Central analgesic activity of nonsteroidal antiinflammatory drugs in animal and human pain models

Surface modified multifaceted nanocarriers for oral non-conventional cancer therapy; synthesis and evaluation

Inflammatory cells orchestrate tumor niche for the proliferating neoplastic cells, leading to neoangiogenesis, lymphangiogenesis, tumor growth and metastasis. Emergence of severe side effects, multiple drug resistance and associated high cost has rendered conventional chemotherapy less effectual. The aim was to develop a multipurpose, less toxic, more potent and cheaper, oral non-conventional anticancer therapeutic. Cyclooxygenase associated with tumor niche inflammation and proliferative neoplastic cells were targeted synergistically, through anti-inflammatory and anti-proliferative effects of model drug, diclofenac sodium and fluorescent silver nanoparticles (AgNPs), respectively. Drug entrapped AgNPs were surface modified with PVA (for controlling particle size, preferred cellular uptake, evading opsonization and improved dispersion). XRD, FTIR, DSC, TGA, LIBS, particle size and surface plasmon resonance analysis confirmed the efficient drug encapsulation and PVA coating with 62% loading efficiency. In-vitro, the formulation exhibited 1st order release kinetics with sustained and maximal release at slightly acidic conditions (pH 4.5) enabling the potential for passive tumor targeting. Also, nanoparticles showed efficient protein denaturation inhibition potential, hemo-compatibility (<0.8%) and potent anti-cancer activity (P < 0.05) against breast cancer cell line (MCF-7). In-vivo, developed nanoparticles improved pharmacokinetics (2.8 fold increased AUC, 6.9 h t_1/2, C_max = 1.6 ± 0.03 μg/ml, K_el = 0.1) and pharmacodynamics manifested by potent anti-inflammatory, analgesic and anti-pyretic effects (P < 0.05) at 20 fold lower doses. LD₅₀ determination revealed a wide therapeutic window. The study showed promise of synthesized nanomaterials as cheaper, less toxic, hemo-compatible, oral and more potent anti-inflammatory and non-conventional fluorescent anti-cancer agents, vanquishing tumor niche inflammation and repressing proliferation of malignant cells.

Pharmacokinetics of meloxicam after intramuscular and oral administration of a single dose to American flamingos (Phoenicopertus ruber)

OBJECTIVE To determine pharmacokinetics after IM and oral administration of a single dose of meloxicam to American flamingos (Phoenicopertus ruber). ANIMALS 14 adult flamingos. PROCEDURES Flamingos were allocated to 2 groups. Each group received a dose of meloxicam (1 mg/kg) by the IM or oral route. After a 4-week washout period, groups received meloxicam via the other route of administration. Plasma meloxicam concentrations were measured with high-performance liquid chromatography. Data for each bird were analyzed. Estimated values of selected pharmacokinetic parameters were compared by use of a linear mixed-effects ANOVA. Pooled concentration-time profiles for each route of administration were analyzed to examine the influence of body weight on pharmacokinetics. RESULTS Mean ± SD maximum plasma concentration was 1.00 ± 0.88 μg/mL after oral administration. This was approximately 15% of the mean maximum plasma concentration of 5.50 ± 2.86 μg/mL after IM administration. Mean time to maximum plasma concentration was 1.33 ± 1.32 hours after oral administration and 0.28 ± 0.17 hours after IM administration. Mean half-life of the terminal phase after oral administration (3.83 ± 2.64 hours) was approximately twice that after IM administration (1.83 ± 1.22 hours). CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the extent and rate of meloxicam absorption were less after oral administration than after IM administration. Intramuscular administration resulted in a short period during which mean plasma concentrations met or exceeded reported efficacious analgesic concentrations in other species, whereas oral administration did not. These results suggested that higher doses may be required for oral administration.

Effects of meloxicam on hematologic and plasma biochemical analysis variables and results of histologic examination of tissue specimens of Japanese quail (Coturnix japonica)

OBJECTIVE

To determine the effects of meloxicam on values of hematologic and plasma biochemical analysis variables and results of histologic examination of tissue specimens of Japanese quail (Coturnix japonica).

ANIMALS

30 adult Japanese quail.

PROCEDURES

15 quail underwent laparoscopic examination of the left kidneys, and 15 quail underwent laparoscopic examination and biopsy of the left kidneys. Quail in each of these groups received meloxicam (2.0 mg/kg, IM, q 12 h; n = 10) or a saline (0.9% NaCl) solution (0.05 mL, IM, q 12 h; control birds; 5) for 14 days. A CBC and plasma biochemical analyses were performed at the start of the study and within 3 hours after the last treatment. Birds were euthanized and necropsies were performed.

RESULTS

No adverse effects of treatments were observed, and no significant changes in values of hematologic variables were detected during the study. Plasma uric acid concentrations and creatine kinase or aspartate aminotransferase activities were significantly different before versus after treatment for some groups of birds. Gross lesions identified during necropsy included lesions at renal biopsy sites and adjacent air sacs (attributed to the biopsy procedure) and pectoral muscle hemorrhage and discoloration (at sites of injection). Substantial histopathologic lesions were limited to pectoral muscle necrosis, and severity was greater for meloxicam-treated versus control birds.

CONCLUSIONS AND CLINICAL RELEVANCE

Meloxicam (2.0 mg/kg, IM, q 12 h for 14 days) did not cause substantial alterations in function of or histopathologic findings for the kidneys of Japanese quail but did induce muscle necrosis; repeated IM administration of meloxicam to quail may be contraindicated.

Acute castration and/or tailing distress and its alleviation in lambs

PURPOSES AND APPROACH: Acute castration and/or tailing distress in lambs has been examined extensively during the last decade. At least 59 different approaches to assessing and alleviating this distress have been reported so that the literature is quite complex. The purpose of this paper is to provide an overview of the literature on castration and/or tailing distress, where the distress was assessed using acute changes in plasma cortisol concentrations. A method of analysis involving the integrated cortisol response (i.e. the areas under the cortisol curves while the plasma concentration is above pretreatment values) to each treatment and using treatments which were common to different studies as reference points, allowed meaningful comparison within and between studies. A 6-point ranking scale emerged, where rank 1 represented the least distress and rank 6 the most distress.

COMPARISON OF ACUTE DISTRESS RESPONSES

This analysis revealed the following major points. Surgical methods of castration and/or tailing cause the greatest cortisol responses (rank 5 or 6). Most ring and ring plus clamp methods of castration plus tailing or castration, used without a local anaesthetic or systemic analgesic, cause rank 4 responses. One form of ring plus clamp castration (i.e. applying the clamp for 10 s across the full width of the scrotum distal to the ring in lambs aged no more than 1 week) reduces the cortisol response to rank 1. When these lambs are also tailed by applying a ring and clamp in a similar manner to the tail, they also exhibit a rank 1 response. Local anaesthetic given 10-20 or 12 min or 10-15 s before or immediately after ring only castration and/or tailing can virtually abolish the cortisol response (rank 1), depending on the site(s) of injection. For ring or ring plus clamp castration, the most effective sites (as judged by cortisol responses) are the neck of the scrotum or the testes. Delivery of local anaesthetic to achieve successful nerve blockade can be by needle, high-pressure needleless administration or, for the tail only, by an aerosol spray. Local anaesthetic injected into the scrotal neck, spermatic cords and/or testes has little effect on the overall cortisol response to clamp castration. Reductions in cortisol responses to clamp castration or to ring tailing can occur after administration of non-steroidal anti-inflammatory drugs. Most tailing methods elicit cortisol responses that are several ranks lower than those caused by castration plus tailing or castration alone. Although tailing by most methods elicits rank 1 cortisol responses, the use of local anaesthetic or non-steroidal anti-inflammatory drugs can reduce the response within the rank 1 range.

RECOMMENDATION

Farmers should be encouraged to choose the lowest ranked method that is economically and practically feasible for them. Specific methods such as surgical castration should be discouraged.

Safety of reduced-dosage ketoprofen for long-term oral administration in healthy dogs

OBJECTIVE

To evaluate the safety of reduced-dosage ketoprofen (RDKET) for long-term oral administration in healthy dogs.

ANIMALS

14 healthy Beagles.

PROCEDURES

Racemic ketoprofen (0.25 mg/kg, PO) and gelatin capsules, as a drug-free placebo, were each administered to 7 dogs for 30 days. Dogs were periodically monitored via physical examination, blood analyses, endoscopic examinations, fecal occult blood tests (tetramethylbenzidine and guaiac methods), renal function tests (effective renal plasma flow and glomerular filtration rate), urinalyses, urinary enzyme indices (N-acetyl-beta-D-glucosaminidase and gamma-glutamyl-transferase), and hemostatic function tests (buccal mucosa bleeding time, cuticle bleeding time, prothrombin time, activated partial thromboplastin time, and fibrinogen concentration).

RESULTS

Pyloric antrum lesion grade was significantly higher in the RDKET group on day 28, compared with the pretreatment and control group grades. Fecal occult blood grade measured by use of the tetramethylbenzidine method was significantly higher in the RDKET group on day 30, compared with the pretreatment grade. No other significant differences were detected between treatment groups.

CONCLUSIONS AND CLINICAL RELEVANCE

RDKET induced mild to moderate gastric mucosal injuries especially in the pyloric antrum in healthy Beagles, whereas no adverse effects were observed in renal function or hemostasis. Fecal occult blood tests may be useful as screening tests for adverse gastrointestinal effects induced by RDKET in dogs.

Effect of Aspirin and Acetaminophen on Proinflammatory Cytokine-Induced Pain Behavior in Mice

Aspirin (ASA) is a widely used oral analgesic which acts as an inhibitor of cyclooxygenase. Acetaminophen (ACET) is also an effective analgesic and may selectively inhibit brain prostaglandin synthetase. Various proinflammatory cytokines injected into the central nervous system show pain behavior. In the present study, the effects of orally administered ASA and ACET on pain behaviors induced by various proinflammatory cytokines were examined. At a dose of 100 mg/kg, ASA or ACET did not affect the pain behavior induced by TNF-alpha (100 pg), IL-1beta (100 pg) or IFN-gamma (100 pg) administered intrathecally. However, at doses of 200 and 300 mg/kg, ASA or ACET significantly and dose-dependently attenuated pain behavior induced by TNF-alpha, IL-1beta or IFN-gamma administered intrathecally. Our results suggest that orally administered ASA and ACET produce antinociception by inhibiting the nociceptive action of TNF-alpha, IL-1beta or IFN-gamma administered intrathecally.

Comparative study of analgesic efficacy and morphine-sparing effect of intramuscular dexketoprofen trometamol with ketoprofen or placebo after major orthopaedic surgery

AIMS

Multimodal analgesia is thought to produce balanced and effective postoperative pain control. A combined therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates could result in synergistic analgesia by acting through different mechanisms. Currently there are very few parenterally administered NSAIDs suitable for the immediate postoperative period. Therefore, this study was undertaken to assess the analgesic efficacy, relative potency, and safety of parenteral dexketoprofen trometamol following major orthopaedic surgery.

METHODS

One hundred and seventy-two patients elected for prosthetic surgery, were randomized to receive two intramuscular injections (12 hourly) of either dexketoprofen 50 mg, ketoprofen 100 mg or placebo in a double-blind fashion. Postoperatively, the patient's pain was stabilized, then they were connected to a patient- controlled analgesia system (PCA) of morphine for 24 h (1 mg with 5 min lockout).

RESULTS

The mean cumulative amount of morphine (CAM) used was of 39 mg in the dexketoprofen group and 45 mg in the ketoprofen group vs 64 mg in the placebo group. (Reduction in morphine use was approximately one-third between the active compounds compared with placebo (adjusted mean difference of -25 mg between dexketoprofen and placebo and -23 mg between ketoprofen and placebo. These differences were statistically significant: P </= 0.0003; 95% CI -35, -14. Pain-intensity scores were consistently lower with the active compounds, the lowest corresponded to the dexketoprofen-treated patients. Regarding sedation, there were statistically significant differences between the two active compounds and placebo only at the 2nd and 13th hours. Wound bleeding was specifically measured with no statistically significant differences found between all the groups.

CONCLUSIONS

Intramuscular administration of dexketoprofen trometamol 50 mg has good analgesic efficacy both in terms of opioid-sparing effect and control of pain after major orthopaedic surgery.

Antinociceptive profiles of aspirin and acetaminophen in formalin, substance P and glutamate pain models

Aspirin (ASA) is widely used oral analgesics and acts as an inhibitor of cyclo-oxygenase. Also, acetaminophen (APAP) is effective analgesics and may selectively inhibit brain prostaglandin synthetase. However, their mechanisms of action in CNS are poorly defined, although several authors have shown that the antinociceptive effects of ASA and APAP have different underlying mechanisms and play some possible roles on spinal nociceptive processing, such as inhibition of prostaglandin synthesis. To define and characterize antinociceptive profiles of ASA and APAP on various pain models, we performed intraplantar formalin injection test, intrathecal (i.t.) substance P (0.7 microg)-induced nociceptive response test, and i.t. glutamate (20 microg)-induced nociceptive response test after ASA or APAP (from 10 to 300 mg/kg) administered orally to the mouse. In the formalin test, ASA produced an antinociceptive effect during only the 2nd phase (20-40 min), but not the 1st phase (0-5 min), in a dose-dependent manner. However, APAP showed a dose-dependent antinociceptive effect during both phases of the formalin test. In addition, both ASA and APAP reduced nociceptive behavior induced by glutamate administered i.t. in a dose-dependent manner. In substance P-induced nociceptive response, APAP, but not ASA, showed antinociceptive effect in a dose-dependent manner. Our results suggest that ASA and APAP administered orally may be mediated by different nociceptive processing at the spinal cord level.

Opioid poorly-responsive cancer pain. Part 3. Clinical strategies to improve opioid responsiveness

Some pain syndromes may be difficult to treat due to a poor response to opioids. This situation demands a range of alternative measures, including the use of adjuvant drugs with independent effects, such as antidepressants, sodium channel-blocking agents, steroids and anti-inflammatory drugs (NSAIDs); drugs that reduce opioid side effects; and drugs that enhance analgesia produced by opioids, such as N-methyl-D-aspartate (NMDA) antagonists, calcium channel antagonists, and clonidine. Other approaches, including opioid trials, neural blockade when necessary, and psychological interventions, also may be useful.

The clinical, cerebrospinal fluid, and histopathologic effects of epidural ketorolac in dogs

OBJECTIVE

To evaluate the clinical, cerebrospinal fluid (CSF), and histopathologic effects of epidural ketorolac.

STUDY DESIGN

Blinded, randomized, placebo controlled study.

ANIMALS

Twenty-two adult mixed breed dogs with 16 treatment and 6 control dogs, weighing 14.4 to 29.8 kg.

METHODS

Dogs were anesthetized and epidural catheters were placed at the lumbosacral space. Catheter placement was evaluated fluoroscopically. Ketorolac (0.4 mg/kg) or placebo (5% ethanol) was administered epidurally over a 52-hour period, with 5 injections given at 12-hour intervals. At 1, 2, 4, or 8 hours after the first and last injection of ketorolac, dogs were anesthetized and CSF was obtained. Control dogs had CSF sampled 1 hour after the first and last ethanol injection. Neurologic function and pain responses were evaluated before and during the study. Selected dogs were then killed and necropsies performed.

RESULTS

None of the dogs exhibited any clinical or neurologic abnormalities during the study. No statistical difference was noted in pain response or CSF analysis between treatment and control dogs. Gross necropsy revealed gastrointestinal ulceration of varying degrees in all treatment dogs. Histopathologic analysis of the spinal cord and meninges revealed minimal focal leptomeningeal phlebitis in 2 of 8 treatment dogs and minor subdural inflammation in 1 control dog. No changes to the neural structures were noted in any dogs.

CONCLUSIONS

Epidural administration of ketorolac did not cause clinical signs, alteration in CSF values, or pathologic changes to the spinal cord when used for short duration. Gastrointestinal ulceration was common when ketorolac was administered epidurally at 0.4 mg/kg every 12 hours for 5 treatments.

CLINICAL RELEVANCE

This study documented the neurologic safety of epidural ketorolac in dogs before an efficacy trial can be performed. Gastrointestinal ulceration may limit use to short duration or a single injection.

Phenacetin, acetaminophen and dipyrone: analgesic and rewarding effects

The antinociceptive and rewarding effects of phenacetin, a mild analgesic with abuse liability, were compared with those of acetaminophen, dipyrone and indomethacin in the formalin and conditioned place preference tests. Phenacetin, acetaminophen and dipyrone attenuated the pain response, beginning at 50, 50 and 100 mg/kg, respectively. Systemically active drugs produced weaker antinociception when injected into the paw or intracerebroventricularly at doses approximately 10(3) lower than those required for systemic effects; dose effect relations were bell-shaped by the intracerebroventricular route. By all three routes, there was a clear ceiling to the effects of acetaminophen that is consistent with its clinical efficacy. Systemic phenacetin and acetaminophen produced a conditioned place preference at doses that produced antinociception. Dipyrone produced a place aversion by the systemic route and a place preference intracerebroventricularly. The latter had a bell-shaped dose effect relationship identical to that in the formalin test. Indomethacin was inactive in all tests, except for mild hyperalgesia by the intraventricular route. The results indicate that the antinociceptive effects of phenacetin, acetaminophen and dipyrone reflect a combination of peripheral and central actions, neither of which involves inhibition of cyclooxygenase. The central component of the antinociceptive effects may be related to activation of brain mechanisms that are involved in reinforcement.

Central nervous system manifestations of an ibuprofen overdose reversed by naloxone

Ibuprofen overdose is usually characterized by GI upset, dizziness, and mild sedation. On rare occasions, severe complications such as respiratory failure, metabolic acidosis, renal failure, coma, and death have been reported in both adults and children. Presently, treatment of acute ibuprofen intoxication with complications requires supportive therapy until the symptoms resolve over 24 to 48 hours. We report the case of an 11-month-old female infant with a depressed level of consciousness after ingestion of ibuprofen whose mental status markedly improved with administration of naloxone.

The use of analgesics in the management of pain in rheumatic diseases

Pain is the most common complaint of patients who see rheumatologists. In this article, the current treatment options for pain are reviewed; these include acetaminophen, nonsteroidal anti-inflammatory drugs, new specific cyclooxygenase-2 inhibitors, opioid analgesics, centrally acting muscle relaxants, antidepressants, and topical analgesics and counterirritants. The doses of medication and known adverse effects of these medications are highlighted.

Nonsteroidal anti-inflammatory drugs and corticosteroids for the management of canine osteoarthritis

Anti-inflammatory medications have long been prescribed for relief of the pain and discomfort associated with OA. This occurs despite the recognized side effects associated with use of NSAIDs and corticosteroids. Available evidence suggests that NSAIDs provide this relief through a combination of central and peripheral actions. Recent discovery of two isoforms of cyclooxygenase has increased our understanding of NSAID activity and may result in identification of drugs that potentially will have fewer side effects. A review of NSAIDs used in veterinary medicine indicates that relatively little is known regarding their role in treating OA, although controlled studies involving carprofen and etodolac have increased our knowledge of the efficacy of specific NSAIDs used for this purpose.

Stereoselective inhibition of rat brain cyclooxygenase by dexketoprofen

Although it has been assumed that the effects of nonsteroidal antiinflammatory drugs (NSAIDs) are mainly the result of their action on local synthesis of prostaglandins, there is growing evidence to suggest that they may also exert a central analgesic action. Some authors have suggested that inhibition of prostaglandin synthesis in the brain could contribute to the analgesic action. The effect of dexketoprofen trometamol (tromethamine salt of the enantiomer (+)-S-ketoprofen) on prostaglandin synthesis was investigated in rat brain fragments and in cyclooxygenase preparations from rat brain microsomes. Effects of the (-)-R-enantiomer and the racemic mixture were also evaluated. Significant levels of prostaglandin F2 alpha (PGF2 alpha) were synthesized in rat brain fragments after 10 min of incubation at 37 degrees C. Dexketoprofen was found to be a potent inhibitor of this PGF2 alpha production in rat brain (IC50 = 6.2 nM), and it completely suppressed PGF2 alpha production at 1 microM concentration. In addition, inhibition of PGF2 alpha synthesis by dexketoprofen was highly stereoselective since the enantiomer (-)-R-ketoprofen was significantly less potent (IC50 = 294 nM); with this enantiomer, even at high concentrations such as 1 microM, less than 60% inhibition was achieved. These results correlated with those obtained in the study of racemic ketoprofen and its enantiomers on cyclooxygenase activity of rat brain microsomes, where dexketoprofen also inhibited enzymatic activity stereoselectively. IC50 values obtained for dexketoprofen, (-)-R-ketoprofen, and rac-ketoprofen were 3.5 microM, 45.3 microM, and 5.8 microM, respectively. The above results could be related to the potent analgesic effect of dexketoprofen observed in vivo, which was also stereoselective. Taken together, these findings suggest that prostaglandin synthesis inhibition in rat brain by dexketoprofen could be associated, at least in part, with the analgesic effect of this NSAID.

Preclinical and clinical development of dexketoprofen

Dexketoprofen trometamol is a water-soluble salt of the dextrorotatory enantiomer of the nonsteroidal anti-inflammatory drug (NSAID) ketoprofen. Racemic ketoprofen is used as an analgesic and an anti-inflammatory agent, and is one of the most potent in vitro inhibitors of prostaglandin synthesis. This effect is due to the S(+)-enantiomer (dexketoprofen), while the R(-)-enantiomer is devoid of such activity. The pharmacokinetic profile of ketoprofen and its enantiomers was assessed in several animals species and in human volunteers. In humans, the relative bioavailability of oral dexketoprofen trometamol (12.5 and 25 mg, respectively) is similar to that of oral racemic ketoprofen (25 and 50 mg, respectively), as measured in all cases by the area under the concentration-time curve values for S(+)-ketoprofen. Dexketoprofen trometamol, given as a tablet, is rapidly absorbed, with a time to maximum plasma concentration (tmax) of between 0.25 and 0.75 hours, whereas the tmax for the S-enantiomer after the racemic drug, administered as tablets or capsules prepared with the free acid, is between 0.5 and 3 hours. Peak plasma concentrations of 1.4 and 3.1 mg/L are reached after administration of dexketoprofen trometamol 12.5 and 25 mg, respectively. From 70 to 80% of the administered dose is recovered in the urine during the first 12 hours, mainly as the acyl-glucuronoconjugated parent drug. No R(-)-ketoprofen is found in the urine after administration of dexketoprofen [S(+)-ketoprofen], confirming the absence of bioinversion of the S(+)-enantiomer in humans. in animal studies, the anti-inflammatory potency of dexketoprofen was always equivalent to that demonstrated by twice the dose of ketoprofen. Similarly, animal studies showed a high analgesic potency for dexketoprofen trometamol. The R(-)-enantiomer demonstrated a much lower potency, its analgesic action being apparent only in conditions where the metabolic bioinversion to the S(+)-enantiomer was significant. The gastric ulcerogenic effect of dexketoprofen at various oral doses (1.5 to 6 mg/kg) in the rat do not differ from those of the corresponding double doses (3 to 12 mg/kg) of racemic ketoprofen. Repeated (5-day) oral administration of dexketoprofen as the trometamol salt causes less gastric ulceration than was observed after the acid form of both dexketoprofen and the racemate. In addition, single dose dexketoprofen as the free acid at 10 to 20 mg/kg does not show a significant intestinal ulcerogenic effect in rats, while racemic ketoprofen 20 or 40 mg/kg is clearly ulcerogenic to the small intestine. The analgesic efficacy of oral dexketoprofen trometamol 10 to 20 mg is superior to that of placebo and similar to that of ibuprofen 400 mg in patients with moderate to serve pain after third molar extraction. The time to onset of pain relief appeared to be shorter in patients treated with dexketoprofen trometamol than in those treated with ibuprofen 400 mg. Dexketoprofen trometamol was well tolerated, with a reported incidence of adverse events similar to that of placebo.

Pain mechanisms and management: an update

1. Recent findings have further helped to elucidate the mechanisms involved in the transmission and modulation of pain. It is now known that pain, inflammation and nervous system damage results in a number of changes in peripheral nerves, spinal cord and supraspinal structures. These changes themselves may be responsible for the development and maintenance of chronic pain syndromes. 2. In response to these findings, new agents and techniques have been applied in the clinical setting and new approaches have been developed to use existing agents more effectively. This review presents some of the findings from recent studies and the implications they have for the management of pain.

Recent advances in pain management

Over the last 20 years there has been an upsurge of interest in the basic mechanisms of pain. The findings that have arisen as a result of this interest have flowed through to the clinical area and have seen applications in a variety of settings. Identification of receptors and processes that are involved in the transmission of pain has led to the use of new agents in pain management. New techniques have provided new and more effective approaches in managing pain. These include the use of pre-emptive analgesia, postoperative pain management with patient controlled analgesia and use of techniques such as intrathecal drug administration and epidural spinal cord stimulation. This review presents some of the findings from basic research which have led to these developments, in particular those that relate to the changes that occur following inflammation and nerve injury, and the implications that these findings have had on pain management.

Non-steroidal anti-inflammatory drugs and spinal nociceptive processing

Non-steroidal anti-inflammatory drugs have a direct action on spinal nociceptive processing in vivo with a relative order of potency which correlates with their capacity as inhibitors of cyclooxygenase activity. However, recent clinical surveys and new in vivo evidence strongly suggest that for some of these agents, centrally mediated analgesia may also be achieved by additional mechanisms, which are independent of prostaglandin synthesis inhibition. In this review we explore the likelihood for such mechanisms following an extensive survey of existing data. The implications of these mechanisms are discussed in the light of our current understanding of spinal nociceptive processing.