Blood pressure effects of COX-2 inhibitors

Pharmacological Management of Acute Endodontic Pain

Pain associated with infections of the tooth pulp and periapical tissues is intense and often the most common reason for patients seeking emergency dental care. Effective management of acute dental pain requires a deep understanding of pain mechanisms, which enables accurate diagnosis and definitive treatment. While drugs are only used as an adjunct to definitive dental treatment, a thorough understanding of their mechanism of action and effectiveness enables clinicians to effectively control intra-operative and post-operative pain and prevent persistent pain. This review describes how pain is detected, processed, and perceived. It also provides information on evidence-based strategies on the use of different classes of drugs to effectively manage endodontic pain.

A systems pharmacology approach to investigate the mechanism of Oryeong-san formula for the treatment of hypertension

ETHNOPHARMACOLOGICAL RELEVANCE

Oryeong-san (ORS) is a traditional formula that has long been used for the treatment of dysfunctions of body fluids and electrolyte homeostasis in Korea, China and Japan. Recent reports have shown that ORS may suppress hypertension by controlling the renin-angiotensin-aldosterone system (RAAS) in the kidney, but its action mechanism has not been well defined.

AIM OF THE STUDY

The aim of this study was to decipher the ORS mechanisms in the treatment of hypertension using a systems pharmacology approach.

MATERIALS AND METHODS

The compounds of ORS were obtained from the TM-MC (database of medicinal materials and chemical compounds in Northeast Asian traditional medicine), and the drug-likeness (DL) and oral bioavailability (OB) of the compounds were evaluated. The potential targets of the compounds were identified using various pharmacology databases. To analyze the mechanisms of the ORS for hypertension, a Compound-Target-Disease (C-T-D) network was established with respect to the genes related to hypertension.

RESULTS

A screening evaluation of the DL and OB of the ORS compounds identified a list of 232 active compounds. The pharmacological activity of the targets was investigated by exploring the interaction network between the compounds and the targets. Analysis of the interactions between the compounds and the hypertension-related targets revealed that 14 ORS compounds regulate the RAAS and vasoconstrictors in the kidney.

CONCLUSIONS

This study used the systems pharmacology approach to decipher the mechanisms of action of ORS for the treatment of hypertension. When hypertension drugs and ORS are used in combination for treatment, possible side effects should be considered because most hypertension drugs are related to the RAAS. The results of this study may provide clues to not only analyze the pharmacological activity of ORS for the treatment of hypertension but other diseases as well.

Nonsteroidal antiinflammatory drugs, acetaminophen, and hypertension

Selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) as well as acetaminophen belong to the most widely prescribed therapeutic agents worldwide. Their efficacy in pain relief notwithstanding, the use of NSAIDs is associated with an increased cardiovascular risk, which can be partly attributed to their blood pressure raising potential. Adequately powered placebo-controlled trials specifically evaluating the cardiovascular safety of NSAIDs vs. selective COX inhibitors are currently underway. This review summarizes the current knowledge on the cardiovascular effects of NSAIDs and acetaminophen, and their potential clinical consequences.

Cardiovascular safety of non-steroidal anti-inflammatory drugs among healthy individuals

IMPORTANCE OF THE FIELD

Studies have raised concern on the cardiovascular safety of NSAIDs. We studied safety of NSAID therapy in a nationwide cohort of healthy individuals.

AREAS COVERED IN THIS REVIEW

This is a review of the literature regarding cardiovascular safety of NSAIDs with special focus on the few studies investigating healthy individuals.

WHAT THE READER WILL GAIN

Due to a high frequency of gastrointestinal complications related to NSAID treatment a new generation of NSAID, called the selective COX-2 inhibitors, were developed in order to use the beneficial pain-relieving effect of NSAIDs without the COX-1 related risk of gastrointestinal bleeding. However, the selective COX-2 inhibitor rofecoxib was withdrawn from the market in 2004 after studies had documented an increased risk of myocardial infarction related to this drug. Focus also turned to the traditional NSAIDs and found similar results for some of the older drugs, especially diclofenac and high-dose ibuprofen. Most interventional studies have not been designed specifically to evaluate the cardiovascular safety of NSAIDs and no studies have previously investigated the relationship between NSAID treatment and cardiovascular risk in healthy individuals. Overall, evidence regarding the selective COX-2 inhibitors' cardiovascular risk profile (mostly thrombo-embolic events) is derived from the clinical trials whereas results on the traditional NSAIDs are based on observational studies and meta-analyses. Importantly, some of the randomized trials comparing COX-2 inhibitors with traditional NSAIDs did not show a difference in cardiovascular risk and it cannot be denied that the traditional NSAIDs are characterized by a different cardiovascular risk-profile than the COX-2 inhibitors. A recent cohort study among one million healthy people showed that the selective COX-2 inhibitors as well as diclofenac are associated with an increased risk of death or myocardial infarction. This was further underlined by a dose-response relationship.

TAKE HOME MESSAGE

Individual NSAIDs have different cardiovascular safety that needs to be considered when choosing appropriate treatment. In particular, rofecoxib and diclofenac were associated with increased cardiovascular mortality and morbidity and should be used with caution in most individuals. This notion is also valid for healthy individuals and underlines the importance of critical use of NSAID therapy in the general population and also that over-the-counter retail of NSAIDs should be reassessed.

4 years after withdrawal of rofecoxib: where do we stand today?

On the 24th of October 2006, the European Medicines Agency (EMEA) stated that "it cannot be excluded that non-selective non-steroidal anti-inflammatory drugs (nsNSAIDs) may be associated with a small increase in the absolute risk for thrombotic events". Reviewing the most recent literature including meta-analyses of randomized clinical studies and pharmacoepidemiological studies show that this statement contrasts with the 2005 EMEA evaluation of cyclooxygenase-2 inhibitors, which contained a number of regulations including several contraindications for coxibs. Recent clinical data indicate that the entire substance group of NSAIDs may have cardiovascular side effects but to different degrees. Results of basic research support these observations showing that the increase for cardiovascular risk not only depends on the ratio of inhibition of thromboxan and prostacyclin but also on other mechanisms including blood pressure elevation and cyclooxygenase independent actions. In clinical practice, many patients require anti-inflammatory therapy with NSAIDs but are at high cardiovascular and gastrointestinal risk. The combination of nsNSAIDs with proton pump inhibitors shows comparable safety to coxibs in averting upper gastrointestinal events, but evidence is increasing coxibs have advantages regarding lower gastrointestinal side effects. Concomitant therapy with aspirin is another issue. There is a negative effect on gastrointestinal safety, as well as the influence of nsNSAIDs on the cardioprotective effect of aspirin. As the contraindications for coxibs announced by the EMEA may prevent some patients from receiving optimal treatment, a warning for the entire substance group, as issued by the American Food and Drug Administration, with no contraindictions, would certainly be more reasonable.

Clinical pharmacology of celecoxib, a COX-2 selective inhibitor

NSAIDs are extensively used worldwide; nonetheless, they are associated with adverse gastrointestinal (GI) effects. COX-2 inhibitors (coxibs) have been developed to reduce pain and inflammation without associated GI and bleeding risks. Celecoxib was the first COX-2 inhibitor introduced on the market, and it still remains so, whereas rofecoxib and valdecoxib were withdrawn due to excess cardiovascular (CV) risk. There is consequently a concern that CV toxicity reflects a class effect of all COX-2 inhibitors. Celecoxib possesses anti-inflammatory and analgesic properties, and the evidence for CV risk is rather small and comparable to that of other traditional NSAIDs in short-term treatments (of < 4 weeks). It could be suggested that the use of low doses of celecoxib (100 mg b.i.d.) in short-treatment, especially in patients with previous experience of GI events and the recommendation of avoiding use of celecoxib in patients with CV history or risk, contribute in the decision-making process of prescribing COX-2 or NSAIDs.

The classical vs nonclassical NSAIDs: can the reduction in pain overcome the thrombotic risk?

The advent of cyclooxygenase-2 inhibitors has been both a blessing and a curse for pain management. An in-depth understanding of the biological molecules in the arachidonic acid metabolism may alleviate pain without risk.