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Antia A, Aomreore K, Udongwo N, Menon S, Ibebuogu U. In-hospital outcomes and trends of patients with autoimmune diseases undergoing percutaneous coronary intervention: A nationwide analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 65:37-43. [PMID: 38531708 DOI: 10.1016/j.carrev.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND The risk of coronary artery disease is exaggerated in patients with autoimmune diseases (AID). A higher risk of complications has been reported during and after percutaneous coronary intervention (PCI) in these patients. We aimed to analyze the in-hospital outcomes and trends of patients with AID, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and inflammatory bowel disease (IBD) undergoing PCI. METHOD We identified all PCI procedures using the National In-patient Sample database from 2016 to 2020. Stratified them into cohorts with RA, SLE and IBD and compared them to cohorts without AID. The Chi-square test and multivariate logistic regression were used for analysis. A p-value <0.005 was considered statistically significant. RESULT We identified 2,367,475 patients who underwent PCI. Of these, 1.6 %, 0.5 %, and 0.4 % had RA, IBD and SLE respectively. The odds of mortality were lower among patients with IBD (aOR: 0.56; CI 0.38-0.81, p = 0.002) but patients with RA had higher odds of having composite major complications [(MC) including cerebrovascular accident (CVA), cardiac arrest, acute heart failure (AHF), ventricular arrhythmia (VA), major bleeding, and acute kidney injury (AKI)] (aOR: 0.90; CI 0.83-0.98, p = 0.013). Our SLE cohort had higher rates of CVA (p = 0.017) and AKI (p = 0.002). Our cohort with IBD had lower rates of cardiac arrest but had longer hospital length of stay (4.9 days vs 3.9 days) and they incurred higher hospital charges compared to cohort without IBD. CONCLUSION This study depicts the immediate adverse outcomes observed in patients with AID undergoing PCI. In contrast to those without AID, our cohorts with RA exhibited worse outcomes, as indicated by the higher odds of major complications. IBD is associated with lower risks of in-hospital adverse outcomes but with higher resource utilization.
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Affiliation(s)
- Akanimo Antia
- Department of Medicine, Lincoln Medical Center, Bronx, NY, United States of America.
| | - Kessiena Aomreore
- Department of Medicine, Lincoln Medical Center, Bronx, NY, United States of America
| | - Ndausung Udongwo
- Department of Medicine, Division of Cardiovascular Medicine, Morehouse School of Medicine, Atlanta, GA, United States of America
| | - Sharika Menon
- Department of Medicine, Division of Rheumatology, Lincoln Medical Center, Bronx, NY, United States of America
| | - Uzoma Ibebuogu
- Department of Medicine, Division of Cardiovascular Medicine, University of Tennessee Health Science Center, Memphis, TN, United States of America
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Kim BY, Moon H, Kim SS, Kim HS. Outcomes of Percutaneous Coronary Intervention in Elderly Patients with Rheumatoid Arthritis: A Nationwide Population-Based Cohort Study. Healthcare (Basel) 2023; 11:healthcare11101381. [PMID: 37239666 DOI: 10.3390/healthcare11101381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Rheumatoid arthritis (RA) increases the risk of cardiovascular disease. This study aimed to evaluate the clinical outcomes of elderly patients with and without RA who underwent percutaneous coronary intervention (PCI). The Korean National Health Insurance Service claims database was used to extract data on 74,623 patients (14,074 with RA and 60,549 without RA) aged ≥ 65 years who were diagnosed with acute coronary syndrome and underwent PCI between 2008 and 2019. The primary outcome was survival of elderly patients with and without RA. The secondary outcome was survival in the RA subgroup. During a 10-year follow-up, the all-cause mortality survival rate was lower in patients with RA than that in patients without (53.7% vs. 58.3%, respectively, log-rank: p < 0.001). In the all-cause mortality RA subgroup, patients with elderly-onset RA had poor survival outcomes, whereas patients with young-onset RA had good survival outcomes compared with that in patients without RA (48.1% vs. 73.7% vs. 58.3%, respectively, log-rank: p < 0.001). Elderly patients with RA who underwent PCI had an increased mortality risk, particularly those with elderly rather than young-onset RA.
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Affiliation(s)
- Bo Young Kim
- Division of Rheumatology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung 25440, Republic of Korea
| | | | - Sung-Soo Kim
- Division of Rheumatology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung 25440, Republic of Korea
| | - Hyun-Sook Kim
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea
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Clinical outcomes of patients with rheumatoid arthritis who underwent percutaneous coronary intervention: A Korean nationwide cohort study. PLoS One 2023; 18:e0281067. [PMID: 36787310 PMCID: PMC9928100 DOI: 10.1371/journal.pone.0281067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/15/2023] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVE Rheumatoid arthritis (RA) increases the risk of cardiovascular disease. This study aimed to investigate the short-and long-term prognosis of patients with and without RA who underwent percutaneous coronary intervention (PCI). METHODS The Korean National Health Insurance Service claims database was used to extract data on 236,134 patients (34,493 with RA and 201,641 without RA) who underwent PCI between 2008 and 2019. The primary outcome was major adverse cardiovascular events (MACE), including all-cause mortality, myocardial infarction, stroke, transient ischemic attack, or coronary revascularization with short-term (30-day) and long-term outcomes. The secondary outcomes were the individual components of MACE. RESULTS During a 10-year follow-up, patients with RA showed a shorter median survival time from MACE than their counterparts (with RA: 4.29 years vs. without RA: 6.10 years). RA was significantly associated with an increased risk of MACEs in long-term outcomes (hazard ratio (HR) 1.07, 95% confidence intervals (CI) 1.06-1.09, p<0.001), but not with short-term outcomes (HR 1.02, 95% CI 0.99-1.06, p = 0.222). RA was an independent predictor of an increased risk of all the MACE components. CONCLUSION In patients who underwent PCI, RA did not increase the risk of short-term cardiovascular outcomes but increased the risk of long-term adverse outcomes.
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Effects of nitro-butoxyl- and butyl-esters of non-steroidal anti-inflammatory drugs compared with parent compounds on the contractility of digital arterial smooth muscle from the fallow deer (Dama dama). Inflammopharmacology 2021; 29:1459-1473. [PMID: 34532846 PMCID: PMC8514390 DOI: 10.1007/s10787-021-00858-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/26/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are a major cause of upper gastro-intestinal (GI) ulceration and bleeding as well as cardiovascular (CV) diseases (e.g., myocardial infarction and stroke). A feature common to both these adverse events is a variety of vascular reactions. One approach to overcome these side effects has been the development of nitric-oxide (NO)-donating NSAIDs. The NO is considered to overcome some of these vascular reactions caused by NSAIDs. Unfortunately, the NO-NSAIDs developed so far have not had the expected benefits compared with NSAIDs alone. OBJECTIVES Using in vitro preparations it is hoped to gain insight into the vascular and smooth muscle reactions induced by NO-NSAIDs compared with NSAIDs as a basis for improving the protective responses attributed to the NO-donating properties of these drugs. METHODS A range of NO-NSAIDs was synthesized based on the esterification of NSAIDs with the nitro-butoxylate as a prototype of an NO-donor. These compounds, as well as NO-donor agents and NSAIDS, were examined for their possible effects on isolated segments of digital arteries of fallow deer, which provide a robust model for determining the effects of vasodilator and vasoconstrictor activities, in comparison with those of standard pharmacological agents. RESULTS The NO-NSAIDs were found to antagonise the smooth muscle contractions produced by 5-hydroxytryptamine (serotonin, 5-HT). However, while almost all their parent NSAIDs had little or no effect, with the exception of the R-(-)-isomers of both ibuprofen and flurbiprofen, which caused vasodilatation, all the NO-NSAIDs tested antagonised the increase in tension produced by 5-HT. CONCLUSIONS R-(-)-ibuprofen and R-(-)-flurbiprofen, along with the nitro-butoxyl esters of the NSAIDs examined, produce relaxation of segments of deer digital artery smooth muscle in vitro. The evidence presented suggests that their mechanism involves the release of NO or its products.
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Inflammation and tumor progression: signaling pathways and targeted intervention. Signal Transduct Target Ther 2021; 6:263. [PMID: 34248142 PMCID: PMC8273155 DOI: 10.1038/s41392-021-00658-5] [Citation(s) in RCA: 743] [Impact Index Per Article: 247.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 05/11/2021] [Accepted: 05/23/2021] [Indexed: 02/06/2023] Open
Abstract
Cancer development and its response to therapy are regulated by inflammation, which either promotes or suppresses tumor progression, potentially displaying opposing effects on therapeutic outcomes. Chronic inflammation facilitates tumor progression and treatment resistance, whereas induction of acute inflammatory reactions often stimulates the maturation of dendritic cells (DCs) and antigen presentation, leading to anti-tumor immune responses. In addition, multiple signaling pathways, such as nuclear factor kappa B (NF-kB), Janus kinase/signal transducers and activators of transcription (JAK-STAT), toll-like receptor (TLR) pathways, cGAS/STING, and mitogen-activated protein kinase (MAPK); inflammatory factors, including cytokines (e.g., interleukin (IL), interferon (IFN), and tumor necrosis factor (TNF)-α), chemokines (e.g., C-C motif chemokine ligands (CCLs) and C-X-C motif chemokine ligands (CXCLs)), growth factors (e.g., vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β), and inflammasome; as well as inflammatory metabolites including prostaglandins, leukotrienes, thromboxane, and specialized proresolving mediators (SPM), have been identified as pivotal regulators of the initiation and resolution of inflammation. Nowadays, local irradiation, recombinant cytokines, neutralizing antibodies, small-molecule inhibitors, DC vaccines, oncolytic viruses, TLR agonists, and SPM have been developed to specifically modulate inflammation in cancer therapy, with some of these factors already undergoing clinical trials. Herein, we discuss the initiation and resolution of inflammation, the crosstalk between tumor development and inflammatory processes. We also highlight potential targets for harnessing inflammation in the treatment of cancer.
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Dawson LP, Dinh D, O'Brien J, Duffy SJ, Guymer E, Brennan A, Clark D, Oqueli E, Hiew C, Freeman M, Reid CM, Ajani AE. Outcomes of Percutaneous Coronary Intervention in Patients With Rheumatoid Arthritis. Am J Cardiol 2021; 140:39-46. [PMID: 33144158 DOI: 10.1016/j.amjcard.2020.10.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p <0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p <0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (hazard ratio 1.53, 95% confidence interval 1.30 to 1.80; median follow-up 5.0 years), whereas 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery, and target vessel revascularization were similar. In subgroup analysis, patients with RA and lower BMI (Pfor interaction < 0.001) and/or acute coronary syndromes (Pfor interaction = 0.05) had disproportionately higher risk of long-term mortality compared with patients without RA. In conclusion, patients with RA who underwent PCI had more co-morbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes was similar, whereas risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower body mass index.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Jessica O'Brien
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Emma Guymer
- Department of Rheumatology, Monash Medical Centre, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital, Geelong, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Medicine, Melbourne University, Victoria, Australia.
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Mitchell JA, Kirkby NS, Ahmetaj-Shala B, Armstrong PC, Crescente M, Ferreira P, Lopes Pires ME, Vaja R, Warner TD. Cyclooxygenases and the cardiovascular system. Pharmacol Ther 2021; 217:107624. [DOI: 10.1016/j.pharmthera.2020.107624] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
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Mechanisms of action of hydroxychloroquine and chloroquine: implications for rheumatology. Nat Rev Rheumatol 2020; 16:155-166. [PMID: 32034323 DOI: 10.1038/s41584-020-0372-x] [Citation(s) in RCA: 797] [Impact Index Per Article: 199.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 12/15/2022]
Abstract
Despite widespread clinical use of antimalarial drugs such as hydroxychloroquine and chloroquine in the treatment of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other inflammatory rheumatic diseases, insights into the mechanism of action of these drugs are still emerging. Hydroxychloroquine and chloroquine are weak bases and have a characteristic 'deep' volume of distribution and a half-life of around 50 days. These drugs interfere with lysosomal activity and autophagy, interact with membrane stability and alter signalling pathways and transcriptional activity, which can result in inhibition of cytokine production and modulation of certain co-stimulatory molecules. These modes of action, together with the drug's chemical properties, might explain the clinical efficacy and well-known adverse effects (such as retinopathy) of these drugs. The unknown dose-response relationships of these drugs and the lack of definitions of the minimum dose needed for clinical efficacy and what doses are toxic pose challenges to clinical practice. Further challenges include patient non-adherence and possible context-dependent variations in blood drug levels. Available mechanistic data give insights into the immunomodulatory potency of hydroxychloroquine and provide the rationale to search for more potent and/or selective inhibitors.
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Jiang Q, Liu H, Wang S, Wang J, Tang Y, He Z, Wu F, Huang Z, Cong X, Ding R, Liang C. Circadian locomotor output cycles kaput accelerates atherosclerotic plaque formation by upregulating plasminogen activator inhibitor-1 expression. Acta Biochim Biophys Sin (Shanghai) 2018; 50:869-879. [PMID: 30124738 DOI: 10.1093/abbs/gmy087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Indexed: 11/13/2022] Open
Abstract
To explore the association between clock circadian regulator circadian locomotor output cycles kaput gene (CLOCK) and the forming of atherosclerotic plaques and its underlying mechanisms, mouse aortic endothelial cells (MAECs) and atherosclerosis (AS) mouse model were recruited for our study. The apoE gene knockout mouse was used as the model of AS and we accelerated the formation of unstable plaques through the combination of carotid artery ligation and high-fat (HF) diet administration (0.2% cholesterol, 20% fat). The mRNA and protein expressions of CLOCK in peripheral blood monouclear cells of acute coronary syndrome (ACS) patients or mouse AS model were detected by qPCR, western blot analysis and immunohistochemical staining. The number of adherent cells and atherosclerotic plaques was counted to assess the effects of CLOCK on the progression of ACS, and adherence-associated genes, such as vascular cell adhesion molecule (VCAM)-1, C-C motif chemokine ligand 2 (CCL-2), and CCL-5. The results showed that CLOCK expression was significantly increased in both ACS patients and AS mouse model. The levels of CLOCK, leukemia inhibitory factor (LIF), intercellular adhesion molecule 1 (ICAM-1), perilipin 2 (ADFP), nuclear factor kappa B (NF-κB), and plasminogen activator inhibitor-1 (PAI-1), as well as the number of atherosclerotic plaques were elevated in the AS mouse model, as compared with the control group. Chromatin immunoprecipitation assay showed that CLOCK bound directly to the promoter of PAI-1 gene and CLOCK could positively regulate the expressions of LIF, ICAM-1, ADFP, NF-κB, and PAI-1. Reduction of CLOCK expression would decrease the expressions of VCAM-1, CCL-2, and CCL-5, and the number of adherent cells and atherosclerotic plaques, but these effects were neutralized when PAI-1 was simultaneously overexpressed in either mouse model or MAECs. Our results demonstrate that CLOCK overexpression triggers the formation of atherosclerotic plaques by directly upregulating PAI-1 expression.
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Affiliation(s)
- Qixia Jiang
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Hua Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Shengyun Wang
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jiamei Wang
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yehua Tang
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhiqing He
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Feng Wu
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhigang Huang
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiaoliang Cong
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ru Ding
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chun Liang
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Kopschina Feltes P, Doorduin J, Klein HC, Juárez-Orozco LE, Dierckx RAJO, Moriguchi-Jeckel CM, de Vries EFJ. Anti-inflammatory treatment for major depressive disorder: implications for patients with an elevated immune profile and non-responders to standard antidepressant therapy. J Psychopharmacol 2017; 31:1149-1165. [PMID: 28653857 PMCID: PMC5606303 DOI: 10.1177/0269881117711708] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Major depressive disorder (MDD) is a prevalent and disabling psychiatric disease with rates of non-responsiveness to antidepressants ranging from 30-50%. Historically, the monoamine depletion hypothesis has dominated the view on the pathophysiology of depression. However, the lack of responsiveness to antidepressants and treatment resistance suggests that additional mechanisms might play a role. Evidence has shown that a subgroup of depressive patients may have an underlying immune deregulation that could explain the lack of therapeutic benefit from antidepressants. Stimuli like inflammation and infection can trigger the activation of microglia to release pro-inflammatory cytokines, acting on two main pathways: (1) activation of the hypothalamic-pituitary adrenal axis, generating an imbalance in the serotonergic and noradrenergic circuits; (2) increased activity of the enzyme indoleamine-2,3-dioxygenase, resulting in depletion of serotonin levels and the production of quinolinic acid. If this hypothesis is proven true, the subgroup of MDD patients with increased levels of pro-inflammatory cytokines, mainly IL-6, TNF-α and IL-1β, might benefit from an anti-inflammatory intervention. Here, we discuss the pre-clinical and clinical studies that have provided support for treatment with non-steroidal anti-inflammatory drugs in depressed patients with inflammatory comorbidities or an elevated immune profile, as well as evidences for anti-inflammatory properties of standard antidepressants.
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Affiliation(s)
- Paula Kopschina Feltes
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
- Instituto de Geriatria e Gerontologia, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brasil
| | - Janine Doorduin
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Hans C Klein
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Luis Eduardo Juárez-Orozco
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Rudi AJO Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Cristina M Moriguchi-Jeckel
- Instituto de Geriatria e Gerontologia, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brasil
- Instituto do Cérebro do Rio Grande do Sul, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brasil
| | - Erik FJ de Vries
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
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Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139:1056e-1071e. [PMID: 28445352 DOI: 10.1097/prs.0000000000003242] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol. METHODS A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society. RESULTS High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery. CONCLUSION Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Arabzadeh S, Ameli N, Zeinoddini A, Rezaei F, Farokhnia M, Mohammadinejad P, Ghaleiha A, Akhondzadeh S. Celecoxib adjunctive therapy for acute bipolar mania: a randomized, double-blind, placebo-controlled trial. Bipolar Disord 2015; 17:606-14. [PMID: 26291962 DOI: 10.1111/bdi.12324] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 04/03/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Recent research has focused on the inflammatory cascade as a key culprit in the etiology of bipolar disorder. We hypothesized that celecoxib, via its anti-inflammatory properties, may have a therapeutic role in mood disorder. METHODS Forty-six inpatients with the diagnosis of acute bipolar mania without psychotic features participated in a parallel, randomized, double-blind, placebo-controlled trial, and underwent six weeks of treatment with either celecoxib (400 mg daily) or placebo as an adjunctive treatment to sodium valproate. Patients were evaluated using the Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS). The primary outcome measure with respect to efficacy was the mean decrease in YMRS score from baseline to the study endpoint, which was compared between the two groups. RESULTS A significant difference was observed in the change in YMRS scores on Day 42 compared to baseline in the two groups (p < 0.001). The changes at the endpoint compared to baseline were -29.78 ± 21.78 (mean ± standard deviation) and -21.78 ± 7.16 for the celecoxib and placebo groups, respectively. A significantly higher remission rate was observed in the celecoxib group (87.0%) than the placebo group (43.5%) at Week 6 (p = 0.005). General linear model repeated measures demonstrated a significant effect for the time × treatment interaction on the YMRS scores [F(2.27,99.98) = 6.67, p = 0.001]. CONCLUSIONS Celecoxib is an effective adjuvant therapy in the treatment of manic episodes (without psychotic features) of bipolar mood disorder. The mood-stabilizing role of the drug might be mediated via its action on the inflammatory cascade.
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Affiliation(s)
- Somayeh Arabzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Niusha Ameli
- Qods Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Atefeh Zeinoddini
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzin Rezaei
- Qods Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mehdi Farokhnia
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Payam Mohammadinejad
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Ghaleiha
- Research Center for Behavioral Disorders and Substance Abuse, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Rainsford KD, Parke AL, Clifford-Rashotte M, Kean WF. Therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases. Inflammopharmacology 2015; 23:231-69. [PMID: 26246395 DOI: 10.1007/s10787-015-0239-y] [Citation(s) in RCA: 349] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/23/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This review examines the pharmacokinetics, modes of action and therapeutic properties of the anti-malarial drugs, hydroxychloroquine (HCQ) and chloroquine (CQ), in the treatment of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and related conditions, as well as osteoarthritis (OA). KEY FINDINGS Both HCQ and CQ have historically been employed successfully for the treatment of SLE and RA for over 70 years. HCQ has been used extensively for SLE where it has a good reputation for controlling the dermatological complications in SLE. It has also been reported to effectively control the symptoms of Sjøgren's syndrome, as well as preventing thrombosis in phospholipid antibody (aPL) syndrome. In RA and SLE, HCQ is preferred because of the lower incidence of gastrointestinal adverse reactions compared with CQ and it might have a lower risk of ocular adverse reactions. There is increasing evidence that HCQ may reduce atherosclerosis and risks of cardiovascular disease in rheumatic patients. Both HCQ and CQ have been shown to improve glycaemia and reduce the risks of type II diabetes mellitus. Although both HCQ and CQ are effective in low-moderate RA, HCQ is now preferred as part of combination therapy for more severe disease. The advantages of combination therapy are that the doses of the individual drugs may be lowered so reducing adverse reactions. Both HCQ and CQ are diastereoisomers, have basic properties and are given as the sulphate and phosphate salts. While being relatively well absorbed orally and with good bioavailability, they have long and variable plasma terminal elimination half-lives (approximately 40-60 days). This reflects their high volume of distribution, V D (HCQ 44,000L; CQ 65,000L) which extends into aqueous compartments, long mean residence time (HCQ 1300 h; CQ 900 h) and with about half the drugs (metabolites) undergoing renal clearance. The strong binding to melanin reflects the ocular injury and dermatological properties of these drugs. The consensus is that the occurrence of ocular adverse reactions can be minimised by close attention to the dose (which should be set on a body weight basis) with regular (e.g. quarterly) retinal examination. Although HCQ and CQ can pass through the placenta, the use of these drugs during pregnancy does not appear to risk harm to the baby and might be beneficial to the mother with SLE and her child by controlling the SLE disease activity, which is known to be an important factor affecting pregnancy outcome. The modes of action of HCQ and CQ in these arthritides represent somewhat of an enigma. Undoubtedly, these drugs have multiple actions related, in part, their ability to accumulate in lysosomes and autophagosomes of phagocytic cells as well as affecting MHC Class II expression and antigen presentation; actions of the production of pro-inflammatory cytokines [e.g. interleukin-1 (IL-1) tumour necrosis factor-α (TNFα)]; control of toll-like receptor-9 activation; and leucocyte generation of reactive oxygen species (ROS); i.e. antioxidant activity. The actions of these drugs on T and B cells are less clear but may depend on these leucocyte-mediated actions. Anti-malarials also protect against cytokine-mediated cartilage resorption. This and other actions may underlie the potential benefits in treating OA. The exact relationships of these various actions, mostly determined in vitro, have not been specifically defined in vivo or ex vivo in relation to clinical efficacy. OUTCOMES HCQ and CQ have a good reputation for being effective and relatively safe treatments in SLE, mild-moderate RA and Sjøgren's syndrome. There is need for (a) more information on their mode of action in relation to the control of these diseases, (b) scope for developing formulations that have improved pharmacokinetic and therapeutic properties and safety, and (c) further exploring their use in drug combinations not only with other disease modifying agents but also with biologics.
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Affiliation(s)
- K D Rainsford
- Biomedical Research Centre, Sheffield Hallam University, Howard Street, Sheffield, S1 1WB, UK
| | - Ann L Parke
- Department of Rheumatology, St Francis Hospital and Medical Center, Hartford, CT, 06105, USA
| | | | - W F Kean
- Department of Medicine (Rheumatology), McMaster University Faculty of Health Sciences, Hamilton, ON, L8S 4K9, Canada.
- Department of Medicine (Rheumatology), McMaster University Faculty of Health Sciences, Suite #708, 1 Young Street, Hamilton, ON, L8N 1T8, Canada.
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Anwar A, Anwar IJ, Delafontaine P. Elevation of cardiovascular risk by non-steroidal anti-inflammatory drugs. Trends Cardiovasc Med 2015; 25:726-35. [PMID: 25956433 DOI: 10.1016/j.tcm.2015.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 02/13/2015] [Accepted: 03/06/2015] [Indexed: 12/27/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most frequently used medications. NSAIDs profoundly modify prostaglandin homeostasis through inhibition of the enzyme, cyclooxygenase (COX), especially COX-2. COX-2 inhibition is associated with adverse cardiovascular outcomes as demonstrated by recent trials using this type of drug. This review explores the latest available data, including recent, randomized, clinical trials, controversies, and pathophysiology of the adverse effects of COX-inhibition.
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Affiliation(s)
- Asif Anwar
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA.
| | - Imran John Anwar
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA
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Abstract
The discovery of ibuprofen's anti-inflammatory activity by Dr (now Professor) Stewart Adams and colleagues (Boots Pure Chemical Company Ltd, Nottingham, UK) 50 years ago represented a milestone in the development of anti-inflammatory analgesics. Subsequent clinical studies were the basis for ibuprofen being widely accepted for treating painful conditions at high anti-rheumatic doses (≤ 2400 mg/d), with lower doses (≤ 1200 mg/d for ≤ 10 days) for mild-moderate acute pain (e.g. dental pain, headache, dysmenorrhoea, respiratory symptoms and acute injury). The early observations have since been verified in studies comparing ibuprofen with newer cyclo-oxygenase-2 selective inhibitors ('coxibs'), paracetamol and other non-steroidal anti-inflammatory drugs (NSAIDs). The use of the low-dose, non-prescription, over-the-counter (OTC) drug was based on marketing approval in 1983 (UK) and 1984 (USA); and it is now available in over 80 countries. The relative safety of OTC ibuprofen has been supported by large-scale controlled studies. It has the same low gastro-intestinal (GI) effects as paracetamol (acetaminophen) and fewer GI effects than aspirin. Ibuprofen is a racemate. Its physicochemical properties and the short plasma-elimination half-life of the R(-) isomer, together with its limited ability to inhibit cyclo-oxygenase-1 (COX-1) and thus prostaglandin (PG) synthesis, compared with that of S(+)-ibuprofen, are responsible for the relatively low GI toxicity. The R(-) isomer is then converted in the body to the S(+) isomer after absorption in the GI tract. Ex vivo inhibition of COX-1 (thromboxane A(2)) and COX-2 (PGE(2)) at the plasma concentrations of S(+)-ibuprofen corresponding to those found in the plasma following ingestion of 400 mg ibuprofen in dental and other inflammatory pain models provides evidence of the anti-inflammatory mechanism at OTC dosages. R(-)-ibuprofen has effects on leucocytes, suggesting that ibuprofen has anti-leucocyte effects, which underlie its anti-inflammatory actions. Future developments include novel gastro-tolerant forms for 'at risk' patients, and uses in the prevention of neuro-inflammatory states and cancers.
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Affiliation(s)
- K D Rainsford
- Biomedical Research Centre, Sheffield Hallam University, Sheffield, UK.
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16
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Desoxyrhapontigenin, a potent anti-inflammatory phytochemical, inhibits LPS-induced inflammatory responses via suppressing NF-κB and MAPK pathways in RAW 264.7 cells. Int Immunopharmacol 2013; 18:182-90. [PMID: 24295651 DOI: 10.1016/j.intimp.2013.11.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/20/2013] [Accepted: 11/22/2013] [Indexed: 11/21/2022]
Abstract
This study investigates the anti-inflammatory effects of a stilbene compound, desoxyrhapontigenin, which was isolated from Rheum undulatum. To determine the anti-inflammatory effects of this compound, lipopolysaccharide (LPS)-induced RAW 264.7 macrophages were treated with different concentrations of six stilbene derivatives. The results indicated that compared with other stilbene compounds, desoxyrhapontigenin (at 10, 30 and 50μM concentrations) significantly inhibited nitric oxide (NO) production, nuclear factor kappa B (NF-κB) activation, the protein expression of cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) expression. Therefore, the anti-inflammatory mechanism of desoxyrhapontigenin was investigated in detail. The results of this investigation demonstrated that desoxyrhapontigenin suppressed not only LPS-stimulated pro-inflammatory cytokine secretions, including the secretions of tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6), but also PGE2 release. As assayed by electrophoretic mobility shift assays (EMSAs), desoxyrhapontigenin also produced the dose-dependent inhibition of the LPS-induced activation of NF-κB and AP-1. Moreover, desoxyrhapontigenin inhibited the protein expression of myeloid differentiation primary response gene 88 (MyD88), IκB kinase (IKK) phosphorylation and the degradation of IκBα. Activations of p-JNK1 and p-Akt were also significantly inhibited, and phosphorylation of p38 and ERK was down-regulated. A further study revealed that desoxyrhapontigenin (5 and 25mg/kg, i.p.) reduced paw swelling in carrageenan-induced acute inflammation model in vivo. On the whole, these results indicate that desoxyrhapontigenin showed anti-inflammatory properties by the inhibition of iNOS and COX-2 expression via the down-regulation of the MAPK signaling pathways and the inhibition of NF-κB and Akt activation.
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Leung GJ, Rainsford KD, Kean WF. Osteoarthritis of the hand II: chemistry, pharmacokinetics and pharmacodynamics of naproxen, and clinical outcome studies. J Pharm Pharmacol 2013; 66:347-57. [DOI: 10.1111/jphp.12165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/24/2013] [Indexed: 12/13/2022]
Abstract
Abstract
Objective
This article aims to review osteoarthritis of the hand and the role of the non-steroidal anti-inflammatory drug (NSAID) naproxen on its management. We discuss the chemical and pharmacological properties of naproxen and the NSAID class, with an emphasis on its mechanism and adverse reactions. In the context of part I of this paper in characterizing hand osteoarthritis (OA), we review clinical trials that have been conducted involving hand OA and naproxen.
Key findings
The therapeutic effect of NSAIDs stems from its role on inhibiting cyclo-oxygenase (COX)-1 or COX-2 enzyme activity in the body. These enzymes play a major role in maintaining several functions in the body and due NSAIDs' inhibitory effects; many principle adverse reactions occur with the use of NSAIDs such as: gastrointestinal tract issues, cardiovascular risks, renal, hepatic, central nervous system and cutaneous. Review of clinical trials involving naproxen and hand OA show that it is significantly more efficacious when compared with placebo.
Summary
These studies, along with the finding that naproxen is of least cardiovascular risk in the NSAID class, may show that it can be part of one of the approaches in managing the condition. It is important to note that the optimal NSAID to use varies for each individual. The finding that the use of naproxen leads to the smallest increase in cardiovascular risk appeals to those at-risk individuals who suffer from OA and require pharmacological treatment for relief.
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Affiliation(s)
- Garvin J Leung
- Department of Medicine, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
| | - K D Rainsford
- Biomedical Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Walter F Kean
- Department of Medicine, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada
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Chistiakov DA, Sobenin IA, Orekhov AN. Regulatory T cells in atherosclerosis and strategies to induce the endogenous atheroprotective immune response. Immunol Lett 2013; 151:10-22. [DOI: 10.1016/j.imlet.2013.01.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 01/28/2013] [Accepted: 01/31/2013] [Indexed: 01/30/2023]
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Maes M. Targeting cyclooxygenase-2 in depression is not a viable therapeutic approach and may even aggravate the pathophysiology underpinning depression. Metab Brain Dis 2012; 27:405-13. [PMID: 22773310 DOI: 10.1007/s11011-012-9326-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 06/26/2012] [Indexed: 01/25/2023]
Abstract
Depression is a complex progressive disorder accompanied by activation of inflammatory and Th-1 driven pathways, oxidative and nitrosative stress (O&NS), lowered antioxidant levels, mitochondrial dysfunctions, neuroprogression and increased bacterial translocation. In depression, activation of immuno-inflammatory pathways is associated with an increased risk for cardio-vascular disorder (CVD). Because of the inflammatory component, the use of cyclooxygenase 2 (COX-2) inhibitors, such as celecoxib, has been advocated to treat depression. Electronic databases, i.e. PUBMED, Scopus and Google Scholar were used as sources for this selective review on the effects of COX-2 inhibitors aggravating the abovementioned pathways. COX-2 inhibitors may induce neuroinflammation, exacerbate Th1 driven responses, increase lipid peroxidation, decrease the levels of key antioxidants, damage mitochondria and aggravate neuroprogression. COX-2 inhibitors may aggravate bacterial translocation and CVD through Th1-driven mechanisms. COX-2 inhibitors may aggravate the pathophysiology of depression. Since Th1 and O&NS pathways are risk factors for CVD, the use of COX-2 inhibitors may further aggravate the increased risk for CVD in depression. Selectively targeting COX-2 may not be a viable therapeutic approach to treat depression. Multi-targeting of the different pathways that play a role in depression is more likely to yield good treatment results.
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Affiliation(s)
- Michael Maes
- Maes Clinics @ TRIA, Piyavate Hospital 998 Rimklongsamsen Road, Bangkok, 10310, Thailand.
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20
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Atherosclerosis and rheumatoid arthritis: more than a simple association. Mediators Inflamm 2012; 2012:147354. [PMID: 23024462 PMCID: PMC3449150 DOI: 10.1155/2012/147354] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/10/2012] [Indexed: 11/17/2022] Open
Abstract
In the last decades a large amount of evidence linked rheumatoid arthritis (RA) to atherosclerosis. In fact, RA patients have an increased risk of cardiovascular events that is not fully explained by other classic cardiovascular risk factors. RA and atherosclerosis may share several common pathomechanisms and inflammation undoubtedly plays a primary role. The proinflammatory cytokines such as tumor necrosis factor alpha and interleukin-6, involved in the pathogenesis of RA, are also independently predictive of subsequent cardiovascular disease (CVD). In RA, inflammation alters HDL constituents and the concentration of LDL and HDL, thus facilitating atherosclerosis and CVD events. On the other hand, also the increase of oxidative processes, frequently observed in RA, induces atherosclerosis. Interestingly, some genetic polymorphisms associated with RA occurrence enhance atherosclerosis, however, other polymorphisms associated with RA susceptibility do not increase CVD risk. Several other mechanisms may influence atherosclerotic processes in RA. Moreover, atherosclerosis may be directly mediated also by underlying autoimmune processes, and indirectly by the occurrence of metabolic syndrome and impaired physical activity. Finally, the effects of RA therapies on cardiovascular system in general and on atherosclerosis in particular are really wide and different. However, the starting point of every RA treatment is that disease control, or better remission, is the best way we have for the reduction of CVD occurrence.
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Capra V, Bäck M, Barbieri SS, Camera M, Tremoli E, Rovati GE. Eicosanoids and Their Drugs in Cardiovascular Diseases: Focus on Atherosclerosis and Stroke. Med Res Rev 2012; 33:364-438. [DOI: 10.1002/med.21251] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Valérie Capra
- Department of Pharmacological Sciences; University of Milan; Via Balzaretti 9 20133 Milan Italy
| | - Magnus Bäck
- Department of Cardiology and Center for Molecular Medicine; Karolinska University Hospital; Stockholm Sweden
| | | | - Marina Camera
- Department of Pharmacological Sciences; University of Milan; Via Balzaretti 9 20133 Milan Italy
- Centro Cardiologico Monzino; I.R.C.C.S Milan Italy
| | - Elena Tremoli
- Department of Pharmacological Sciences; University of Milan; Via Balzaretti 9 20133 Milan Italy
- Centro Cardiologico Monzino; I.R.C.C.S Milan Italy
| | - G. Enrico Rovati
- Department of Pharmacological Sciences; University of Milan; Via Balzaretti 9 20133 Milan Italy
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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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23
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Elliott WJ. Do the blood pressure effects of nonsteroidal antiinflammatory drugs influence cardiovascular morbidity and mortality? Curr Hypertens Rep 2011; 12:258-66. [PMID: 20524091 DOI: 10.1007/s11906-010-0120-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There are many theories about why selective inhibitors of the second isoform of cyclooxygenase (COX-2) increase cardiovascular risk. Although torcetrapib raises blood pressure and cardiovascular risk, it has been difficult to prove such a link for COX-2 inhibitors in randomized clinical trials. This review shows a significant correlation in placebo-controlled trials between the five agents' elevations in blood pressures and their rate ratios for cardiovascular events. A larger body of evidence arises from randomized clinical trial comparisons of selective versus nonselective inhibitors of COX-2, but these results are heterogeneous for naproxen versus other traditional agents. The best current trial evidence comes from the centrally adjudicated placebo-controlled trials of celecoxib for colonic polyps: If the blood pressure did not rise at 1 or 3 years after randomization, cardiovascular risk did not significantly increase. Many more data will become available in 2013, after the only prospective clinical trial involving cardiovascular end points is completed.
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Affiliation(s)
- William J Elliott
- Division of Pharmacology, Pacific Northwest University of Health Sciences, 200 University Parkway, Yakima, WA 98901, USA.
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25
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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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Rainsford KD. Cardiovascular adverse reactions from NSAIDs are more than COX-2 inhibition alone. Rheumatology (Oxford) 2010; 49:834-6. [DOI: 10.1093/rheumatology/kep451] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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