The time to onset and overall analgesic efficacy of rofecoxib 50 mg: a meta-analysis of 13 randomized clinical trials

Reverse phase protein arrays: mapping the path towards personalized medicine

Reverse phase protein array (RPPA) technology evolved from the advent of miniaturized immunoassays and gene microarray technology. Reverse phase protein arrays provide either a low throughput or high throughput methodology for quantifying proteins and their post-translationally modified forms in both cellular and non-cellular samples. As the demand for patient tailored therapies increases so does the need for precise and sensitive technology to accurately profile the molecular circuitry driving an individual patient's disease. RPPAs are currently utilized in clinical trials for profiling and comparing the functional state of protein signaling pathways, either temporally within tumors, between patients, or within the same patients before/after treatment. RPPAs are generally employed for quantifying large numbers of samples on one array, under identical experimental conditions. However, the goal of personalized cancer medicine is to design therapies based on the molecular portrait of a patient's tumor, which in turn result in more efficacious treatments with less toxicity. Therefore, RPPAs are also being validated for low throughput assays of individual patient samples. This review explores RPPA technology in the cancer research field, concentrating on its role as a fundamental tool for deciphering protein signaling networks and its emerging role in personalized medicine.

An evaluation of 10 percent and 20 percent benzocaine gels in patients with acute toothaches: efficacy, tolerability and compliance with label dose administration directions

BACKGROUND

The authors evaluated the efficacy and tolerability of 10 percent and 20 percent benzocaine gels compared with those of a vehicle (placebo) gel for the temporary relief of toothache pain. They also assessed the compliance with the label dose administration directions on the part of participants with toothache pain.

METHODS

Under double-masked conditions, 576 participants self-applied study gel to an open tooth cavity and surrounding oral tissues. Participants evaluated their pain intensity and pain relief for 120 minutes. The authors determined the amount of gel the participants applied.

RESULTS

The responders' rates (the primary efficacy parameter), defined as the percentage of participants who had an improvement in pain intensity as exhibited by a pain score reduction of at least one unit on the dental pain scale from baseline for two consecutive assessments any time between the five- and 20-minute points, were 87.3 percent, 80.7 percent and 70.4 percent, respectively, for 20 percent benzocaine gel, 10 percent benzocaine gel and vehicle gel. Both benzocaine gels were significantly (P ≤ .05) better than vehicle gel; the 20 percent benzocaine gel also was significantly (P ≤ .05) better than the 10 percent benzocaine gel. The mean amount of gel applied was 235.6 milligrams, with 88.2 percent of participants applying 400 mg or less.

CONCLUSIONS

Both 10 percent and 20 percent benzocaine gels were more efficacious than the vehicle gel, and the 20 percent benzocaine gel was more efficacious than the 10 percent benzocaine gel. All treatments were well tolerated by participants. Practical Implications. Patients can use 10 percent and 20 percent benzocaine gels to temporarily treat toothache pain safely.

Onset of action of diclofenac potassium liquid-filled capsules in dental surgery patients

OBJECTIVE

Diclofenac potassium soft gelatin capsules (DPSGC) are a low-dose, liquid-filled formulation that uses patented dispersion technology to facilitate rapid and consistent gastrointestinal absorption. Onset of pain relief experienced by patients receiving DPSGC was evaluated in two dental pain studies. Confirmed perceptible pain relief was evaluated in a post hoc analysis from these randomized controlled trials.

RESEARCH DESIGN AND METHODS

Adult patients (n = 514) were enrolled in two multicenter, parallel group, double-blind, placebo-controlled studies. Patients undergoing third molar extraction and experiencing a requisite level of pain (≥50 mm on a 100-mm visual analog scale within 4 hours post-surgery) were randomized to receive single doses of DPSGC 25 mg, 50 mg, 100 mg, or placebo. Pain was assessed at baseline and during 6 hours after dosing. Times to onset of perceptible and meaningful pain relief were recorded using the two-stopwatch method. Confirmed perceptible pain relief was determined in the DPSGC and placebo groups by calculating the median time to onset of perceptible pain relief (first stopwatch) in only those individuals who reported meaningful pain relief (second stopwatch).

RESULTS

More than 80% of patients achieved confirmed perceptible pain relief in the DPSGC groups compared with less than 30% of patients in the placebo group (Study 1 and Study 2, p < 0.0001). The median time to onset of confirmed perceptible pain relief in the two studies was less than 30 minutes for patients receiving any dose of DPSGC and more than 360 minutes in the placebo group (Study 1 and Study 2, p < 0.0001). DPSGC was well tolerated and no serious adverse events were reported. Study design limitations include the short duration of the trial and evaluation of a relatively limited patient population.

CONCLUSIONS

These results indicate that DPSGC was efficacious in providing a rapid onset of confirmed perceptible pain relief within 30 minutes of administration in these single dose postoperative dental pain studies.

Controlled phase III clinical trial of diclofenac potassium liquid-filled soft gelatin capsule for treatment of postoperative dental pain

PURPOSE

The purpose of the present study was to assess the safety and efficacy of oral diclofenac potassium liquid-filled soft gelatin capsule (DPSGC) that uses ProSorb dispersion technology (Xanodyne Pharmaceuticals, Inc, licensed from AAIPharma, Wilmington, NC), to treat adult patients with acute pain after third molar extraction.

PATIENTS AND METHODS

In the present multicenter, randomized, double-blind, placebo-controlled trial, patients experiencing a baseline level of pain (≥ 50 mm on a 100-mm visual analog scale within 4 hours after surgery) were randomized to receive a single dose of DPSGC at 25, 50, or 100 mg or placebo. Pain intensity and relief were assessed for 6 hours after dosing. The efficacy endpoints included the summed pain intensity difference, total pain relief, and the median time to the onset of perceptible and meaningful pain relief (using the 2-stopwatch method).

RESULTS

A total of 249 randomized patients had a significant increase in the summed pain intensity difference and total pain relief values at 3 and 6 hours across all DPSGC-treated groups compared with the placebo group (P < .0001). The onset of perceptible and meaningful pain relief was significantly faster in all DPSGC groups than in the placebo group, including the DPSGC 25-mg group (25 minutes [P = .0002] and 52 minutes [P < .0001] for perceptible and meaningful pain relief, respectively). Significantly fewer patients in the DPSGC groups required rescue medication compared with those in the placebo group (P < .0001). The global evaluation scores were significantly greater for the patients who received DPSGC than for those who received placebo (P < .0001), and more than 65% of DPSGC-treated patients rated the medication as good, very good, or excellent compared with 18% of the placebo-treated patients. DPSGC was generally well tolerated, and no serious adverse events were reported.

CONCLUSIONS

The results from the present single-dose study of postoperative dental pain suggest that DPSGC offers significant pain relief compared with placebo and that the study medication provided was well tolerated by patients who required pain relief after third molar extraction.

Time to significant pain reduction following DETP application vs placebo for acute soft tissue injuries

OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) provide fast and effective acute pain relief, but systemic administration has increased risk for some adverse reactions. The diclofenac epolamine 1.3% topical patch (DETP) is a topical NSAID with demonstrated safety and efficacy in treatment of acute pain from minor soft tissue injuries. Significant pain reduction has been observed in clinical trials within several hours following DETP application, suggesting rapid pain relief; however, this has not been extensively studied for topical NSAIDs in general. This retrospective post-hoc analysis examined time to onset of significant pain reduction after DETP application compared to a placebo patch for patients with mild-to-moderate acute ankle sprain, evaluating the primary efficacy endpoint from two nearly identical studies.

RESEARCH DESIGN AND METHODS

Data from two double-blind, randomized, parallel-group, placebo-controlled studies (N = 274) of safety and efficacy of the DETP applied once daily for 7 days for acute ankle sprain were evaluated post-hoc using statistical modeling to estimate time to onset of significant pain reduction following DETP application.

MAIN OUTCOME MEASURES

Pain on active movement on a 100 mm Visual Analog Scale (VAS) recorded in patient diaries; physician- and patient-assessed tolerability; and adverse events.

RESULTS

DETP treatment resulted in significant pain reduction within approximately 3 hours compared to placebo. Within-treatment post-hoc analysis based on a statistical model suggested significant pain reduction occurred as early as 1.27 hours for the DETP group. The study may have been limited by the retrospective nature of the analyses. In both studies, the DETP was well tolerated with few adverse events, limited primarily to application site skin reactions.

CONCLUSION

The DETP is an effective treatment for acute minor soft tissue injury, providing pain relief as rapidly as 1.27 hours post-treatment. Statistical modeling may be useful in estimating time to onset of pain relief for comparison of topical and oral NSAIDs.

A walking model to assess the onset of analgesia in osteoarthritis knee pain

OBJECTIVE

To assess a walking model utilizing a set of standardized treadmill walks to measure acute analgesic response in osteoarthritis (OA) of the knee.

DESIGN

Randomized, double-blind, placebo-controlled, multiple dose, three-period crossover study. Patients > or =45 years of age (N=22) with symptomatic knee OA were randomized to naproxen 500 mg bid, tramadol/acetaminophen 37.5 mg/325 mg in forced titration, or placebo in each of three periods. Patients performed multiple 20-minute treadmill walks on Day 1 and Day 3 at a consistent self-selected pace predetermined at screening. Pain intensity (PI) during the walks was assessed on an 11-point numerical rating scale at 0, 3, 6, 9, 12, 15, 18, and 20 min. The primary endpoint was the time-weighted average (TWA) change from baseline PI on Day 3 for the two self-paced walks for the active treatments vs placebo. Time to moderate pain (TTMP) was a key secondary endpoint.

RESULTS

Compared with placebo, the TWA change from baseline PI on Day 3 was significantly better with tramadol/acetaminophen (P=0.043) but not with naproxen (P=0.089). TWA change from baseline on Day 1 was also significantly better with both tramadol/acetaminophen (P=0.001) and naproxen (P=0.048) compared with placebo. TTMP was significantly better for tramadol/acetaminophen and naproxen than placebo (P<0.001 to P=0.015) for walks on Day 1 after a single dose and on Day 3.

CONCLUSIONS

This novel OA pain model was able to discriminate both tramadol/acetaminophen and naproxen from placebo after single and multiple doses. ClinicalTrials.gov identifier: NCT00772967.

The efficacy of rofecoxib 50 mg and hydrocodone/acetaminophen 7.5/750 mg in patients with post-arthroscopic pain

OBJECTIVE

To compare the efficacy and tolerability of rofecoxib, hydrocodone/acetaminophen 7.5 mg/750 mg (H/A) and placebo in treating pain after arthroscopy of the knee.

METHODS

A randomized, double-blind, placebo-controlled, single dose study enrolling patients experiencing moderate or severe pain after knee arthroscopy. Patients with moderate-to-severe postoperative pain received either rofecoxib 50 mg (n = 151), H/A (n = 145), or placebo (n = 147). Pain was measured over 24 h. The primary endpoint was total pain relief at 6 h for rofecoxib 50 mg compared with placebo.

RESULTS

H/A (p = 0.003), but not rofecoxib (p = 0.256) was significantly more effective than placebo for total pain relief at 6 h (TOPAR6). Although analgesic onset and peak were significantly better for H/A than for both rofecoxib (p < 0.01, p < 0.05, respectively) and placebo (p < 0.05, p < 0.001, respectively), rofecoxib patients used significantly less rescue analgesia (p < 0.001) over 24 h. Rofecoxib also provided better Brief Pain Inventory Severity (p = 0.008) and Interference Domain (p = 0.045) scores at 24 h compared to placebo and had lower 24-h Pain Severity scores than H/A (p < 0.05). Treatments were generally well tolerated, with no significant difference in the frequency of patient-reported adverse events between groups.

CONCLUSIONS

Rofecoxib 50 mg did not provide significantly different pain relief than placebo at 6 h, and the primary endpoint TOPAR was not attained, although it did show several efficacy benefits at 24 h, including a significant opioid-sparing effect. All treatments were well tolerated, with no significant differences observed. The limited efficacy of rofecoxib in this study contrasts to the results of previous surgical studies evaluating rofecoxib, and may be partially explained by the postoperative dosing in this arthroscopic surgical model.

Unmet Needs in Non-steroidal Anti-inflammatory Drug-induced Upper Gastrointestinal Diseases

The use of traditional and cyclooxygenase (COX)-2-selective non-steroidal anti-inflammatory drugs (NSAID) for the relief of pain and inflammation increases the risk of gastrointestinal side-effects ranging from dyspepsia to symptomatic and complicated ulcers. The COX-2-selective agents were designed to provide comparable pain relief to traditional NSAID, with a reduced rate of adverse gastrointestinal events. However, there appears to be little clinically significant difference between COX-2 and traditional NSAID in terms of dyspepsia, a common cause of the discontinuation of a traditional NSAID. Furthermore, concomitant aspirin use substantially reduces the gastrointestinal safety advantage of COX-2-selective drugs. An increase in the numbers of people taking low-dose aspirin for cardioprotection, an aging population and potential chemoprevention benefits are resulting in the rising consumption of NSAID. Proton pump inhibitors have a demonstrated role in the treatment and prevention of both non-selective NSAID and selective COX-2 inhibitor-related upper gastrointestinal damage. However, the use of gastroprotective agents is far from optimal, and many high-risk patients are not being clearly identified. At the same time, inappropriate low-dose aspirin use is placing low cardiovascular risk patients at risk of gastrointestinal bleeding. Combined with the recent withdrawal of rofecoxib and valdecoxib from the market because of excess cardiovascular adverse events, and concerns about the safety of other COX-2 inhibitors, a review of strategies to reduce the overall risks in users of anti-inflammatory drugs is timely. This article examines the current issues of understanding and managing NSAID-induced upper gastrointestinal diseases.