from a similar study, assigned to lumiracoxib, rofecoxib or placebo (n = 155), were included for analysis of the primary variable, Summed Pain Intensity Difference over the first 8 h post dose (SPID-8). For SPID-8, lumiracoxib was superior to rofecoxib (p < 0.05), celecoxib (p < 0.001) and placebo (p < 0.001). Lumiracoxib demonstrated the fastest onset of analgesia and the longest time to rescue medication use. Patient global evaluation of lumiracoxib was comparable to rofecoxib and superior to celecoxib and placebo. All treatments were well tolerated. Lumiracoxib 400 mg provides rapid, effective and sustained relief of post-operative dental pain, comparable or superior to rofecoxib.

Solubility enhancement of celecoxib using β-cyclodextrin inclusion complexes

Celecoxib has very low water solubility. It forms a complex with beta-cyclodextrin (betaCD) both in aqueous and in solid state. It was observed that due to formation of the inclusion complex, the solubility and dissolution rate of celecoxib were enhanced. The formation of 1:1 complex with betaCD in solution was confirmed by phase solubility and spectral shift studies. The apparent stability constants calculated by these techniques were 881.5 and 341.5 M(-1), respectively. The solid inclusion complexes of celecoxib and betaCD were prepared by the kneading method using different molar proportions of betaCD, and formation of solid inclusion complexes of celecoxib and betaCD at different molar ratios were confirmed by differential scanning calorimetry. Enhancement of dissolution rates with increasing quantity of betaCD in the complex was observed. It was also observed that the complexes exhibit higher dissolution rates than the pure drug and physical mixture.

Antinociception and the new COX inhibitors: research approaches and clinical perspectives

New generations of cyclooxygenase (COX) inhibitors are more potent and efficacious than their traditional parent compounds. They are also safer than the classic non-steroidal anti-inflammatory drugs (NSAIDs) and are starting to be used not only for low to moderate intensity pain, but also for high intensity pain. Three different strategies have been followed to improve the pharmacological profile of COX inhibitors: 1. Development of COX-2 selective inhibitors. This is based on the initial hypothesis that considered COX-2 as the enzyme responsible for the generation of prostaglandins only in inflammation, and, therefore, uniquely responsible for inflammation, pain and fever. Initial expectations gave rise to controversial results, still under discussion. The second generation of these compounds is being developed and should contribute to clarifying both their efficacy and the specific functions of the COX enzymes. 2. Modified non-selective COX inhibitors. Molecules like nitro-NSAIDs or tromethamine salt derivatives have been synthesized considering that both COX-1 and COX-2 are responsible for the synthesis of prostaglandins involved either in homeostatic functions or inflammation. Nitroaspirin, nitroparacetamol or dexketoprofen trometamol are some examples of molecules that are already showing an important clinical efficacy. The modifications performed in their structures seem to lower the unwanted side effects as well as to enhance their analgesic efficacy. 3. Combined therapy of classic NSAIDs with other drugs. This strategy looks for improvements in the incidence of adverse effects or to take advantage of the synergistic enhancement of their therapeutic effects. Some of the molecules resulting from these strategies are very valuable as therapeutic agents and open a wide range of possibilities in the treatment of high intensity pain, including neuropathic pain, and opiate sparing therapy.

Effect of celecoxib and dexamethasone on postoperative pain after lumbar disc surgery

OBJECTIVE

This study was designed to assess the efficacy of perioperative administration of celecoxib (Celebrex; Pharmacia GmbH, Erlangen, Germany) in reducing pain and opioid requirements after single-level lumbar microdiscectomy.

METHODS

We studied 34 patients (mean age, 44.26 yr; standard deviation [SD], 13.09 yr) allocated randomly to receive celecoxib 200 mg twice a day for 72 hours starting on the evening before surgery or placebo capsules in a double-blind study. Fourteen patients received 20 to 80 mg dexamethasone intravenously during surgery (mean, 40 mg; SD, 19.22 mg) because of visible signs of compression of the affected nerve root. After lumbar disc surgery, patients were monitored for visual analog scores for pain at rest and on movement, patient-controlled analgesia (PCA) piritramide requirements, and von Frey thresholds in the wound area.

RESULTS

Pain scores decreased and wound von Frey thresholds increased continuously until discharge, with no intergroup differences. Mean 24-hour PCA piritramide requirements were 22.63 mg (SD, 23.72 mg) and 26.14 mg (SD, 22.57 mg) in the celecoxib and placebo groups, respectively (P = not significant). However, patients with intraoperative dexamethasone (n = 14) required only 10.29 mg (SD, 8.55 mg) 24-hour PCA piritramide, in contrast to the 34.25 mg (SD, 24.69 mg) needed in those who did not receive intraoperative dexamethasone (P = 0.001). In addition, 24 hours after the operation, pain scores on movement were significantly lower in the dexamethasone subgroup (P = 0.003).

CONCLUSION

Celecoxib has no effect on postoperative pain scores and PCA piritramide requirements. The intraoperative use of 20 to 80 mg dexamethasone is able to significantly decrease postoperative piritramide consumption and pain scores on the first day after surgery.

Effects of MF-tricyclic, a selective cyclooxygenase-2 inhibitor, on atherosclerosis progression and susceptibility to cytomegalovirus replication in apolipoprotein-E knockout mice

OBJECTIVES

We examined whether selective cyclooxygenase-2 (COX-2) inhibition in apolipoprotein-E (apoE) deficient mice reduces cytomegalovirus (CMV) replication, and determined whether COX-2 anti-inflammatory activity leads to decreased atherosclerosis.

BACKGROUND

Evidence suggests that CMV infection contributes to atherosclerosis and that this occurs in part through inflammatory mechanisms. Cyclooxygenase-2 inhibitors are potent anti-inflammatory agents. They also inhibit CMV replication in vitro.

METHODS

The apoE deficient mice were either treated or not treated with a selective COX-2 inhibitor, and either infected or not infected with CMV. Viral deoxyribonucleic acid load in salivary glands was determined by quantitative polymerase chain reaction. Atherosclerotic lesion analysis was performed by standard methods.

RESULTS

In vivo COX-2 inhibition, unexpectedly increased viral load: in the CMV-infected animals viral load was 2.58 +/- 1.0 in the nontreated group, 4.74 +/- 1.38 in the group treated with 12 mg/kg/day MF-tricyclic, and 6.51 +/- 1.64 in the group treated with 24 mg/kg/day MF-tricyclic (p trend = 0.050). This increased viral load was paralleled by increased anti-CMV antibody titers. Most surprisingly, COX-2 inhibition significantly increased early atherosclerotic lesion area, independent of viral infection.

CONCLUSIONS

Our study demonstrates that selective inhibition of COX-2 in vivo increases viral load. The finding that inhibition of COX-2 increases atherosclerosis development in apoE deficient mice suggests, unexpectedly, that this enzyme exerts antiatherosclerosis activity, at least in this model.

Acute pain management for patients undergoing thoracotomy

Management of thoracotomy pain can be difficult, but the benefits of effective pain control are significant. A variety of modalities for treating postoperative pain after thoracotomy are available, including systemic opiates, regional analgesics, and new oral and parenteral agents. This work provides a review of the literature and recommendations for the clinician.

Effects of selective cyclooxygenase-2 inhibition on gingival tissue levels of prostaglandin E2 and prostaglandin F2alpha and clinical parameters of chronic periodontitis

BACKGROUND

The purpose of the present study was to evaluate the effect of a relatively selective cyclooxygenase (COX)-2 inhibitor (nimesulide) and non-selective COX-1/COX-2 inhibitor (naproxen) used as an adjunct to non-surgical (scaling and root planing [SRP]) periodontal therapy in chronic periodontitis patients on the gingival tissue (GT) levels of prostaglandin (PG)E2 and PGF2alpha.

METHODS

Thirty patients with chronic periodontitis were divided into 3 groups of 10 each. One group received 100 mg of nimesulide; one received 275 mg of naproxen sodium; and the third group received placebo tablets in a 2 x 1 regimen for 10 days as an adjunct to SRP. GT samples were obtained before drug intake and on day 10. Plaque index (PI) and papillary bleeding index (PBI) scores were recorded at baseline, day 10, and at 3 months; probing depth (PD) and clinical attachment level (CAL) were recorded at baseline and at 3 months. The levels of PGE2 were detected using an enzyme immunoassay (EIA), and the levels of PGF2alpha were analyzed by radioimmunoassay (RIA). Differences among and within the groups were assessed using non-parametric statistical analysis. Ten periodontally healthy individuals served as controls.

RESULTS

All 3 groups showed statistically significant reductions in PBI and PI on day 10 and at 3 months (P < 0.02), and in PD and CAL at 3 months (P < 0.02, P < 0.05, respectively). In the naproxen group, GT PGE2 levels exhibited a significant decrease (P < 0.05). However, the decrease of GT PGE2 levels in the nimesulide group was insignificant (P > 0.05), while a significant increase was observed in the placebo group (P < 0.05) on day 10. Both the nimesulide and naproxen groups showed a significant decrease (P<0.05) in PGF2alpha level, while the placebo group showed a significant increase (P<0.05).

CONCLUSIONS

Nimesulides, relatively selective COX-2 inhibitors, may have additional inhibitory effects on GT PGF2alpha levels in the first week following non-surgical periodontal treatment. However, nimesulide has an insignificant effect on reducing PGE2 levels in gingival tissue. The determination of GT levels of COX-1 and COX-2 enzymes as well as PGE2 and PGF2alpha in long-term studies may provide further support for the adjunctive use of selective COX-2 inhibitors in treatment of chronic periodontitis.

Expression of cyclooxygenase-2 in the periprosthetic capsule surrounding a silicone shell implant in the rat

Prosthetic breast implants are used frequently for both aesthetic and reconstructive purposes. Histologically, the normal tissue response to silicone implants typically involves an inflammatory infiltrate that consists initially of macrophages, and later consists of fibroblasts, myofibroblasts, and lymphocytes. To characterize further the nature of the inflammatory response to silicone breast implants, the authors evaluated the expression of the enzyme cyclooxygenase-2 (COX-2) by the tissues and cells of the breast capsule after silicone augmentation in an animal model. COX-2 is an inducible enzyme that is expressed primarily in response to inflammatory stimuli and mediates the production of prostaglandins that support the inflammatory process. Fifty-nine animals at five time points were evaluated. Specifically, on days 4, 7, 14, 28, and 80 the authors identified cytoplasmic COX-2 expression in each of the three cell types of interest, including endothelial cells, macrophages, and fibroblasts. Selective COX-2 inhibiting agents may be an appropriate pharmacological intervention for modulating the formation of periprosthetic capsules.

Novel concepts for analgesia in pediatric surgical patients. Cyclo-oxygenase-2 inhibitors, alpha 2-agonists, and opioids

Pain has been an understated concern in infants and children. Failure to recognize pain in the past has resulted in undue suffering by infants and children of all ages, but with the introduction of instruments to measure pain and a widespread appreciation of the severity of this problem in this age group, pain is rapidly coming under control. Novel concepts in both old and new analgesics have created safe and effective pain management strategies for infants and children. This review examines three analgesics and their potential roles in infants and children: cyclo-oxygenase (COX)-2 inhibitors, alpha 2-agonists and opioids.

Cyclooxygenase-2--10 years later

The enzyme cyclooxygenase (COX) catalyzes the first step of the synthesis of prostanoids. In the early 1990s, COX was demonstrated to exist as two distinct isoforms. COX-1 is constitutively expressed as a "housekeeping" enzyme in most tissues. By contrast, COX-2 can be up-regulated by various pro-inflammatory agents, including lipopolysaccharide, cytokines, and growth factors. Whereas many of the side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., gastrointestinal ulceration and bleeding, platelet dysfunctions) are caused by a suppression of COX-1 activity, inhibition of COX-2-derived prostanoids facilitates the anti-inflammatory, analgesic, and antipyretic effects of NSAIDs. During the past few years specific inhibitors of the COX-2 enzyme have emerged as important pharmacological tools for treatment of pain and arthritis. However, although COX-2 was initially regarded as a source of pathological prostanoids only, recent studies have indicated that this isoenzyme mediates a variety of physiological responses within the organism. The present review assesses recent advances in COX-2 research, with particular emphasis on new insights into pathophysiological and physiological functions of this isoenzyme.

Cyclooxygenase-2 inhibitor for pain management in osteoid osteoma

Thirteen patients with osteoid osteoma were enrolled in a prospective trial to test whether rofecoxib, a selective cyclooxygenase-2 inhibitor, is as effective for pain control as acetylsalicylic acid. Each patient documented the pain level using a visual analog scale, with 0 being no pain and 10 being unbearable pain, during 2 days of no pain medication, 4 days of 500 mg acetylsalicylic acid three times a day, and 10 days of 25 mg rofecoxib once a day. Oral administration of 500 mg acetylsalicylic acid three times a day led to a significant decrease in pain at night, pain at rest, and pain induced by exercise. Twenty-five milligrams rofecoxib given once a day at midday showed the same remarkable improvement in pain at night, pain at rest, and pain induced by exercise. Rofecoxib in comparison with acetylsalicylic acid showed a trend toward lower pain levels in all categories. Rofecoxib offered a significantly better reduction in pain at rest during the day than did acetylsalicylic acid. Results of the current study suggest that pain induction in osteoid osteoma is related to cyclooxygenase-2, an enzyme that is blocked by acetylsalicylic acid and rofecoxib. Conservative medical treatment with rofecoxib for osteoid osteoma is recommended when percutaneous intervention is associated with significant morbidity.

Postsurgical wound management

Successful outcomes in cutaneous surgery depend on a variety of factors, including preoperative assessment of the patient's health and expectations, intraoperative skill and attention to detail, and managing the postoperative period. Once the procedure is complete, careful selection of dressings, provision of adequate analgesia, judicious management of complications and monitoring the phases of early maturation while providing patient education improve the likelihood of long-term patient and physician satisfaction.

Principles of perioperative pain management in older adults

The consequences of poor planning for pain management during surgery of geriatric patients not only affect the immediate well-being of the patient but also have terrible socioeconomic implications. Delays in rehabilitation, increases in hospital lengths of stay, and increased comorbidity can be expected if interventions for pain management are either inadequate or excessive without appropriate monitoring. During surgery, seniors are likely to suffer from acute and chronic pain that must be addressed aggressively in the postoperative period to ensure a rapid functional recovery. New pain scales have been developed with seniors in mind, and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. This article is designed to help clinicians to strategically implement optimal pain management principles and techniques and, thus, help to fulfill the obligation to relieve pain and suffering in patients in the perioperative period, which will ensure the greatest chance of recovery to optimal independence for patients.

Cyclooxygenase-1 vs. cyclooxygenase-2 inhibitors in the induction of antinociception in rodent withdrawal reflexes

Non-steroidal antiinflammatory drugs (NSAIDs) inhibit the cyclooxygenase (COX) enzyme and so they are effective analgesic, antiinflammatory and antipyretic drugs. The discovery of COX-2 led to the search for new NSAIDs with a selective action over this isoenzyme. The experiments performed to date have shown either more, less or no different efficacy of new COX-2 selective NSAIDs when compared to the non-selective inhibitors, probably because the comparison has not been performed under similar conditions. We have therefore compared the analgesic activity of six NSAIDs with different selectivity for the COX isoenzymes. The experiments were performed using the recording of spinal cord nociceptive reflexes in anaesthetised rats and in awake mice. The non-selective COX inhibitors, such as dexketoprofen trometamol, were effective in reducing nociceptive responses both in normal and monoarthritic rats (ED50s: 0.31 and 3.97 micromol/kg, respectively), and in mice with paw inflammation (12.5 micromol/kg, p < 0.01). The COX-1 selective inhibitor SC-58560 showed efficacy in normal rats (ED50: 0.8 micromol/kg) and in mice with paw inflammation (15 micromol/kg, p < 0.05), but not in monoarthritic rats. The COX-2 selective inhibitors celecoxib (105 micromol/kg) and rofecoxib (128 micromol/kg) however, were not effective in any of the groups studied. We conclude that inhibition of both COX isoenzymes is needed to achieve an effective analgesia in inflammation.

Eficácia e tolerabilidade da nimesulida versus celecoxib na osteoartrite

O objetivo do estudo foi comparar a eficácia e a tolerabilidade da nimesulida versus o celecoxib no tratamento da osteoartrite. A casuística envolveu 57 pacientes com idade entre 40 e 80 anos, que foram randomizados em dois grupos, recebendo as medicações do estudo durante 30 dias de forma simples-cega na dosagem de um comprimido de 100mg de nimesulida duas vezes ao dia e uma cápsula de 100mg de celecoxib duas vezes ao dia. Após a inclusão no estudo na visita basal, foram realizadas três visitas com intervalo de dez dias entre elas. Os aspectos analisados foram: dor em repouso, dor em movimento e dor noturna, através de uma escala analógica da dor, duração da rigidez matinal, capacidade funcional (HAQ), classe funcional ACR-1991 e o índice de gravidade para osteoartrite de joelhos em todas as visitas. Foi também avaliado o tempo para andar 15 metros naqueles pacientes com acometimento de joelhos ou quadril. A avaliação da eficácia e tolerabilidade foi realizada pelo investigador e pelo paciente nas três visitas após o início do tratamento. Os eventos adversos foram registrados durante todo o período do estudo. Houve diminuição significativa e semelhante nas médias da escala para dor ao movimento e dor em repouso para ambos medicamentos em todas as visitas. Houve diminuição da dor noturna ao longo do tratamento no grupo celecoxib e a partir da visita 3 no grupo nimesulida, e ao final do estudo, as médias dos dois grupos foram semelhantes ( p = 0,152). As médias da duração da rigidez matinal diminuíram significativamente no grupo tratado com nimesulida durante todo o seguimento, e no grupo celecoxib a partir da visita 3, sendo semelhantes ao final do estudo ( p= 0,993). O tempo médio para andar 15 metros diminuiu significativamente no grupo nimesulida na visita 4 (p < 0,001*), e todas as médias deste intervalo de tempo foram menores do que no grupo celecoxib a partir da segunda visita. Houve diminuição significativa nas médias de capacidade funcional ( escala HAQ) no grupo nimesulida durante todo o período do estudo, enquanto que no grupo celecoxib, apenas na visita 4, onde as médias foram semelhantes ( p=0,517). No grupo nimesulida o índice de gravidade de Lequesne e Samson (1991) para osteoartrite de joelhos diminuiu significativamente a partir da visita 3, o que não ocorreu no grupo celecoxib. Os dois grupos tiveram evolução semelhante quanto à classificação funcional ACR-1991 durante o período do estudo. Ambos grupos foram semelhantes na avaliação da eficácia e da tolerabilidade segundo o paciente, e da eficácia segundo o médico. Durante o período do estudo, 21% dos pacientes do grupo nimesulida e 25% do grupo celecoxib apresentaram eventos adversos. Em conclusão, a nimesulida demonstrou eficácia e tolerabilidade semelhante ao celecoxib no tratamento da osteoartrite. A dor noturna diminuiu mais precocemente no grupo celecoxib; nos parâmetros rigidez matinal, capacidade funcional e o índice de gravidade para a osteoartrite de joelho constatou-se uma resposta mais rápida nos pacientes tratados com a nimesulida.

Pain management in older adults: prevention and treatment

The release of guidelines in 1998 by the American Geriatrics Society on "The Management of Chronic Pain in Older Persons" was a breakthrough in helping to manage pain in this population. Already advances have fostered a need to update recommendations. This article focuses on the treatment strategies available for seniors that are likely to help to fulfill the obligation to relieve pain and suffering in patients. A review was done of the literature using Medline and other search techniques. New pain scales have been developed with seniors in mind and greater testing of older scales in elderly populations have helped to identify measures of pain more suited to frail seniors. Advances in cyclooxygenase inhibition selectivity, alternative medicine, and progress in the identification of nonopioid pain receptors and the development of products to target them are just a few of changes that have altered the way clinicians think about treating pain. The use of hospice in end-of-life palliative care is a valuable resource for clinicians managing pain at that phase in care as well. Tools are available to prevent and treat pain successfully in seniors. Educating clinicians about available assessment tools, techniques and interventions may be the biggest challenge to comforting the older adult in pain.

Hyaluronan-induced cyclooxygenase-2 expression promotes thromboxane A2 production by renal cells

BACKGROUND

Matrix degradation products such as fragmented hyaluronan (HA) display important proinflammatory effects on renal tubular epithelial cells (TECs) and macrophages (MPhis). We hypothesized that HA could up-regulate cyclooxygenase type 2 (COX-2) in these cells and that the subsequent production of thromboxane A2 (TXA2) could play a role in inflammatory renal lesions.

METHODS

We used an in vitro approach to examine the expression of COX-1 and COX-2 and the production of TXA2 in response to fragments of HA. COX-2 mRNA, protein, and the resulting TXA2 production were measured in CD44-positive, HA-responsive cells lines of TECs and MPhi. COX-2 mRNA was also measured in vivo in MRL-Faslpr mice and in mice with anti-glomerular basement membrane (anti-GBM) nephritis.

RESULTS

In TECs and MPhis, HA increased the steady-state COX-2 mRNA and protein levels markedly, whereas COX-1 mRNA levels did not change. The HA-induced response was comparable to lipopolysaccharide stimulation. In comparison with MPhi, the response was much weaker in TECs. Likewise, the production of TXA2 in response to HA was markedly increased in MPhi, but less in TECs. In TECs and in MPhi, the HA-stimulated TXA2 synthesis was inhibited with the COX-2-selective inhibitors SC58125 (12.5 micromol/L) or celecoxib (0.25 to 5.00 micromol/L). COX-2 mRNA levels were increased in nephritic mice with MRL-Faslpr lupus nephritis and in mice with anti-GBM disease.

CONCLUSIONS

HA is a proinflammatory factor that stimulates COX-2 expression and subsequent TXA2 production. Since HA accumulates markedly in renal injury, we speculate that this matrix molecule could therefore play a significant role in thromboxane-mediated immune events in the kidney.

Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis

The results of 32 total knee arthroplasties performed for osteoarthritis in 32 patients who were 40 years of age or younger are reviewed. At a mean followup of 7.9 years (minimum, 5 years), the Knee Society knee scores increased from an average of 47 to 88 points, and the function scores increased from 45 to 70 points. Overall, Knee Society knee scores were considered good or excellent in 82% of patients (26 knees) and fair or poor in 18% (six knees). Postoperative function scores were good or excellent in only 40% (13 knees). The average postoperative flexion arc was 110 degrees. If patients involved in worker's compensation cases are excluded from analysis, the results improved substantially, with range of motion averaging 113 degrees, and Knee Society knee scores and function scores averaging 92 points and 77 points, respectively. Excluding the five patients involved in workmen's compensation cases, knee scores were good or excellent in 91% of patients (25 knees) and function scores were good or excellent in 50% of patients (14 knees). Three revisions were performed for aseptic failure; one additional patient has radiographic evidence of tibial loosening, representing an aseptic failure rate of 12.5% at 8 years. Although slightly higher than observed in older patients, this failure rate still may be considered acceptable for this population of patients with severely affected knees who are not considered candidates for nonarthroplasty surgery. Despite a slightly higher tendency for aseptic failures in this group of patients, cemented total knee arthroplasty may provide some patients younger than 40 years of age with severe debilitating and recalcitrant osteoarthrosis, an important option with reasonable mid- and long-term results.

New insights into physiological and pathophysiological functions of cyclo-oxygenase-2

During the past few years specific inhibitors of the cyclo-oxygenase-2 enzyme have emerged as important pharmacological tools for treatment of patients with rheumatoid arthritis or osteoarthritis. In comparison to traditional nonsteroidal anti-inflammatory drugs, specific cyclo-oxygenase-2 inhibitors may provide equal efficacy in terms of antiinflammatory and analgesic action, with significantly fewer gastrointestinal side effects. Although cyclo-oxygenase-2 was once regarded as a source of pathological prostanoids, recent studies have indicated that this isoenzyme also fulfills a variety of physiological functions within the organism. The present review assesses recent advances in cyclo-oxygenase-2 research, with particular emphasis on new insights into the biology of this isoenzyme.

Osteoarthritis pain and its treatment

Pain is the most important symptom of osteoarthritis (OA) and the reason why individuals seek medical treatment. The anatomic cause is unclear and is likely to vary between individuals. Recent work confirms the heterogeneity of pain in OA with differences in severity, location, precipitating and relieving factors, and response to intra-articular anesthetic. Nonpharmacologic treatment of OA is important and evidence is now accumulating for interventions such as aerobic exercise, quadriceps exercises, footwear modification, education, and social support. Analgesia remains the first choice drug therapy: compounds more potent than acetaminophen are now available and effective. New cyclooxygenase-2 (COX-2) inhibitors may have a role in subjects for whom simple analgesia is inadequate. Glucosamine is a simple, safe product that appears to have a weak pain-relieving effect, and intra-articular hyaluronate injections may also have a limited role. Recent community studies confirm the benefit of joint replacement in OA, though a number of questions remain about the timing, indications, and alternatives to surgery.

[Aspirin, pain and inflammation]

SUBJECT

Acetylsalicylic acid (ASA) is among the most commonly analgesic, antipyretic and anti-inflammatory used drugs. The anti-inflammatory effects of ASA are mediated by the inhibition of cyclooxygenase enzymes with the subsequent decrease of prostaglandin synthesis.

NEW DATA

However, since this discovery of Vane in 1971, much of other mechanisms of anti-inflammatory action, without relation with cyclooxygenases, have been proposed. ASA has peripheric analgesic properties by reducing prostaglandin biosynthesis. But there is evidence that the analgesic effects could be mediated by central mechanisms with changes in the monoaminergic and opioid systems. ASA is essentially used in moderate pains with an inflammatory component (rheumatological disorders, headaches, dental and postoperative pains).

PERSPECTIVES

The clinical use of ASA at anti-inflammatory dose is less frequent because the other non steroidal anti-inflammatory drugs are as effective as ASA, but they are associated with less side effects. Nevertheless, the synergism of ASA and morphine association and the possible involvement of the central serotonergic and opiatergic systems in the antinociceptive activity of ASA could confer a greater role of ASA in pain management.