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Maghsoudi H, Sheikhnia F, Sitarek P, Hajmalek N, Hassani S, Rashidi V, Khodagholi S, Mir SM, Malekinejad F, Kheradmand F, Ghorbanpour M, Ghasemzadeh N, Kowalczyk T. The Potential Preventive and Therapeutic Roles of NSAIDs in Prostate Cancer. Cancers (Basel) 2023; 15:5435. [PMID: 38001694 PMCID: PMC10670652 DOI: 10.3390/cancers15225435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Prostate cancer (PC) is the second most common type of cancer and the leading cause of death among men worldwide. Preventing the progression of cancer after treatments such as radical prostatectomy, radiation therapy, and hormone therapy is a major concern faced by prostate cancer patients. Inflammation, which can be caused by various factors such as infections, the microbiome, obesity and a high-fat diet, is considered to be the main cause of PC. Inflammatory cells are believed to play a crucial role in tumor progression. Therefore, nonsteroidal anti-inflammatory drugs along with their effects on the treatment of inflammation-related diseases, can prevent cancer and its progression by suppressing various inflammatory pathways. Recent evidence shows that nonsteroidal anti-inflammatory drugs are effective in the prevention and treatment of prostate cancer. In this review, we discuss the different pathways through which these drugs exert their potential preventive and therapeutic effects on prostate cancer.
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Affiliation(s)
- Hossein Maghsoudi
- Student Research Committee, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (H.M.); (F.S.); (V.R.); (F.M.)
- Department of Clinical Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (S.H.); (F.K.); (N.G.)
| | - Farhad Sheikhnia
- Student Research Committee, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (H.M.); (F.S.); (V.R.); (F.M.)
- Department of Clinical Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (S.H.); (F.K.); (N.G.)
| | - Przemysław Sitarek
- Department of Medical Biology, Medical University of Lodz, 90-151 Lodz, Poland
| | - Nooshin Hajmalek
- Department of Clinical Biochemistry, School of Medicine, Babol University of Medical Sciences, Babol 47176-47754, Iran;
| | - Sepideh Hassani
- Department of Clinical Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (S.H.); (F.K.); (N.G.)
| | - Vahid Rashidi
- Student Research Committee, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (H.M.); (F.S.); (V.R.); (F.M.)
| | - Sadaf Khodagholi
- School of Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada;
| | - Seyed Mostafa Mir
- Metabolic Disorders Research Center, Department of Biochemistry and Biophysics, Gorgan Faculty of Medicine, Golestan University of Medical Sciences, Gorgan 49189-36316, Iran;
| | - Faezeh Malekinejad
- Student Research Committee, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (H.M.); (F.S.); (V.R.); (F.M.)
- Department of Clinical Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (S.H.); (F.K.); (N.G.)
| | - Fatemeh Kheradmand
- Department of Clinical Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (S.H.); (F.K.); (N.G.)
- Cellular and Molecular Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, Urmia 57147-83734, Iran
- Solid Tumor Research Center, Cellular and Molecular Medicine Research Institute, Urmia University of Medical Sciences, Urmia 57147-83734, Iran
| | - Mansour Ghorbanpour
- Department of Medicinal Plants, Faculty of Agriculture and Natural Resources, Arak University, Arak 38156-88349, Iran;
| | - Navid Ghasemzadeh
- Department of Clinical Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia 57147-83734, Iran; (S.H.); (F.K.); (N.G.)
| | - Tomasz Kowalczyk
- Department of Molecular Biotechnology and Genetics, Faculty of Biology and Environmental Protection, University of Lodz, 90-237 Lodz, Poland;
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Abstract
A 77-year-old man presented with abdominal pain for 1 week. He was taking enteric-coated low-dose aspirin (LDA) to prevent secondary cardiovascular events and a proton pump inhibitor (PPI). Computed tomography indicated a small intestinal perforation; thus, small intestine resection was performed. Two months after surgery, he experienced a recurrence of the perforation. Since his repeated perforation was suspected to be due to LDA, LDA was discontinued. He has experienced no further recurrence since then. This is the first case of small intestinal perforation caused by enteric-coated LDA. Enteric-coated LDA may cause small intestinal perforation in patients with severe atherosclerosis under PPI administration.
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Affiliation(s)
| | - Ken-Ei Sada
- Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Japan
| | - Haruo Sawada
- Department of Internal Medicine, Oida Hospital, Japan
| | - Jiro Oida
- Department of Surgery, Oida Hospital, Japan
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Mallah N, Zapata-Cachafeiro M, Aguirre C, Ibarra-García E, Palacios-Zabalza I, Macías-García F, Piñeiro-Lamas M, Ibáñez L, Vidal X, Vendrell L, Martin-Arias L, Sáinz-Gil M, Velasco-González V, Bacariza-Cortiñas M, Salgado A, Estany-Gestal A, Figueiras A. Synergism interaction between genetic polymorphisms in drug metabolizing enzymes and NSAIDs on upper gastrointestinal haemorrhage: a multicenter case-control study. Ann Med 2022; 54:379-392. [PMID: 35114859 PMCID: PMC8820810 DOI: 10.1080/07853890.2021.2016940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Interindividual genetic variations contribute to differences in patients' response to drugs as well as to the development of certain disorders. Patients who use non-steroidal anti-inflammatory drugs (NSAIDs) may develop serious gastrointestinal disorders, mainly upper gastrointestinal haemorrhage (UGIH). Studies about the interaction between NSAIDs and genetic variations on the risk of UGIH are scarce. Therefore, we investigated the effect of 16 single nucleotide polymorphisms (SNPs) involved in drug metabolism on the risk of NSAIDs-induced UGIH. MATERIALS AND METHODS We conducted a multicenter case-control study of 326 cases and 748 controls. Participants were sub-grouped into four categories according to NSAID exposure and genetic profile. We estimated odds ratios (ORs) and their 95% confidence intervals (CI) using generalized linear mixed models for dependent binomial variables and then calculated the measures of interaction, synergism index (S), and relative excess risk due to interaction (RERI). We undertook stratified analyses by the type of NSAID (aspirin, non-aspirin). RESULTS We observed an excess risk of UGIH due to an interaction between any NSAID, non-aspirin NSAIDs or aspirin and carrying certain SNPs. The greatest excess risk was observed for carriers of: rs2180314:C>G [any NSAID: S = 3.30 (95%CI: 1.24-8.80), RERI = 4.39 (95%CI: 0.70-8.07); non-aspirin NSAIDs: S = 3.42 (95%CI: 1.12-10.47), RERI = 3.97 (95%CI: 0.44-7.50)], and rs4809957:A>G [any NSAID: S = 2.11 (95%CI: 0.90-4.97), RERI = 3.46 (95%CI: -0.40-7.31)]. Aspirin use by carriers of rs6664:C>T is also associated with increased risk of UGIH [ORaspirin(+),wild-type: 2.22 (95%CI: 0.69-7.17) vs. ORaspirin(+),genetic-variation: 7.72 (95%CI: 2.75-21.68)], yet larger sample size is needed to confirm this observation. CONCLUSIONS The joint effect of the SNPs s2180314:C>G and rs4809957:A>G and NSAIDs are more than three times higher than the sum of their individual effects. Personalized prescriptions based on genotyping would permit a better weighing of risks and benefits from NSAID consumption.KEY MESSAGESMulticenter case-control study of the effect of genetic variations involved in drug metabolism on upper gastrointestinal haemorrhage (UGIH) induced by NSAIDs (aspirin and non-aspirin).There is a statistically significant additive synergism interaction between certain genetic polymorphisms and NSAIDs on UGIH: rs2180314:C>G and rs4809957:A>G. The joint effect of each of these single nucleotide polymorphisms and NSAIDs on UGIH is more than three times higher than the sum of their individual effects.Genetic profiling and personalized prescriptions would be useful in managing the risks and benefits associated with NSAIDs.
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Affiliation(s)
- Narmeen Mallah
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,WHO Collaborating Centre for Vaccine Safety, Santiago de Compostela, Spain.,Genetics, Vaccines and Pediatric Infectious Diseases Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBER-ES), Carlos III Health Institute, Madrid, Spain
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Carlos III Health Institute, Madrid, Spain
| | - Carmelo Aguirre
- Pharmacotherapy Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Basque Country Pharmacovigilance Unit, University Hospital of Galdakao-Usansolo, Osakidetza, Spain.,Pharmacology Department, Medicine and Nursing Faculty, University of the Basque Country, Barakaldo, Spain
| | - Eguzkiñe Ibarra-García
- Pharmacotherapy Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Osakidetza Basque Health Service, Pharmacy Department, Urduliz Hospital, Urduliz, Spain
| | - Itziar Palacios-Zabalza
- Pharmacotherapy Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Basque Country Pharmacovigilance Unit, University Hospital of Galdakao-Usansolo, Osakidetza, Spain
| | - Fernando Macías-García
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - María Piñeiro-Lamas
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Carlos III Health Institute, Madrid, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Luisa Ibáñez
- Department of Pharmacology, Therapeutics and Toxicology, Catalonian Institute of Pharmacology, Clinical Pharmacology Service, Vall d'Hebron University Teaching Hospital, Autonomous University, Barcelona, Spain
| | - Xavier Vidal
- Department of Pharmacology, Therapeutics and Toxicology, Catalonian Institute of Pharmacology, Clinical Pharmacology Service, Vall d'Hebron University Teaching Hospital, Autonomous University, Barcelona, Spain
| | - Lourdes Vendrell
- Department of Pharmacology, Therapeutics and Toxicology, Catalonian Institute of Pharmacology, Clinical Pharmacology Service, Vall d'Hebron University Teaching Hospital, Autonomous University, Barcelona, Spain
| | - Luis Martin-Arias
- Centre for Research on Drug Safety (CESME), Valladolid University, Valladolid, Spain
| | - María Sáinz-Gil
- Centre for Research on Drug Safety (CESME), Valladolid University, Valladolid, Spain
| | | | | | - Angel Salgado
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ana Estany-Gestal
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Carlos III Health Institute, Madrid, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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Alhamadi N, Asiri AH, Alshahrani FM, Alqahtani AY, Al Qout MM, Alnami RA, Alasiri AS, AL-Zomia AS. Gastrointestinal Complications Associated With Non-steroidal Anti-inflammatory Drug Use Among Adults: A Retrospective, Single-Center Study. Cureus 2022; 14:e26154. [PMID: 35891867 PMCID: PMC9302552 DOI: 10.7759/cureus.26154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/20/2022] Open
Abstract
Background Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are recognized to injure the upper gastrointestinal tract (GIT) mucosa. For example, gastric mucosal hemorrhages can be caused by a single dose of 650 mg of aspirin. Nearly 30% to 50% of NSAID users showed endoscopic lesions including subepithelial hemorrhages, erosions, and ulcerations. These lesions are often asymptomatic and are mostly found in the gastric antrum. With the chronic exposure, the mucosa adapts to the aggression of the NSAIDs, whereby these lesions slowly lessen or fade. Aim The aim of this study is to detect the association between NSAIDs and gastrointestinal complications among the general population in the Aseer region, Saudi Arabia. Methodology A record-based retrospective study was conducted targeting people with GIT complications who were 20 years old and above. We reviewed patients' records from the GIT clinic in the Aseer region of Saudi Arabia. We reviewed specifically patients who had GIT complications like gastritis, abdominal pain, GIT bleeding, heartburn, nausea, vomiting, peptic ulcer, and diarrhea. Then we contacted those patients individually to fill out a questionnaire. Participants less than 18 years, those who refused to complete the questionnaire, or any patients with no history of GIT complications were excluded. An online questionnaire was sent to the patients with GIT complications. The questionnaire included participant's personal data, NSAID use, and associated GIT complications. The questionnaire was uploaded online using social media platforms by the researchers and their relatives and friends during the period from March 2012 to May 2022. Results A total of 211 participants with GIT complications completed the study questionnaire. Participant ages ranged from 20-59 years with a mean age of 31.2 ± 12.9 years old. A total of 140 (66.4%) were males and 175 (82.9%) were from urban areas. A total of 156 (73.9%) were non-smokers. A total of 103 (48.8%) participants used NSAIDs. As for complications, the most reported were peptic ulcer (37.9%), GIT bleeding (5.8%), GIT erosions (4.9%), and intestinal obstruction (3.9%) while 59.2% had no complications. Conclusions The current study revealed that nearly one out of every two participants in the Aseer region mainly used NSAIDs as tablets for pain. Regarding high utilization rates, less than half of them developed GIT complications, mainly peptic ulcers.
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McEvoy L, Carr DF, Pirmohamed M. Pharmacogenomics of NSAID-Induced Upper Gastrointestinal Toxicity. Front Pharmacol 2021; 12:684162. [PMID: 34234675 PMCID: PMC8256335 DOI: 10.3389/fphar.2021.684162] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/11/2021] [Indexed: 12/19/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of drugs which are widely used globally for the treatment of pain and inflammation, and in the case of aspirin, for secondary prevention of cardiovascular disease. Chronic non-steroidal anti-inflammatory drug use is associated with potentially serious upper gastrointestinal adverse drug reactions (ADRs) including peptic ulcer disease and gastrointestinal bleeding. A few clinical and genetic predisposing factors have been identified; however, genetic data are contradictory. Further research is needed to identify clinically relevant genetic and non-genetic markers predisposing to NSAID-induced peptic ulceration.
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Affiliation(s)
- L McEvoy
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - D F Carr
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - M Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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Sonowal H, Ramana KV. 2'-Hydroxyflavanone prevents LPS-induced inflammatory response and cytotoxicity in murine macrophages. Toxicol In Vitro 2020; 69:104966. [PMID: 32800949 PMCID: PMC7572836 DOI: 10.1016/j.tiv.2020.104966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/31/2020] [Accepted: 08/08/2020] [Indexed: 12/13/2022]
Abstract
2'-Hydroxyflavanone (2-HF) is a natural flavonoid isolated from citrus fruits. Multiple studies have demonstrated that 2-HF with its anti-proliferative and pro-apoptotic effects prevent the growth of various cancers. Although 2-HF is a well known anti-oxidative and chemopreventive agent, its role as an anti-inflammatory agent is not well established. In this study, we examined the effect of 2-HF on LPS-induced cytotoxicity and inflammatory response in murine RAW 264.7 macrophages. Flow cytometry analysis showed that pre-treatment of RAW 264.7 macrophages with 2-HF significantly prevented LPS-induced macrophage apoptosis. 2-HF also prevented LPS-induced reactive oxygen species (ROS) and nitric oxide (NO) production, lipid peroxidation, and loss of mitochondrial membrane potential in murine macrophages. Most importantly, the release of multiple inflammatory cytokines and chemokines such as eotaxin, IL-2, IL-10, IL-12p40, LIX, IL-15, IL-17, MCP-1, and TNF-α induced by LPS in the macrophages was inhibited by 2-HF. 2-HF also prevented LPS-induced activation of protein kinases p38MAPK and SAPK/JNK. Apart from this, LPS-induced phosphorylation, nuclear translocation, and DNA-binding of the redox transcription factor, NF-κB, was prevented by 2-HF. Our results demonstrate that 2-HF by regulating ROS/MAPK/NF-κB prevents LPS-induced inflammatory response and cytotoxicity in murine macrophages suggesting that the need of potential development of 2-HF as an anti-inflammatory agent to ameliorate various inflammatory complications.
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Affiliation(s)
- Himangshu Sonowal
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Kota V Ramana
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA.
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Peng S, Hu C, Liu X, Lei L, He G, Xiong C, Wu W. Rhoifolin regulates oxidative stress and proinflammatory cytokine levels in Freund's adjuvant-induced rheumatoid arthritis via inhibition of NF-κB. ACTA ACUST UNITED AC 2020; 53:e9489. [PMID: 32401927 PMCID: PMC7233197 DOI: 10.1590/1414-431x20209489] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/26/2020] [Indexed: 12/18/2022]
Abstract
Rheumatoid arthritis (RA) is an autoimmune disease of knee joints involving pain and inflammation. Rhoifolin is a plant flavonoid known to have antioxidant and anti-inflammatory properties. This study was taken to identify the effect of rhoifolin on complete Freund’s adjuvant (CFA)-induced arthritis in the rat model. Treatment with rhoifolin (10 and 20 mg/kg) showed a significant improvement in the overall health parameters such as paw edema and weight loss. This improvement in morphological parameters corroborated the findings with gross morphological changes observed in the histopathological analysis. Rhoifolin treatment also caused a significant decrease in oxidative stress, evident from changes in intracellular levels of glutathione, glutathione peroxidase, malondialdehyde, and superoxide dismutase in the articular cartilage tissue. Moreover, proinflammatory cytokines, tumor necrosis factor (TNF)-α, interleukin(IL)-1β, and IL-6 showed a significant downregulation of gene expression and intracellular protein concentration levels. The NF-κB pathway showed a significant attenuation as evident in the significant reduction in the levels of NF-κB p65 and p-IκB-α. These results indicated that rhoifolin can be a natural therapeutic alternative to the extant regimens, which include non-steroidal anti-inflammatory drugs and immunosuppressants. Additionally, the antioxidant and anti-inflammatory action of rhoifolin was probably mediated by the NF-κB pathway. However, the exact target molecules of this pathway need to be determined in further studies.
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Affiliation(s)
- Shanqin Peng
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Congqi Hu
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xi Liu
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lei Lei
- Department of Gastroenterology, The 455th Hospital of Chinese People's Liberation Army, Shanghai, China
| | - Guodong He
- YouJiang Medical University for Nationalities, Baise, China
| | - Chenming Xiong
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Wenqian Wu
- Department of Traditional Chinese Medical Gynecology, Wenzhou Hospital of Chinese Medicine, Wenzhou, China
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Fornai M, Pellegrini C, Benvenuti L, Tirotta E, Gentile D, Natale G, Ryskalin L, Colucci R, Piccoli E, Ghelardi E, Blandizzi C, Antonioli L. Protective effects of the combination Bifidobacterium longum plus lactoferrin against NSAID-induced enteropathy. Nutrition 2019; 70:110583. [PMID: 31739175 DOI: 10.1016/j.nut.2019.110583] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Nonsteroidal anti-inflammatory drugs can exert detrimental effects in the lower digestive tract. The aim of this study was to examine the protective effects of a combination of the probiotic Bifidobacterium longum BB536 (Bifidobacterium) with the prebiotic lactoferrin in a rat model of diclofenac-induced enteropathy. METHODS Enteropathy was induced in 40-wk-old male rats by intragastric diclofenac (4 mg/kg twice daily for 14 d). Lactoferrin (100 mg/kg twice daily), Bifidobacterium (2.5 × 106 CFU/rat twice daily) or their combination were administered 1 h before diclofenac. At the end of treatments, the ileum was processed for the evaluation of histologic damage, myeloperoxidase (MPO) and malondialdehyde (MDA) levels, as well as the expression of Toll-like receptors 2 and 4 (TLR-2/-4) and the activation of downstream signaling molecules (MyD88 and nuclear factor [NF]-κB p65). Blood hemoglobin and fecal calprotectin were also assessed. RESULTS Diclofenac induced intestinal damage, along with increments of MPO and MDA, overexpression of TLR-2, TLR-4, MyD88, and NF-κB p65, increased fecal calprotectin and decreased blood hemoglobin levels. Lactoferrin or Bifidobacterium alone prevented diclofenac-induced enteric damage, and the changes in blood hemoglobin, MPO, MDA, fecal calprotectin, and NF-κB p65. Bifidobacterium, but not lactoferrin, decreased TLR-4 expression, although none of them affected MyD88 overexpression. TLR-2 expression was slightly enhanced by all treatments. The combined administration of lactoferrin and Bifidobacterium reduced further the intestinal damage, and restored MPO and blood hemoglobin levels. CONCLUSIONS Diclofenac induced ileal mucosal lesions by activation of inflammatory and pro-oxidant mechanisms. These detrimental actions were prevented by the combination of lactoferrin with Bifidobacterium likely through the modulation of TLR-2/-4/NF-κB proinflammatory pathways.
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Affiliation(s)
- Matteo Fornai
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | | | - Laura Benvenuti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erika Tirotta
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Daniela Gentile
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gianfranco Natale
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Larisa Ryskalin
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Rocchina Colucci
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Elena Piccoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Corrado Blandizzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Antonioli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Colucci R, Pellegrini C, Fornai M, Tirotta E, Antonioli L, Renzulli C, Ghelardi E, Piccoli E, Gentile D, Benvenuti L, Natale G, Fulceri F, Palazón-Riquelme P, López-Castejón G, Blandizzi C, Scarpignato C. Pathophysiology of NSAID-Associated Intestinal Lesions in the Rat: Luminal Bacteria and Mucosal Inflammation as Targets for Prevention. Front Pharmacol 2018; 9:1340. [PMID: 30555323 PMCID: PMC6281992 DOI: 10.3389/fphar.2018.01340] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/31/2018] [Indexed: 12/11/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) can damage the small intestine, mainly through an involvement of enteric bacteria. This study examined the pathophysiology of NSAID-associated intestinal lesions in a rat model of diclofenac-enteropathy and evaluated the effect of rifaximin on small bowel damage. Enteropathy was induced in 40-week old male rats by intragastric diclofenac (4 mg/kg BID, 14 days). Rifaximin (delayed release formulation) was administered (50 mg/kg BID) 1 h before the NSAID. At the end of treatments, parameters dealing with ileal damage, inflammation, barrier integrity, microbiota composition, and TLR-NF-κB-inflammasome pathway were evaluated. In addition, the modulating effect of rifaximin on NLRP3 inflammasome was tested in an in vitro cell system. Diclofenac induced intestinal damage and inflammation, triggering an increase in tissue concentrations of tumor necrosis factor and interleukin-1β, higher expression of TLR-2 and TLR-4, MyD88, NF-κB and activation of caspase-1. In addition, the NSAID decreased ileal occludin expression and provoked a shift of bacterial phyla toward an increase in Proteobacteria and Bacteroidetes abundance. All these changes were counterbalanced by rifaximin co-administration. This drug was also capable of increasing the proportion of Lactobacilli, a genus depleted by the NSAID. In LPS-primed THP-1 cells stimulated by nigericin (a model to study the NLRP3 inflammasome), rifaximin reduced IL-1β production in a concentration-dependent fashion, this effect being associated with inhibition of the up-stream caspase-1 activation. In conclusion, diclofenac induced ileal mucosal lesions, driving inflammatory pathways and microbiota changes. In conclusion, rifaximin prevents diclofenac-induced enteropathy through both anti-bacterial and anti-inflammatory activities.
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Affiliation(s)
- Rocchina Colucci
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy
| | - Carolina Pellegrini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Fornai
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erika Tirotta
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Antonioli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Cecilia Renzulli
- Reasearch & Development Department, Alfasigma SpA, Bologna, Italy
| | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Elena Piccoli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Daniela Gentile
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Laura Benvenuti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gianfranco Natale
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Federica Fulceri
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pablo Palazón-Riquelme
- Manchester Collaborative Centre for Inflammation Research, University of Manchester, Manchester, United Kingdom
| | - Gloria López-Castejón
- Manchester Collaborative Centre for Inflammation Research, University of Manchester, Manchester, United Kingdom
| | - Corrado Blandizzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Parma, Italy
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10
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Taslidere E, Vardi N, Parlakpinar H, Yıldız A, Taslidere B, Karaaslan MG. Effects of melatonin on acetylsalicylic acid induced gastroduodenal and jejunal mucosal injury. Biotech Histochem 2018; 93:485-495. [PMID: 30388896 DOI: 10.1080/10520295.2018.1442020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We evaluated the effects of melatonin on acetylsalicylic acid (ASA) induced gastroduodenal and jejunal mucosal injury. We used 40 postpubertal rats divided randomly into five groups of eight animals. The control group consisted of untreated animals. The Mel group was injected intraperitoneally (i.p.) with 5 mg/kg melatonin. The ASA group was injected i.p. with 200 mg/kg ASA. The ASA + Mel group was injected i.p. with 5 mg/kg melatonin 45 min after administering 200 mg/kg ASA i.p. The Mel + ASA group was injected i.p. with 5 mg/kg melatonin 45 min before administering 200 mg/kg ASA i.p. We found no statistically significant differences in mean histopathological scores in the ASA + Mel group compared to the ASA group. ASA caused shortened villi and loss of the apical villus in the duodenum. The histopathological score was increased and villus height was decreased in the ASA group compared to untreated controls. Treatment with melatonin attenuated the histological damage. In the ASA group, occasional areas showed erosion of villi in the jejunum; however, differences in mean histopathological score in ASA group compared to the other groups were not statistically significant. Malondialdehyde (MDA), glutathione (GSH) and superoxide dismutase (SOD) activities were measured in stomach, duodenal and jejunum tissue. We found increased MDA activity in both stomach and duodenal tissues in the ASA group compared to the control group (p < 0.05). We found no statistically significant changes in MDA levels in jejunal tissue in the ASA group compared to the control group. We found no change in SOD activity in either stomach or duodenal tissues in the ASA group compared to the control group. We observed decreased SOD activity in jejunal tissue in the ASA group compared to the control group (p < 0.05). We detected no change in GSH activity in stomach, duodenal or jejunal tissues in the ASA group compared to the control group. The stomach damage was less in melatonin treated groups, but the lesions were not completely eliminated. The jejunum in the ASA group retained a nearly normal appearance. We found that melatonin exhibited some healing effects on ASA induced duodenal mucosal injury.
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Affiliation(s)
- E Taslidere
- a Department of Histology and Embryology, Medical Faculty , Bezmialem Vakif University , Istanbul
| | - N Vardi
- b Department of Histology and Embryology, Medical Faculty , Inonu University , Malatya , Turkey
| | - H Parlakpinar
- c Department of Pharmacology, Medical Faculty , Inonu University , Malatya , Turkey
| | - A Yıldız
- b Department of Histology and Embryology, Medical Faculty , Inonu University , Malatya , Turkey
| | - B Taslidere
- d Department of Emergency Medicine , Malatya State Hospital , Malatya , Turkey
| | - M G Karaaslan
- e Department of Biochemistry, Medical Faculty , Inonu University , Malatya , Turkey
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García-Rayado G, Navarro M, Lanas A. NSAID induced gastrointestinal damage and designing GI-sparing NSAIDs. Expert Rev Clin Pharmacol 2018; 11:1031-1043. [DOI: 10.1080/17512433.2018.1516143] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Guillermo García-Rayado
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- IIS Aragón, Zaragoza, Spain
| | - Mercedes Navarro
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- IIS Aragón, Zaragoza, Spain
| | - Angel Lanas
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- IIS Aragón, Zaragoza, Spain
- CIBERehd, Madrid, Spain
- University of Zaragoza, Zaragoza, Spain
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12
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Association of ibuprofen at the polar/apolar interface of lipid membranes. Arch Biochem Biophys 2018; 654:77-84. [DOI: 10.1016/j.abb.2018.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/09/2018] [Accepted: 07/13/2018] [Indexed: 12/11/2022]
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Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.
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Ho KY, Gwee KA, Cheng YK, Yoon KH, Hee HT, Omar AR. Nonsteroidal anti-inflammatory drugs in chronic pain: implications of new data for clinical practice. J Pain Res 2018; 11:1937-1948. [PMID: 30288088 PMCID: PMC6160277 DOI: 10.2147/jpr.s168188] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
COX2-selective and nonselective (ns) nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for chronic pain management. There are marked differences in the risk of adverse gastrointestinal (GI) and cardiovascular (CV) events among different NSAIDs. In 2017, publication of two randomized controlled trials and an individual patient-data meta-analysis provided robust data on the relative GI and CV tolerability profiles of currently available NSAIDs. The PRECISION study showed similar CV-event rates with celecoxib vs naproxen and ibuprofen, but GI tolerability was better for celecoxib. In the CONCERN study of high-GI-risk patients, celecoxib was associated with fewer adverse GI-tract events than naproxen. The meta-analysis showed no significant difference between celecoxib and ns-NSAIDs in the rate of acute myocardial infarction, and celecoxib was the only COX2-selective NSAID with a lower risk of adverse CV and GI events vs ns-NSAIDs. These data add to the body of knowledge about the relative tolerability of different NSAIDs and were used to propose an updated treatment algorithm. The decision about whether to use an NSAID and which one should be based on a patient's risk of developing adverse GI and CV events. Lower- and upper-GI-tract events need to be considered. Celecoxib has a better lower-GI-tract tolerability profile than ns-NSAIDs plus a proton-pump inhibitor. In addition, the latest data suggest that long-term use of celecoxib 200 mg/day may be appropriate for patients at increased CV risk.
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Affiliation(s)
| | - Kok Ann Gwee
- Stomach, Liver, and Bowel Centre, Gleneagles Hospital
| | - Yew Kuang Cheng
- Farrer Park Hospital
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Kam Hon Yoon
- El Shaddai Arthritis and Rheumatism Specialist Medical Centre
| | - Hwan Tak Hee
- Pinnacle Spine and Scoliosis Centre, Mt Elizabeth Medical Centre
| | - Abdul Razakjr Omar
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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15
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Varrassi G, Hanna M, Macheras G, Montero A, Montes Perez A, Meissner W, Perrot S, Scarpignato C. Multimodal analgesia in moderate-to-severe pain: a role for a new fixed combination of dexketoprofen and tramadol. Curr Med Res Opin 2017; 33:1165-1173. [PMID: 28326850 DOI: 10.1080/03007995.2017.1310092] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Untreated and under-treated pain represent one of the most pervasive health problems, which is worsening as the population ages and accrues risk for pain. Multiple treatment options are available, most of which have one mechanism of action, and cannot be prescribed at unlimited doses due to the ceiling of efficacy and/or safety concerns. Another limitation of single-agent analgesia is that, in general, pain is due to multiple causes. Combining drugs from different classes, with different and complementary mechanism(s) of action, provides a better opportunity for effective analgesia at reduced doses of individual agents. Therefore, there is a potential reduction of adverse events, often dose-related. Analgesic combinations are recommended by several organizations and are used in clinical practice. Provided the two agents are combined in a fixed-dose ratio, the resulting medication may offer advantages over extemporaneous combinations. CONCLUSIONS Dexketoprofen/tramadol (25 mg/75 mg) is a new oral fixed-dose combination offering a comprehensive multimodal approach to moderate-to-severe acute pain that encompasses central analgesic action, peripheral analgesic effect and anti-inflammatory activity, together with a good tolerability profile. The analgesic efficacy of dexketoprofen/tramadol combination is complemented by a favorable pharmacokinetic and pharmacodynamic profile, characterized by rapid onset and long duration of action. This has been well documented in both somatic- and visceral-pain human models. This review discusses the available clinical evidence and the future possible applications of dexketoprofen/tramadol fixed-dose combination that may play an important role in the management of moderate-to-severe acute pain.
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Affiliation(s)
- Giustino Varrassi
- a European League Against Pain, Zurich and Rome , Switzerland and Italy
| | - Magdi Hanna
- b Analgesics and Pain Research Unit (APRU), King's College Hospital , London , UK
| | | | - Antonio Montero
- d Anaesthesiology & Surgery Department , Hospital Arnau de Vilanova , Lleida , Spain
| | - Antonio Montes Perez
- e Anaesthesiology Department , Hospitales Mar-Eseranza , Barcelona , Spain
- f Universitat Autonoma de Barcelona
| | - Winfried Meissner
- g Department of Anaesthesiology and Intensive Care , Jena University Hospital , Jena , Germany
| | - Serge Perrot
- h Centre de la Douleur, Université Paris Descartes, INSERM U987, Hopital Cochin , Paris , France
| | - Carmelo Scarpignato
- i Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Pharmacology , University of Parma , Parma , Italy
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Wang CC, Guo L, Tian FD, An N, Luo L, Hao RH, Wang B, Zhou ZH. Naringenin regulates production of matrix metalloproteinases in the knee-joint and primary cultured articular chondrocytes and alleviates pain in rat osteoarthritis model. ACTA ACUST UNITED AC 2017; 50:e5714. [PMID: 28355351 PMCID: PMC5423744 DOI: 10.1590/1414-431x20165714] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/22/2016] [Indexed: 01/08/2023]
Abstract
Inflammation of cartilage is a primary symptom for knee-joint osteoarthritis. Matrix metalloproteinases (MMPs) are known to play an important role in the articular cartilage destruction related to osteoarthritis. Naringenin is a plant-derived flavonoid known for its anti-inflammatory properties. We studied the effect of naringenin on the transcriptional expression, secretion and enzymatic activity of MMP-3 in vivo in the murine monosodium iodoacetate (MIA) osteoarthritis model. The assessment of pain behavior was also performed in the MIA rats. The destruction of knee-joint tissues was analyzed microscopically. Moreover, the effect of naringenin was also studied in vitro in IL-1β activated articular chondrocytes. The transcriptional expression of MMP-3, MMP-1, MMP-13, thrombospondin motifs (ADAMTS-4) and ADAMTS-5 was also studied in primary cultured chondrocytes of rats. Naringenin caused significant reduction in pain behavior and showed marked improvement in the tissue morphology of MIA rats. Moreover, a significant inhibition of MMP-3 expression in MIA rats was observed upon treatment with naringenin. In the in vitro tests, naringenin caused a significant reduction in the transcriptional expression, secretion and enzymatic activity of the studied degradative enzymes. The NF-κB pathway was also found to be inhibited upon treatment with naringenin in vitro. Overall, the study suggests that naringenin alleviated pain and regulated the production of matrix-metalloproteinases via regulation of NF-κB pathway. Thus, naringenin could be a potent therapeutic option for the treatment of osteoarthritis.
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Affiliation(s)
- C C Wang
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - L Guo
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - F D Tian
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - N An
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - L Luo
- Department of Respiratory Medicine, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - R H Hao
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - B Wang
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Z H Zhou
- Department II of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
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17
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Takahashi H, Kawaguchi M, Kitamura K, Narumiya S, Kawamura M, Tengan I, Nishimoto S, Hanamure Y, Majima Y, Tsubura S, Teruya K, Shirahata S. An Exploratory Study on the Anti-inflammatory Effects of Fucoidan in Relation to Quality of Life in Advanced Cancer Patients. Integr Cancer Ther 2017. [PMID: 28627320 PMCID: PMC6041928 DOI: 10.1177/1534735417692097] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background. Conventional anticancer therapies still cause difficulties with selective eradication and accompanying side effects that reduce patients’ quality of life (QOL). Fucoidan is extracted from seaweeds and has already exhibited broad bioactivities, including anticancer and anti-inflammatory properties, in basic studies. It is expected to enhance therapeutic efficacy and minimize side effects in cancer patients; however, despite its potential benefits, there are very few clinical trials using fucoidans. Therefore, we performed an exploratory clinical study for advanced cancer patients to examine the efficacy of fucoidans, especially focusing on inflammation in relation to QOL scores. Methods. We conducted a prospective, open-label clinical study for advanced cancer patients using fucoidans via oral administration; 20 advanced cancer patients with metastases were recruited and were given 400 mL/d fucoidan (10 mg/mL) for at least 4 weeks. Inflammatory biomarkers, including high-sensitivity C-reactive protein and various cytokines, and QOL scores were monitored before treatment, after 2 weeks, and after 4 weeks of fucoidan ingestion. Results. The main proinflammatory cytokines, including interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α) were significantly reduced after 2 weeks of fucoidan ingestion. QOL scores, including fatigue, stayed almost stable without significant changes during the study period. The univariate and multivariate analyses revealed that the responsiveness of IL-1β was a significant independent prognostic factor. Conclusion. This is the first study providing evidence of the anti-inflammatory effects of fucoidans for advanced cancer patients. In future studies, larger blinded, controlled trials are required to establish the efficacy of fucoidan as supportive care for cancer patients, especially those undergoing chemotherapy.
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Affiliation(s)
- Hidenori Takahashi
- 1 University of the Ryukyus Hospital, Nakagami-gun, Okinawa, Japan.,2 Seren Clinic Fukuoka, Fukuoka, Japan.,3 Clinic Ginowan, Ginowan-shi, Okinawa, Japan
| | | | | | | | | | | | | | - Yasuo Hanamure
- 9 Hanamure Hospital, Ichikikushikino-shi, Kagoshima, Japan
| | - Yasuo Majima
- 10 Majima Digestive Organ Clinic, Kurume-shi, Fukuoka, Japan
| | - Shuichi Tsubura
- 11 Nippon Dental University School of Life Dentistry at Niigata, Hamaura-cho, Chuo-ku, Niigata, Japan
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18
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Lee HL, Chua SS, Mahadeva S. Utilization of gastroprotective strategies for nonsteroidal anti-inflammatory drug-induced gastrointestinal events in a major teaching hospital. Ther Clin Risk Manag 2016; 12:1649-1657. [PMID: 27877048 PMCID: PMC5110204 DOI: 10.2147/tcrm.s119722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background and purpose Clinical guidelines recommend the prescribing of gastroprotective strategies in nonsteroidal anti-inflammatory drug (NSAID) users with risk factors for gastrointestinal (GI) ulcer or ulcer complications. However, these guidelines are not often translated into clinical practice. Therefore, the aim of this study was to investigate the utilization of gastroprotective strategies for NSAID-induced upper GI events in at-risk users in a major teaching hospital. Patients and methods A cross-sectional, observational, pharmacy-based study was conducted in a major Asian institution with both primary and secondary health care services. This study involved the screening of prescriptions for regular NSAIDs, and patients who met the inclusion criteria were recruited and interviewed using a questionnaire. Results Of the 409 participants recruited, 83.1% had at least one GI risk factor, of whom 70.3% did not receive appropriate gastroprotection. The most common GI risk factor was the use of high-dose NSAIDs (69.2%), followed by participants aged 65 years and older (22%) and concomitant use of low-dose aspirin (11.7%). Appropriate gastroprotective strategies utilized consisted of the use of a cyclooxygenase (COX)-2 inhibitor alone or a nonselective NSAID plus a proton pump inhibitor (PPI) in the moderate-risk group and a COX-2 inhibitor plus a PPI in the high-risk group. Gastroprotective strategies were underutilized in 67.1% of at-risk participants and overutilized in 59.4% of those without risk factors. Co-prescription of a histamine-2 receptor antagonist at lower-than-recommended doses constituted 59% of the inappropriate gastroprotective agents used. Logistic regression analysis revealed patients aged 65 years and older (odds ratio, 1.89; 95% CI =1.15–3.09) as a predictor for the prescribing of gastroprotection by the clinicians. Conclusion Approximately 70% of at-risk NSAID users, mainly on high-dose NSAIDs, were not prescribed appropriate gastroprotective strategies. Further measures are warranted to improve the safe prescribing of regular NSAIDs.
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Affiliation(s)
| | | | - Sanjiv Mahadeva
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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19
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Singh DP, Borse SP, Nivsarkar M. Clinical importance of nonsteroidal anti-inflammatory drug enteropathy: the relevance of tumor necrosis factor as a promising target. Transl Res 2016; 175:76-91. [PMID: 27083387 DOI: 10.1016/j.trsl.2016.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/13/2022]
Abstract
The pathogenesis of nonsteroidal anti-inflammatory drug (NSAID) enteropathy is still unclear, and consequently, there is no approved therapeutic strategy for ameliorating such damage. On the other hand, molecular treatment strategies targeting tumor necrosis factor (TNF) exerts beneficial effects on NSAID-induced intestinal lesions in rodents and rheumatoid arthritis patients. Thus, TNF appears to be a potential therapeutic target for both the prevention and treatment of NSAID enteropathy. However, the causative relationship between TNF and NSAID enteropathy is largely unknown. Currently approved anti-TNF agents are highly expensive and exhibit numerous side effects. Hence, in this review, the pivotal role of TNF in NSAID enteropathy has been summarized and plant-derived polyphenols have been suggested as useful alternative anti-TNF agents because of their ability to suppress TNF activated inflammatory pathways both in vitro and in vivo.
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Affiliation(s)
- Devendra Pratap Singh
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Swapnil P Borse
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Manish Nivsarkar
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India.
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20
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Fornai M, Antonioli L, Pellegrini C, Colucci R, Sacco D, Tirotta E, Natale G, Bartalucci A, Flaibani M, Renzulli C, Ghelardi E, Blandizzi C, Scarpignato C. Small bowel protection against NSAID-injury in rats: Effect of rifaximin, a poorly absorbed, GI targeted, antibiotic. Pharmacol Res 2015; 104:186-96. [PMID: 26747402 DOI: 10.1016/j.phrs.2015.12.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 12/17/2015] [Accepted: 12/25/2015] [Indexed: 12/22/2022]
Abstract
Nonsteroidal anti-inflammatory drugs, besides exerting detrimental effects on the upper digestive tract, can also damage the small and large intestine. Although the underlying mechanisms remain unclear, there is evidence that enteric bacteria play a pivotal role. The present study examined the enteroprotective effects of a delayed-release formulation of rifaximin-EIR (R-EIR, 50mg/kg BID, i.g.), a poorly absorbed antibiotic with a broad spectrum of antibacterial activity, in a rat model of enteropathy induced by indomethacin (IND, 1.5mg/kg BID for 14 days) administration. R-EIR was administered starting 7 days before or in concomitance with IND administration. At the end of treatments, blood samples were collected to evaluate hemoglobin (Hb) concentration (as an index of digestive bleeding). Small intestine was processed for: (1) histological assessment of intestinal damage (percentage length of lesions over the total length examined); (2) assay of tissue myeloperoxidase (MPO) and TNF levels, as markers of inflammation; (3) assay of tissue malondialdehyde (MDA) and protein carbonyl concentrations, as an index of lipid and protein peroxidation, respectively; (4) evaluation of the major bacterial phyla. IND significantly decreased Hb levels, this effect being significantly blunted by R-EIR. IND also induced the occurrence of lesions in the jejunum and ileum. In both intestinal regions, R-EIR significantly reduced the percentage of lesions, as compared with rats receiving IND alone. Either the markers of inflammation and tissue peroxidation were significantly increased in jejunum and ileum from IND-treated rats. However, in rats treated with R-EIR, these parameters were not significantly different from those observed in controls. R-EIR was also able to counterbalance the increase in Proteobacteria and Firmicutes abundance induced by INDO. To summarize, R-EIR treatment significantly prevents IND-induced intestinal damage, this enteroprotective effect being associated with a decrease in tissue inflammation, oxidative stress and digestive bleeding as well as reversal of NSAID-induced alterations in bacterial population.
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Affiliation(s)
- Matteo Fornai
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Luca Antonioli
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Carolina Pellegrini
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Rocchina Colucci
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Padova, Italy
| | - Deborah Sacco
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Erika Tirotta
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Gianfranco Natale
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Alessia Bartalucci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Marina Flaibani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Cecilia Renzulli
- Department of Research & Development, Alfa Wassermann SpA, Via Ragazzi del'99, 5, 40133 Bologna, Italy
| | - Emilia Ghelardi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via San Zeno 37, 56127 Pisa, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Via Roma 55, 56126 Pisa, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Via Gramsci 14, 43125 Parma, Italy.
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21
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Kang HA, Lee SM, Park C, Kim DS. Prevalence and predictors of non-steroidal anti-inflammatory drug/analgesic therapeutic duplication in the South Korean ambulatory care setting. Eur J Clin Pharmacol 2015; 72:109-16. [DOI: 10.1007/s00228-015-1958-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
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Al-Saffar A, Nogueira da Costa A, Delaunois A, Leishman DJ, Marks L, Rosseels ML, Valentin JP. Gastrointestinal Safety Pharmacology in Drug Discovery and Development. Handb Exp Pharmacol 2015; 229:291-321. [PMID: 26091645 DOI: 10.1007/978-3-662-46943-9_12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although the basic structure of the gastrointestinal tract (GIT) is similar across species, there are significant differences in the anatomy, physiology, and biochemistry between humans and laboratory animals, which should be taken into account when conducting a gastrointestinal (GI) assessment. Historically, the percentage of cases of drug attrition associated with GI-related adverse effects is small; however, this incidence has increased over the last few years. Drug-related GI effects are very diverse, usually functional in nature, and not limited to a single pharmacological class. The most common GI signs are nausea and vomiting, diarrhea, constipation, and gastric ulceration. Despite being generally not life-threatening, they can greatly affect patient compliance and quality of life. There is therefore a real need for improved and/or more extensive GI screening of candidate drugs in preclinical development, which may help to better predict clinical effects. Models to identify drug effects on GI function cover GI motility, nausea and emesis liability, secretory function (mainly gastric secretion), and absorption aspects. Both in vitro and in vivo assessments are described in this chapter. Drug-induced effects on GI function can be assessed in stand-alone safety pharmacology studies or as endpoints integrated into toxicology studies. In silico approaches are also being developed, such as the gut-on-a-chip model, but await further optimization and validation before routine use in drug development. GI injuries are still in their infancy with regard to biomarkers, probably due to their greater diversity. Nevertheless, several potential blood, stool, and breath biomarkers have been investigated. However, additional validation studies are necessary to assess the relevance of these biomarkers and their predictive value for GI injuries.
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Affiliation(s)
- Ahmad Al-Saffar
- Faculty of Medicine, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
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Eupatilin Exerts Antinociceptive and Chondroprotective Properties in a Rat Model of Osteoarthritis by Downregulating Oxidative Damage and Catabolic Activity in Chondrocytes. PLoS One 2015; 10:e0130882. [PMID: 26083352 PMCID: PMC4471346 DOI: 10.1371/journal.pone.0130882] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 05/26/2015] [Indexed: 01/08/2023] Open
Abstract
Increases in oxidative stress are thought to be associated with the development of osteoarthritis (OA). Eupatilin, one of the major compounds present in artemisia species, was shown to have both anti-oxidative and anti-inflammatory properties. Here, we investigated the in vivo effects of eupatilin on pain severity and cartilage degradation in an experimental rat model of OA, along with the mechanisms of action underlying these effects. Experimental OA was induced via an intra-articular injection of monosodium iodoacetate (MIA), with oral administration of eupatilin initiated on the day of MIA injection. Pain was assessed by measuring the paw withdrawal latency and threshold. Cartilage destruction was analyzed macroscopically and histomorphologically. The effects of eupatilin on mRNA expression were investigated in interleukin-1β (IL-1β)-stimulated human OA chondrocytes. Eupatilin treatment exhibited clear antinociceptive effects, along with an attenuation of cartilage degradation in OA rats. Additionally, the number of osteoclasts present in the subchondral bone region was significantly decreased following eupatilin treatment. Eupatilin reduced the expression of interleukin-1β (IL-1β), interleukin-6 (IL-6), nitrotyrosine and inducible nitric oxide synthase (iNOS) in cartilage. mRNA levels of matrix metalloproteinase-3 (MMP-3), MMP13, and a disintegrin and metalloproteinase with thrombospondin motifs-5 (ADAMTS-5) were reduced in IL-1β-stimulated human OA chondrocytes, while tissue inhibitor of metalloproteinases-1 (TIMP-1) was induced. Phosphorylated protein levels of the c-jun N-terminal kinase (JNK) was reduced by eupatilin. Taken together, these results suggest that eupatilin suppresses oxidative damage and reciprocally enhances extracellular matrix production in articular chondrocytes, making eupatilin a promising therapeutic option for the treatment of OA.
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Scarpignato C, Lanas A, Blandizzi C, Lems WF, Hermann M, Hunt RH. Safe prescribing of non-steroidal anti-inflammatory drugs in patients with osteoarthritis--an expert consensus addressing benefits as well as gastrointestinal and cardiovascular risks. BMC Med 2015; 13:55. [PMID: 25857826 PMCID: PMC4365808 DOI: 10.1186/s12916-015-0285-8] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 01/29/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There are several guidelines addressing the issues around the use of NSAIDs. However, none has specifically addressed the upper versus lower gastrointestinal (GI) risk of COX-2 selective and non-selective compounds nor the interaction at both the GI and cardiovascular (CV) level of either class of drugs with low-dose aspirin. This Consensus paper aims to develop statements and guidance devoted to these specific issues through a review of current evidence by a multidisciplinary group of experts. METHODS A modified Delphi consensus process was adopted to determine the level of agreement with each statement and to determine the level of agreement with the strength of evidence to be assigned to the statement. RESULTS For patients with both low GI and CV risks, any non-selective NSAID (ns-NSAID) alone may be acceptable. For those with low GI and high CV risk, naproxen may be preferred because of its potential lower CV risk compared with other ns-NSAIDs or COX-2 selective inhibitors, but celecoxib at the lowest approved dose (200 mg once daily) may be acceptable. In patients with high GI risk, if CV risk is low, a COX-2 selective inhibitor alone or ns-NSAID with a proton pump inhibitor appears to offer similar protection from upper GI events. However, only celecoxib will reduce mucosal harm throughout the entire GI tract. When both GI and CV risks are high, the optimal strategy is to avoid NSAID therapy, if at all possible. CONCLUSIONS Time is now ripe for offering patients with osteoarthritis the safest and most cost-effective therapeutic option, thus preventing serious adverse events which could have important quality of life and resource use implications. Please see related article: http://dx.doi.org/10.1186/s12916-015-0291-x.
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Affiliation(s)
- Carmelo Scarpignato
- grid.10383.390000000417580937Department of Clinical & Experimental Medicine, Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125 Parma, Italy
| | - Angel Lanas
- grid.11205.370000000121528769Service of Digestive Diseases, Clinic Hospital Lozano Blesa, Aragón Institute for Health Research (IIS Aragón), CIBERehd, University of Zaragoza, Zaragoza, Spain
| | - Corrado Blandizzi
- grid.5395.a0000000417573729Department of Clinical & Experimental Medicine, Division of Pharmacology & Chemotherapy, University of Pisa, Pisa, Italy
| | - Willem F Lems
- grid.16872.3a000000040435165XDepartment of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Matthias Hermann
- grid.412004.30000000404789977Department of Cardiology, University Hospital, Zurich, Switzerland
| | - Richard H Hunt
- grid.25073.330000000419368227Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON Canada
| | - For the International NSAID Consensus Group
- grid.10383.390000000417580937Department of Clinical & Experimental Medicine, Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125 Parma, Italy
- grid.11205.370000000121528769Service of Digestive Diseases, Clinic Hospital Lozano Blesa, Aragón Institute for Health Research (IIS Aragón), CIBERehd, University of Zaragoza, Zaragoza, Spain
- grid.5395.a0000000417573729Department of Clinical & Experimental Medicine, Division of Pharmacology & Chemotherapy, University of Pisa, Pisa, Italy
- grid.16872.3a000000040435165XDepartment of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
- grid.412004.30000000404789977Department of Cardiology, University Hospital, Zurich, Switzerland
- grid.25073.330000000419368227Department of Medicine, Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON Canada
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Sostres C, Gargallo CJ, Lanas A. Interaction between Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs and/or low-dose aspirin use: Old question new insights. World J Gastroenterol 2014; 20:9439-9450. [PMID: 25071338 PMCID: PMC4110575 DOI: 10.3748/wjg.v20.i28.9439] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/15/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Previous reports clearly demonstrated that Helicobacter pylori (H. pylori) infection, nonsteroidal anti-inflammatory drugs (NSAID) or low dose aspirin (ASA) use significantly and independently increased the risk for the development of peptic ulcer disease. Today, the presence of H. pylori infection associated with low dose ASA and/or NSAID use in the same patient is becoming more frequent and therefore the potential interaction between these factors and the consequences of it has important implications. Whether NSAID intake in the presence of H. pylori infection may further increase the risk of peptic ulcer carried by the presence of only one risk factor is still a matter of debate. Studies on the interaction between the two risk factors yielded conflicting data and no consensus has been reached in the last years. In addition, the interaction between H. pylori infection and low-dose ASA remains even more controversial. In real clinical practice, we can find different clinical scenarios involving these three factors associated with the presence of different gastrointestinal and cardiovascular risk factors. These huge variety of possible combinations greatly hinder the decision making process of physicians.
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Lanas A, Boers M, Nuevo J. Gastrointestinal events in at-risk patients starting non-steroidal anti-inflammatory drugs (NSAIDs) for rheumatic diseases: the EVIDENCE study of European routine practice. Ann Rheum Dis 2013; 74:675-81. [PMID: 24351518 DOI: 10.1136/annrheumdis-2013-204155] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Data concerning rates of gastrointestinal (GI) events in non-steroidal anti-inflammatory drug (NSAID) users derive mainly from clinical trials. The EVIDENCE study quantified the incidence of symptomatic uncomplicated and/or complicated GI events in at-risk European patients treated with NSAIDs in real-life practice. METHODS This non-interventional study assessed 4144 adults with at least one GI risk factor who recently initiated NSAID therapy for osteoarthritis (85%), rheumatoid arthritis (11%), ankylosing spondylitis (3%) or a combination (1%). Patient characteristics and medical history were collected from medical records. GI events (upper and lower) were recorded at in-clinic visits during 6 months' follow-up. RESULTS Mean time on index NSAID at enrolment was 33 days. The incidence (per 100 person-years) was 18.5 per 100 person-years for uncomplicated GI events and 0.7 per 100 person-years for complicated GI events. Upper GI events were far more common (12%) than lower GI events (1%) during study follow-up (median 182 days (range 61-320)). Other reported rates for cardiovascular, anaemia or non-GI events were much less frequent. A minority (28%) of patients had ongoing proton pump inhibitor use at enrolment, with strong variation by practice and country. CONCLUSIONS EVIDENCE is the largest prospective study of the real-life management of European patients treated with NSAIDs for rheumatic diseases and at increased GI risk. It shows that GI events from the upper GI tract are far more common than those from the lower GI tract. It also shows adherence to guidelines for gastroprotection is generally low. CLINICALTRIALSGOV IDENTIFIER NCT01176682.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Clinic Hospital, University of Zaragoza, Zaragoza, Spain
| | - Maarten Boers
- Departments of Epidemiology and Biostatistics and Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Javier Nuevo
- Observational Research Centre, Global Medicines Development, AstraZeneca, Madrid, Spain
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Scarpignato C. Piroxicam-β-cyclodextrin: a GI safer piroxicam. Curr Med Chem 2013; 20:2415-37. [PMID: 23394552 PMCID: PMC3664509 DOI: 10.2174/09298673113209990115] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 12/28/2012] [Accepted: 01/11/2013] [Indexed: 02/06/2023]
Abstract
Although NSAIDs are very effective drugs, their use is associated with a broad spectrum of adverse reactions in the liver, kidney, cardiovascular (CV) system, skin and gut. Gastrointestinal (GI) side effects are the most common and constitute a wide clinical spectrum ranging from dyspepsia, heartburn and abdominal discomfort to more serious events such as peptic ulcer with life-threatening complications of bleeding and perforation. The appreciation that CV risk is also increased further complicates the choices of physicians prescribing anti-inflammatory therapy. Despite prevention strategies should be implemented in patients at risk, gastroprotection is often underused and adherence to treatment is generally poor. A more appealing approach would be therefore to develop drugs that are devoid of or have reduced GI toxicity. Gastro-duodenal mucosa possesses many defensive mechanisms and NSAIDs have a deleterious effect on most of them. This results in a mucosa less able to cope with even a reduced acid load. NSAIDs cause gastro-duodenal damage, by two main mechanisms: a physiochemical disruption of the gastric mucosal barrier and systemic inhibition of gastric mucosal protection, through inhibition of cyclooxygenase (COX, PG endoperoxide G/H synthase) activity of the GI mucosa. However, against a background of COX inhibition by anti-inflammatory doses of NSAIDs, their physicochemical properties, in particular their acidity, underlie the topical effect leading to short-term damage. It has been shown that esterification of acidic NSAIDs suppresses their gastrotoxicity without adversely affecting anti-inflammatory activity. Another way to develop NSAIDs with better GI tolerability is to complex these molecules with cyclodextrins (CDs), giving rise to so-called “inclusion complexes” that can have physical, chemical and biological properties very different from either those of the drug or the cyclodextrin. Complexation of NSAIDs with β-cyclodextrin potentially leads to a more rapid onset of action after oral administration and improved GI tolerability because of minimization of the drug gastric effects. One such drug, piroxicam-β-cyclodextrin (PBC), has been used in Europe for 25 years. Preclinical and clinical pharmacology of PBC do show that the β-cyclodextrin inclusion complex of piroxicam is better tolerated from the upper GI tract than free piroxicam, while retaining all the analgesic and anti-inflammatory properties of the parent compound. In addition, the drug is endowed with a quick absorption rate, which translates into a faster onset of analgesic activity, an effect confirmed in several clinical studies. An analysis of the available trials show that PBC has a GI safety profile, which is better than that displayed by uncomplexed piroxicam. Being an inclusion complex of piroxicam, whose CV safety has been pointed out by several observational studies, PBC should be viewed as a CV safe anti-inflmmatory compound and a GI safer alternative to piroxicam. As a consequence, it should be considered as a useful addition to our therapeutic armamentarium.
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Affiliation(s)
- C Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Italy.
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Guo GH, Song FQ, Wang J, Wang FF. Strategies for prevention of re-bleeding after NSAIDs-related ulcers. Shijie Huaren Xiaohua Zazhi 2013; 21:2282-2288. [DOI: 10.11569/wcjd.v21.i23.2282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the therapeutic efficacy and safety of teprenone combined with short- versus long-term use of omeprazole in the prevention of re-bleeding after endoscopic hemostasis for NSAIDs-related ulcers.
METHODS: Patients with NSAIDs-related ulcers who underwent Monteggia liquid spraying for bleeding were randomly divided into four groups: a teprenone group (n = 28), an omeprazole group (n = 33), a short-term combination group (n = 31), and a long-term combination group (n = 35). The incidences of re-bleeding and adverse reactions occurring during the periods of 0-13, 14-26, 0-26 and 27-52 wk were compared among the four groups.
RESULTS: The rate of re-bleeding occurring between 0 and 13 wk was significantly higher in the teprenone group than in the other groups (all P < 0.05), and the differences were not statistically significant between the other three groups (all P > 0.05). During the periods between 14 and 26 weeks and between 27 and 52 wk, there were no statistically significant differences in the rates of re-bleeding between the four groups (all P > 0.05). The incidences of adverse reactions showed no significant differences between the four groups during the period of the first 26 weeks (all P > 0.05) or between the omeprazole group and long-term combination group during the period between 27 and 52 wk (P > 0.05), but were significantly higher in the omeprazole group and long-term combination group than in the short-term combination group (both P < 0.05).
CONCLUSION: Teprenone in combination with short-term use of omeprazole has comparable efficacy to long-term use of omeprazole but is associated with significantly less adverse reactions in preventing the occurrence of re-bleeding after NSAIDs-related ulcers.
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Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage. Arthritis Res Ther 2013; 15 Suppl 3:S3. [PMID: 24267289 PMCID: PMC3890944 DOI: 10.1186/ar4175] [Citation(s) in RCA: 224] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
NSAIDs are among the most commonly used drugs worldwide and their beneficial therapeutic properties are thoroughly accepted. However, they are also associated with gastrointestinal (GI) adverse events. NSAIDs can damage the whole GI tract including a wide spectrum of lesions. About 1 to 2% of NSAID users experienced a serious GI complication during treatment. The relative risk of upper GI complications among NSAID users depends on the presence of different risk factors, including older age (>65 years), history of complicated peptic ulcer, and concomitant aspirin or anticoagulant use, in addition to the type and dose of NSAID. Some authors recently reported a decreasing trend in hospitalizations due to upper GI complications and a significant increase in those from the lower GI tract, causing the rates of these two types of GI complications to converge. NSAID-induced enteropathy has gained much attention in the last few years and an increasing number of reports have been published on this issue. Current evidence suggests that NSAIDs increase the risk of lower GI bleeding and perforation to a similar extent as that seen in the upper GI tract. Selective cyclooxygenase-2 inhibitors have the same beneficial effects as nonselective NSAIDs but with less GI toxicity in the upper GI tract and probably in the lower GI tract. Overall, mortality due to these complications has also decreased, but the in-hospital case fatality for upper and lower GI complication events has remained constant despite the new therapeutic and prevention strategies.
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Affiliation(s)
- Carlos Sostres
- Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/Domingo Miral s/n, 50009 Zaragoza, Spain
- Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain
| | - Carla J Gargallo
- Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/Domingo Miral s/n, 50009 Zaragoza, Spain
- Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain
| | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitário Lozano Blesa, c/Domingo Miral s/n, 50009 Zaragoza, Spain
- Aragon Health Sciences Institute, Avd San Juan Bosco 13, 50009 Zaragoza, Spain
- CIBERehd, c/Córcega 180 bajos dcha, 08036 Barcelona, Spain
- University of Zaragoza, c/Pedro Cerbuna s/n, 50009 Zaragoza, Spain
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Moon SJ, Park JS, Jeong JH, Yang EJ, Park MK, Kim EK, Park SH, Kim HY, Cho ML, Min JK. Augmented chondroprotective effect of coadministration of celecoxib and rebamipide in the monosodium iodoacetate rat model of osteoarthritis. Arch Pharm Res 2013; 36:116-24. [PMID: 23338062 DOI: 10.1007/s12272-013-0010-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Osteoarthritis (OA) is a degenerative joint disease characterized by the progressive loss of articular cartilage and chronic pain. Although cyclooxygenase-2 (COX-2) inhibitors such as celecoxib are recommended to patients at high risk of gastrointestinal (GI) adverse events, COX-2 inhibitors do not completely prevent GI adverse events. Rebamipide, a gastroprotective agent, has anti-inflammatory properties and acts as an oxygen radical scavenger. The aim of this study was to investigate the in vivo effects of coadministration of rebamipide and celecoxib in an OA rat model. OA was induced by intra-articular injection of monosodium iodoacetate. Oral administration of rebamipide was initiated on the day of OA induction. In this study, rebamipide showed antinociceptive properties and attenuated cartilage degeneration. Rebamipide reduced the expression of matrix metalloproteinase 13, interleukin-1β, inducible nitric oxide synthase, and nitrotyrosine in OA cartilage. OA rats treated with celecoxib in combination with rebamipide demonstrated a higher pain threshold than those treated with monotherapy. Histological examination also showed that the joints from OA animals treated with combination therapy demonstrated less cartilage damage than those of animals treated with monotherapy. We showed that the potential benefit of combination therapy with celecoxib and rebamipide on pain and cartilage degeneration in OA.
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Affiliation(s)
- Su-Jin Moon
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, Sosa 2-Dong, Wonmi-Gu, Bucheon, Kyunggi-Do 414-717, Republic of Korea
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Marks L, Beard E, Cobey D, Moore N, Motyer V, Valentin JP, Ewart L. An evaluation of the non-invasive faecal pellet assessment method as an early drug discovery screen for gastrointestinal liability. J Pharmacol Toxicol Methods 2013; 68:123-36. [DOI: 10.1016/j.vascn.2013.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/20/2013] [Accepted: 03/21/2013] [Indexed: 12/24/2022]
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Poddubnyy D, van der Heijde D. Therapeutic controversies in spondyloarthritis: nonsteroidal anti-inflammatory drugs. Rheum Dis Clin North Am 2012; 38:601-11. [PMID: 23083758 DOI: 10.1016/j.rdc.2012.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered a first-line therapy in patients with axial spondyloarthritis (axSpA), including ankylosing spondylitis. NSAIDs reduce pain and stiffness effectively in most patients, are able to reduce systemic and local inflammation, and can inhibit progression of structural damage in the spine. However, effective control of symptoms and retardation of radiographic progression often require continuous and long-term treatment, which raises safety concerns. This article discusses controversies related to the current role of NSAIDs in axSpA treatment, risks and benefits of this treatment, and current trends for individualized treatment.
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Affiliation(s)
- Denis Poddubnyy
- Rheumatology, Medical Department I, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin 12203, Germany.
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Prescription of and adherence to non-steroidal anti-inflammatory drugs and gastroprotective agents in at-risk gastrointestinal patients. Am J Gastroenterol 2012; 107:707-14. [PMID: 22334248 PMCID: PMC3368233 DOI: 10.1038/ajg.2012.13] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Patients with gastrointestinal (GI) risk factors who take non-steroidal anti-inflammatory drugs (NSAIDs) should also take gastroprotective agents (GPAs). No studies have evaluated adherence and reasons for non-adherence to GPA and NSAID therapies. METHODS This was a prospective, multicenter, observational, longitudinal study. Patients attending rheumatology/orthopedic clinics who were co-prescribed NSAID plus GPA for at least 15 days and had risk factors for GI complications were followed up by telephone call. Optimal adherence was defined as taking the drug for ≥ 80% of prescribed days. Multivariate logistic regression analysis was used to determine factors associated with non-adherence. RESULTS Of 1,232 patients interviewed, 192 were excluded because of inaccurate data. Of the remaining 1,040 patients, 74 % were prescribed low-dose NSAIDs and 99.8 % were prescribed a standard or high-dose GPA. In all, 70 % of NSAIDs and 63.1 % of GPA prescriptions were short term (< 30 days). The majority of patients who were prescribed either an NSAID (92.5 % ) or GPA (85.9 % ) started therapy. Optimal adherence to GPA or NSAIDs was reported by 79.7 % (95 % confidence interval (CI): 76.9-82.2 % ) and 84.1 % (95 % CI: 81.7-86.3 % ) of patients, respectively. More adverse events occurred among patients who reported non-optimal adherence than among patients with optimal adherence to GPA (22.1 vs. 1.9 % , P < 0.0001). As reasons for non-adherence, patients most frequently cited infrequent/low-intensity rheumatic pain (NSAIDs) or forgetfulness (GPAs). Adverse events and short-term treatment were independent factors associated with poor adherence for both NSAIDs and GPAs. History of uncomplicated peptic ulcer and frequent dosing were additional factors associated with non-adherence to NSAIDs. CONCLUSIONS Most frequent reasons for non-adherence are infrequent/low-intensity rheumatic pain (NSAIDs) or forgetfulness (GPAs). Short-term treatment and adverse events were associated with poor adherence for both therapies.
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Abstract
The presence of gastric acid plays a critical role in the mechanisms of NSAIDs/aspirin-associated gastric and duodenal mucosal injury and ulceration. The role of gastric acid and its relationship to NSAIDs/aspirin in mucosal damage, ulcer and ulcer complications continues to be an important concern because of the increasing worldwide use of NSAIDs and aspirin. Acid suppression continues to be an important prevention strategy for NSAID-associated gastric and duodenal ulcer and ulcer complications. While a coxib or an NSAID and PPI in combination are considered to have comparable safety profiles, the evidence from direct comparisons in high-risk patients is limited, and the cardiovascular safety of coxibs and NSAIDs remains a concern especially in patients with a high risk of cardiovascular disease. An evaluation of individual gastrointestinal and cardiovascular risks and benefits, selection of the most appropriate NSAID and dose for each particular patient should always be emphasized. Twice daily PPI is more appropriate to protect a patient who is taking NSAIDs twice daily. PPI co-therapy is still recommended in patients receiving dual antiplatelet treatment, although conflicting results have been reported about adverse drug interactions between PPIs and clopidogrel.
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Affiliation(s)
- Richard H Hunt
- Farncombe Family Digestive Health Research Institute, Division of Gastroenterology, McMaster University Health Science Centre, Hamilton, Ont., Canada.
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Epidemiology and role of nonsteroidal antiinflammatory drugs in causing gastrointestinal bleeding. Gastrointest Endosc Clin N Am 2011; 21:597-612. [PMID: 21944413 DOI: 10.1016/j.giec.2011.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article outlines the epidemiology and role of nonsteroidal antiinflammatory drugs (NSAIDs) in causing gastrointestinal (GI) bleeding. The morbidity and mortality associated with NSAID-induced GI bleeding are discussed, and the mechanisms of NSAID-related GI injury, the potency of various NSAIDs, new NSAIDs associated with a decrease in GI pathology, dual-acting antiinflammatory drugs, hydrogen sulfide-releasing NSAIDs, lipoxygenase/cyclooxygenase, phospholipid NSAIDs, and the comprehensive effects of NSAIDs on the GI tract are described.
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Wu J, Zhang Y, Frilot N, Kim JI, Kim WJ, Daaka Y. Prostaglandin E2 regulates renal cell carcinoma invasion through the EP4 receptor-Rap GTPase signal transduction pathway. J Biol Chem 2011; 286:33954-62. [PMID: 21832044 DOI: 10.1074/jbc.m110.187344] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Prognosis for patients with early stage kidney cancer has improved, but the treatment options for patients with locally advanced disease and metastasis remain few. Understanding the molecular mechanisms that regulate invasion and metastasis is critical for developing successful therapies to treat these patients. Proinflammatory prostaglandin E(2) plays an important role in cancer initiation and progression via activation of cognate EP receptors that belong to the superfamily of G protein-coupled receptors. Here we report that prostaglandin E(2) promotes renal cancer cell invasion through a signal transduction pathway that encompasses EP4 and small GTPase Rap. Inactivation of Rap signaling with Rap1GAP, like inhibition of EP4 signaling with ligand antagonist or knockdown with shRNA, reduces the kidney cancer cell invasion. Human kidney cells evidence increased EP4 and decreased Rap1GAP expression levels in the malignant compared with benign samples. These results support the idea that targeted inhibition of EP4 signaling and restoration of Rap1GAP expression constitute a new strategy to control kidney cancer progression.
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Affiliation(s)
- Juanjuan Wu
- Department of Pathology, Georgia Health Sciences University, Augusta, Georgia 30912, USA
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Abstract
Aspirin is being used as an effective analgesic and anti-inflammatory agent at doses >325 mg daily. At low doses (75-325 mg daily), aspirin is the key antiplatelet drug in the pharmacological prevention of cardiovascular diseases. Topical and systemic effects of aspirin in the gastrointestinal mucosa are associated with mucosal damage in the upper and lower gastrointestinal tract. The risk of upper gastrointestinal bleeding with aspirin is increased with old age, male sex, ulcer history and concomitant medication with NSAIDs, cyclooxygenase 2 selective inhibitors, corticosteroids or other antithrombotic agents. In some patients, the cardiovascular benefits of low-dose aspirin might be overcome by the risk of gastrointestinal complications, but withdrawal of aspirin therapy can precipitate a cardiovascular event. These patients will need concomitant therapy with antisecretory agents, especially PPIs, to reduce the gastrointestinal risk. Eradication of Helicobacter pylori infection might be an additional option in patients with a history of ulcer. Furthermore, there is growing evidence that long-term use of aspirin decreases the risk of colorectal cancer, even at low doses. As aspirin is one of the most prescribed drugs worldwide and its clinical impact is huge, physicians need to consider the benefits and harms for each individual patient in order to maximize the benefits of aspirin.
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Lanas A, Garcia-Tell G, Armada B, Oteo-Alvaro A. Prescription patterns and appropriateness of NSAID therapy according to gastrointestinal risk and cardiovascular history in patients with diagnoses of osteoarthritis. BMC Med 2011; 9:38. [PMID: 21489310 PMCID: PMC3101123 DOI: 10.1186/1741-7015-9-38] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Accepted: 04/14/2011] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Prescription of non-steroidal anti-inflammatory drugs (NSAIDs) should be based on the assessment of both gastrointestinal (GI) and cardiovascular (CV) risk for the individual patient. We aimed to assess the GI/CV risk profile and the pharmacological management of patients with osteoarthritis (OA) in clinical practice. METHODS We conducted a cross-sectional, multicentre, observational study of consecutive OA patients that visited 1,760 doctors throughout the Spanish National Health System (NHS) in a single day. The presence of GI risk factors, CV histories, hypertension and current pharmacological treatments was recorded. RESULTS Of the 60,868 patients, 17,105 had a diagnosis of OA and were evaluable. The majority (93.4%) had more than one GI risk factor and 60.3% were defined to be at high-GI risk. Thirty-two percent had a history of CV events, 57.6% were treated with anti-hypertensive therapy and 22.6% had uncontrolled hypertension. One-fifth of patients were treated with non-NSAID therapies, whereas the remaining patients received NSAIDs. Non-selective NSAIDs (nsNSAID) plus proton pump inhibitor (PPI) or cyclooxigenase-2 (COX-2)-selective NSAIDs alone were more frequently prescribed in patients at increased GI risk. Patients with a positive CV history received nsNSAIDs or COX-2-selective NSAIDs in 41.3% and 31.7% of cases, respectively. When both the GI and CV histories were combined, 51% of the overall population was being prescribed drugs that were either not recommended or contraindicated. CONCLUSIONS Over 90% of patients with OA are at increased GI and/or CV risk. In over half of these patients, the prescription of NSAIDs was not in accordance with current guidelines or recommendations made by regulatory agencies.
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Affiliation(s)
- Angel Lanas
- University of Zaragoza Medical School, Aragón Health Research Institute (IIS Aragón), CIBERehd, Zaragoza, Spain
| | - Guillermo Garcia-Tell
- CS Salvador Pau, Assistant Professor Department of Medicine.,University of Valencia, Spain
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Thiéfin G, Schwalm MS. Underutilization of gastroprotective drugs in patients receiving non-steroidal anti-inflammatory drugs. Dig Liver Dis 2011; 43:209-14. [PMID: 21051300 DOI: 10.1016/j.dld.2010.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 08/02/2010] [Accepted: 09/23/2010] [Indexed: 12/11/2022]
Abstract
AIM To assess the prevalence of gastroprotective agent prescription in patients treated with non-steroidal anti-inflammatory drugs in France and to analyze the determinants of this prescription. METHODS A cross-sectional observational study was performed in 2576 patients treated with non-steroidal anti-inflammatory drugs recruited prospectively in the French primary care system. RESULTS Thirty-nine percent of the patients (n=1002) received gastroprotective agents, mostly proton pump inhibitors (99.5%). In patients with a single risk factor, the gastroprotection rates were: 50% for age>65, 67% for concurrent use of corticosteroids or antithrombotics, and 87% and 100% for history of uncomplicated and complicated gastroduodenal ulcers. In patients without risk factors, gastroprotective agents were prescribed in 31.8%. Among them, two thirds had symptoms of gastro-oesophageal reflux or history of non-steroidal anti-inflammatory drug intolerance or dyspepsia. Conversely, 40% (n=256) of at-risk non-steroidal anti-inflammatory drug users did not receive gastroprotective agents. Gastroprotection was significantly associated with history of gastroduodenal ulcer (OR: 8.2; 95%CI: 4.3-15.6) or history of non-steroidal anti-inflammatory drug intolerance (OR: 6; 95%CI: 4.5-8.1), gastro-oesophageal reflux (OR: 6; 95%CI: 4.4-8.2), dyspepsia (OR: 5.2; 95%CI: 3.7-7.5), concurrent gastrotoxic treatment (OR: 3.3; 95%CI: 1.9-5.6) and age>65 (OR: 3; 95%CI: 2.3-4.1). CONCLUSIONS Despite widespread recommendations, gastroprotection is still largely underprescribed in patients at risk of gastrointestinal non-steroidal anti-inflammatory drug complications in France. Only half of non-steroidal anti-inflammatory drug users above 65 years are prescribed gastroprotective agents.
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Affiliation(s)
- Gérard Thiéfin
- Hepato-Gastroenterology, Reims University Hospital, Reims, France.
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Abstract
A proton pump inhibitor (PPI) is often co-prescribed with clopidogrel to reduce the gastrointestinal risk of bleeding ulcers in patients following acute coronary syndrome or a stent implant. However, the safety issue of such practice has been scrutinized after some studies reporting an increased incidence of cardiovascular events and mortality, although there have also been contrary research reports. This has lead to a warning statement from the US Food and Drug Administration cautioning the concomitant use of PPI and clopidogrel. This review examines the evidence of PPI as gastroprotective agent, histamine H(2) antagonists as an alternative therapy, the influence of PPI on the antiplatelet effect of clopidogrel, and the controversies of various studies.
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Affiliation(s)
- H J Tan
- Division of Gastroenterology, Sunway Medical Centre, Kuala Lumpur, Malaysia.
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Ahsberg K, Höglund P, Kim WH, von Holstein CS. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol 2010; 45:1404-15. [PMID: 20695720 DOI: 10.3109/00365521.2010.510567] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the impact of increased use of low-dose aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal gastrointestinal (GI) bleeds. METHODS Retrospective review of 731 patients with peptic ulcer bleeds (PUBs), non-ulcer, non-variceal upper (NUUPGIBs) and lower GI bleeds (LGIBs) in 1984, 1994 and 2004 at Lund University Hospital, Sweden. Incidence and mortality rates, risk factors for fatal outcome and associations with different sites of GI bleeds were evaluated. RESULTS Between 1984 and 2004, incidence of PUBs decreased from 62.0 to 32.1 per 100,000 inhabitants (p<0.001). Incidence of NUUPGIBs (29.0-30.4 per 100,000) and LGIBs (45.5-43.2 per 100,000) was stable. The case-fatality rate ranged from 4-6% (p=0.65) for upper GI bleed to 1-8% (p=0.033) for LGIB. No drug impacted on fatal outcome. Aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds than non-users of these drugs. When comparing non-ulcer GI bleeds with PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids (OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI bleeds after adjusting for age, gender and co-morbidity. CONCLUSION Increased use of drugs that promote bleeding has not impacted on incidence and fatal outcome of non-variceal GI bleeds, although the severity of bleeding has increased. Aspirin is more strongly associated with PUBs, while corticosteroids and SSRIs are associated with non-ulcer, non-variceal GI bleeds.
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Affiliation(s)
- Kristina Ahsberg
- Department of Surgery, Lund University Hospital, Lund University, Lund, Sweden.
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Abstract
There is a range of pharmacological options available to the rheumatologist for treating arthritis. Non-selective NSAIDs or Cox-2 selective inhibitors are widely prescribed to reduce inflammation and alleviate pain; however, they must be used with caution in individuals with an increased cardiovascular, renal or gastrointestinal (GI) risk. The potential cardiovascular risks of Cox-2 selective inhibitors came to light over a decade ago. The conflicting nature of the study data reflects some context dependency, but the evidence shows a varying degree of cardiovascular risk with both Cox-2 selective inhibitors and non-selective NSAIDs. This risk appears to be dose dependent, which may have important ramifications for arthritis patients who require long-term treatment with high doses of anti-inflammatory drugs. The renal effects of non-selective NSAIDs have been well characterized. An increased risk of adverse renal events was found with rofecoxib but not celecoxib, suggesting that this is not a class effect of Cox-2 selective inhibitors. Upper GI effects of non-selective NSAID treatment, ranging from abdominal pain to ulceration and bleeding are extensively documented. Concomitant prescription of a proton pump inhibitor can help in the upper GI tract, but probably not in the lower. Evidence suggests that Cox-2 selective inhibitors are better tolerated in the entire GI tract. More evidence is required, and a composite end-point is being evaluated. Appropriate treatment strategies are needed depending on the level of upper and lower GI risk. Rheumatologists must be vigilant in assessing benefit–risk when prescribing a Cox-2 selective inhibitor or non-selective NSAID and should choose appropriate agents for each individual patient.
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Affiliation(s)
- Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Åhsberg K, Höglund P, Staël von Holstein C. Mortality from peptic ulcer bleeding: the impact of comorbidity and the use of drugs that promote bleeding. Aliment Pharmacol Ther 2010; 32:801-10. [PMID: 20653635 DOI: 10.1111/j.1365-2036.2010.04399.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Use of drugs promoting peptic ulcer bleed has increased several folds. AIM To make a time-trend analysis of peptic ulcer bleed patients and evaluate the impact of age, gender, comorbidity and use of drugs promoting peptic ulcer bleed on outcome. METHODS Retrospective review of hospitalizations for peptic ulcer bleed at Lund University Hospital during 1984, 1994 and 2004. Univariate analyses between years and multivariable logistic regression for risk factors of fatal outcome. RESULTS Incidence decreased from 62.0 to 32.1 per 100 000 inhabitants between 1984 and 2004. Mortality rates were stable. Median age (70–77 years; P = 0.001), number of comorbidities (mean +/- s.d.: 0.88 +/- 0.96 to 1.16 +/- 0.77; P = 0.021), use of aspirin (16–57%; P < 0.001) and warfarin (5–17%; P = 0.02) increased. Pharmacological and endoscopic therapy improved. Age above 65 years (OR: 1.11, 95% CI: 1.02–1.23) and number of comorbidities (OR: 6.00, 95% CI: 2.56–17.4) were independent risk factors for in-hospital mortality. Bleeding promoting drugs did not influence outcome negatively. Aspirin decreased the risk of fatal outcome (OR: 0.12, 95% CI: 0.012–0.67). CONCLUSIONS Incidence of peptic ulcer bleed decreased despite higher prescription rates of bleeding promoting drugs. The in-hospital mortality remained unchanged. The effect of improved therapy against peptic ulcer bleed is probably outweighed by older and more comorbid patients. The decreased risk of fatal outcome in aspirin users warrants further investigations.
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Affiliation(s)
- K Åhsberg
- Department of Surgery, Lund University Hospital, Lund University, Sweden.
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Scarpignato C, Hunt RH. Nonsteroidal antiinflammatory drug-related injury to the gastrointestinal tract: clinical picture, pathogenesis, and prevention. Gastroenterol Clin North Am 2010; 39:433-64. [PMID: 20951911 DOI: 10.1016/j.gtc.2010.08.010] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Increasing life expectancy in developed countries has led to a growing prevalence of arthritic disorders, which has been accompanied by increasing prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). These are the most widely used agents for musculoskeletal and arthritic conditions. Although NSAIDs are effective, their use is associated with a broad spectrum of adverse reactions in the liver, kidney, cardiovascular system, skin, and gut. Gastrointestinal (GI) side effects are the most common. The dilemma for the physician prescribing NSAIDs is, therefore, to maintain the antiinflammatory and analgesic benefits, while reducing or preventing GI side effects. The challenge is to develop safer NSAIDs by shifting from a focus on GI toxicity to the increasingly more appreciated cardiovascular toxicity.
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Affiliation(s)
- Carmelo Scarpignato
- Division of Gastroenterology, Department of Clinical Sciences, University of Parma, Italy.
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Sostres C, Gargallo CJ, Arroyo MT, Lanas A. Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol 2010; 24:121-32. [PMID: 20227026 DOI: 10.1016/j.bpg.2009.11.005] [Citation(s) in RCA: 395] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 11/09/2009] [Accepted: 11/25/2009] [Indexed: 01/31/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most widely prescribed medication in the world. Their main benefit derives from their anti-inflammatory and analgesic effect, but the use of these agents is not innocuous since they mainly increase the risk of gastrointestinal (GI) and cardiovascular complications compared with non-NSAID users. NSAIDs injures the upper and lower gut by depleting COX-1 derived prostaglandins and causing topical injury to the mucosa. The risk of upper GI complications varies, depending on the presence of one or more risk factors. Among them, the three main risk factors are prior history of peptic ulcer, the single most important risk factor, age, the most common, and concomitant aspirin use, due to their GI and cardiovascular implications. Those individuals at-risk should be considered for alternatives to NSAID therapy and modifications of risk factors. If NSAID therapy is required, patients at risk will need prevention strategies including co-therapy of NSAID with gastroprotectants (PPI or misoprostol) or the prescription of COX-2 selective inhibitors. The probable introduction of NO-NSAIDs in the market in the near future may open a new therapeutic option for patients with hypertension who need NSAIDs.
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Affiliation(s)
- Carlos Sostres
- Service of Digestive Diseases, University Hospital Lozano Blesa, Zaragoza, Spain
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Whittle BJR. Protocols to assess the gastrointestinal side effects resulting from inhibition of cyclo-oxygenase isoforms. Methods Mol Biol 2010; 644:189-200. [PMID: 20645175 DOI: 10.1007/978-1-59745-364-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A prevalent unwanted action of cyclo-oxygenase (COX) inhibitors, as exemplified by the non-steroidal anti-inflammatory drugs (NSAIDs), is their potential to produce gastrointestinal side effects in clinical use. The injury provoked by such agents includes rapid superficial disruption to the surface layer of the gastric mucosa, the production of acute gastric erosions in the corpus region and the formation of ulcers in the antral region of the stomach. The small intestine is also adversely affected, with a developing enteropathy over a more protracted period that causes lesions and inflammation in the gut. From experimental work, the interactive mechanisms of such damage in the stomach differ distinctly from those that underlie the intestinal injury, yet the damage in both regions involves the inhibition of both COX-1 and COX-2 isoforms. This chapter outlines the in vivo methods that can be used to identify the potential for novel NSAIDs and selective COX-inhibitors to produce acute gastric corpus lesions and more-chronic antral ulcers in the rat, as well as causing small intestinal enteropathy. Such methods can also be utilized to evaluate the ability of novel agents to prevent the gastrointestinal injury provoked by NSAIDs or COX-inhibitors.
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Affiliation(s)
- Brendan J R Whittle
- St. Bart&s and the London School of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Lanas A, Esplugues JV, Zapardiel J, Sobreviela E. Education-based approach to addressing non-evidence-based practice in preventing NSAID-associated gastrointestinal complications. World J Gastroenterol 2009; 15:5953-9. [PMID: 20014459 PMCID: PMC2795182 DOI: 10.3748/wjg.15.5953] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate an evidence-based educational program for improving strategies for prevention of nonsteroidal anti-inflammatory drug (NSAID)-associated gastrointestinal (GI) complications.
METHODS: Four hundred and fifty-six specialists replied to a questionnaire that covered issues related to NSAID-induced adverse effects. They also collected data from their last five consecutive patients before and after they had attended an evidence-based seminar on GI prevention strategies.
RESULTS: Four hundred and forty-one of 456 specialists (96.7%) participated in the survey, and 382 (83.7%) in the education-based study that recorded data from 3728 patients. The specialists overestimated the risk of GI complications with NSAIDs, underestimated the GI safety profile of coxibs, but were aware of the risk factors and of the current prevention strategies. Proton pump inhibitors were co-prescribed with NSAIDs in > 80% of patients with and without risk factors. The educational program had little impact on prescribing habits.
CONCLUSION: Specialists are informed of advances in NSAID-associated adverse effects and have high rates of GI-prevention therapy. Our educational program did not alter these rates.
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Pilotto A, Sancarlo D, Addante F, Scarcelli C, Franceschi M. Non-steroidal anti-inflammatory drug use in the elderly. Surg Oncol 2009; 19:167-72. [PMID: 20022240 DOI: 10.1016/j.suronc.2009.11.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of inflammation and pain of various origins is well established. Prescribing these drugs, however, remains a challenge because a great variety of gastrointestinal and cardiovascular safety issues need to be considered, particularly in older patients. Recent recommendations suggest that the prescription of non-selective NSAIDs and/or selective cyclo-oxygenase-2 inhibitors (coxibs) may be appropriate in patients with low gastrointestinal risk (no prior gastrointestinal events, no concomitant treatments with other damaging drugs). Gastroprotection is appropriate in patients with gastrointestinal risk factors and in older patients. In patients at high risk for gastrointestinal and cardiovascular events, however, NSAID or coxib prescriptions are contraindicated. Multidimensional impairment is a crucial point in evaluating the clinical outcome of older patients; thus, a comprehensive geriatric assessment is useful in predicting adverse outcomes, including morbidity and mortality.
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Affiliation(s)
- Alberto Pilotto
- Department of Medical Sciences, Geriatric Unit and Research Laboratory Gerontology & Geriatrics, I.R.C.C.S. Casa Sollievo della Sofferenza, Viale Cappuccini 1, I-71013 San Giovanni Rotondo (FG), Italy.
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Sostres C, Gargallo C, Lanas A. Drug-related damage of the ageing gastrointestinal tract. Best Pract Res Clin Gastroenterol 2009; 23:849-60. [PMID: 19942163 DOI: 10.1016/j.bpg.2009.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 10/01/2009] [Accepted: 10/05/2009] [Indexed: 01/31/2023]
Abstract
Drug use increases with age and the elderly is at increased risk of adverse drug reactions. Gastrointestinal adverse effects are one of the most often reported. Serious event are mostly caused by NSAIDs and/or aspirin which are the most widely prescribed medications in the world. NSAIDs and/or aspirin use are associated with complications from both the upper and the lower gastrointestinal tract. The risk of these complications depends on presence of risk factors, and age is the most frequent and relevant one. At-risk patients should be on prevention strategies including the use of the lowest effective dose, co-therapy with a gastroprotective agents or use of a COX-2 selective agent. Treatment of Helicobacter pylori infection is beneficial in patients starting therapy with these agents, especially in the presence of ulcer history. The best strategy to prevent lower GI complications has yet to be defined.
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Affiliation(s)
- Carlos Sostres
- Service of Digestive Diseases, University Hospital, Instituto Aragones de Ciencias de la Salud, CIBERehd, University of Zaragoza, Spain
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