Renal effects of cyclooxygenase-2 selective inhibitors

Etoricoxib attenuates effect of antihypertensives in a rodent model of DOCA-salt induced hypertension

While it is known that non-steroidal anti-inflammatory drugs including selective cyclooxygenase-2 (COX-2) inhibitors influence BP, the exact relationship and underlying mechanisms are still unclear. We investigated the effect of etoricoxib, a selective COX-2 inhibitor on the antihypertensive efficacy of atenolol; beta-blocker, ramipril; angiotensin converting enzyme inhibitor and telmisartan; angiotensin receptor blocker in deoxycorticosterone acetate (DOCA)-salt hypertensive rats, a mineralocorticoid volume expansion model. Etoricoxib attenuated the antihypertensive-induced reduction of systolic (atenolol; P < .001, ramipril; P = .011, telmisartan; P = .003) and mean arterial pressure (atenolol; P < .001, ramipril; P = .032, telmisartan; P = .023). These results demonstrate that COX-2 dependent mechanisms play a significant role in blood pressure regulation, and etoricoxib-induced COX-2 inhibition blunts the therapeutic effect of different classes of antihypertensives in this mineralocorticoid volume expansion model of hypertension.

Nonsteroidal Anti-Inflammatory Drugs and the Kidney

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the isoenzymes COX-1 and COX-2 of cyclooxygenase (COX). Renal side effects (e.g., kidney function, fluid and urinary electrolyte excretion) vary with the extent of COX-2-COX-1 selectivity and the administered dose of these compounds. While young healthy subjects will rarely experience adverse renal effects with the use of NSAIDs, elderly patients and those with co-morbibity (e.g., congestive heart failure, liver cirrhosis or chronic kidney disease) and drug combinations (e.g., renin-angiotensin blockers, diuretics plus NSAIDs) may develop acute renal failure. This review summarizes our present knowledge how traditional NSAIDs and selective COX-2 inhibitors may affect the kidney under various experimental and clinical conditions, and how these drugs may influence renal inflammation, water transport, sodium and potassium balance and how renal dysfunction or hypertension may result.

Celecoxib in arthritis: relative risk management profile and implications for patients

Celecoxib is a selective cyclo-oxygenase 2 inhibitor licensed for use in musculoskeletal symptoms as well as in primary dysmenorrhea and acute pain. One advantage celecoxib has over traditional nonsteroidal anti-inflammatory drugs is that of significantly fewer gastrointestinal side-effects associated with its use. Much has been published on the potential cardiovascular and cerebrovascular complications of its administration. This review details the available evidence to allow prescribers to make informed decisions in the light of potentially conflicting evidence. The overall cardiovascular risk is increased with higher doses of celecoxib but is comparable with nonselective nonsteroidal anti-inflammatory use. As with all of these drugs, the potential cardiovascular and gastrointestinal risks of prescription need to be weighed up against possible benefits for each individual patient and discussed with the patients themselves.

Effects of carprofen on renal function during medetomidine-propofol-isoflurane anesthesia in dogs

OBJECTIVE

To investigate effects of carprofen on indices of renal function and results of serum bio-chemical analyses and effects on cardiovascular variables during medetomidine-propofol-isoflurane anesthesia in dogs.

ANIMALS

8 healthy male Beagles.

PROCEDURES

A randomized crossover study was conducted with treatments including saline (0.9% NaCl) solution (0.08 mL/kg) and carprofen (4 mg/kg) administered IV. Saline solution or carprofen was administered 30 minutes before induction of anesthesia and immediately before administration of medetomidine (20 microg/kg, IM). Anesthesia was induced with propofol and maintained with inspired isoflurane in oxygen. Blood gas concentrations and ventilation were measured. Cardiovascular variables were continuously monitored via pulse contour cardiac output (CO) measurement. Renal function was assessed via glomerular filtration rate (GFR), renal blood flow (RBF), scintigraphy, serum biochemical analyses, urinalysis, and continuous CO measurements. Hematologic analysis was performed.

RESULTS

Values did not differ significantly between the carprofen and saline solution groups. For both treatments, sedation and anesthesia caused changes in results of serum biochemical and hematologic analyses; a transient, significant increase in urine alkaline phosphatase activity; and blood flow diversion to the kidneys. The GFR increased significantly in both groups despite decreased CO, mean arterial pressure, and absolute RBF variables during anesthesia.

CONCLUSIONS AND CLINICAL RELEVANCE

Carprofen administered IV before anesthesia did not cause detectable, significant adverse effects on renal function during medetomidine-propofol-isoflurane anesthesia in healthy Beagles.

Combined lipoxygenase/cyclo-oxygenase inhibition in the elderly: the example of licofelone

One of the categories of drugs most frequently used by the elderly, and probably the most commonly self-prescribed class of drug in this age group, is NSAIDs. However, NSAIDs are one of the primary causes of adverse drug reactions and are notorious for their gastric toxicity. They also inhibit renal function and reduce the efficacy of diuretics and ACE inhibitors, drugs that are commonly used by elderly patients. Recent studies have shown that cyclo-oxygenase (COX)-2 is important in renal physiology. This means that selective COX-2 inhibitors, while undoubtedly safer than NSAIDs in terms of gastric toxicity, are not devoid of renal toxicity (in addition to their now clearly established adverse effects on coronary heart disease risk). Both the gastric and renal toxicities induced by traditional NSAIDs and selective COX-2 inhibitors seem to be related to inhibition of prostaglandin, but not leukotriene, synthesis. Maintaining the correct balance between prostaglandins and leukotrienes is essential for continuing good health, but both classes of mediators also play an important role in the pathogenesis of several diseases.Recently, a new class of anti-inflammatory drugs, the lipoxygenase (LOX)/COX inhibitors, has been developed as a means of simultaneously inhibiting the synthesis of prostaglandins, thromboxanes and leukotrienes. Inhibition of leukotriene synthesis increases anti-inflammatory efficacy, particularly in rheumatic diseases, while reducing the risk of gastric damage. The LOX/COX inhibitor licofelone, which is currently in phase III trials, is the first of this new class and in the most advanced stage of development. Preliminary data with this drug seem promising, but further well designed clinical trials of this agent in the elderly will be necessary before a final evaluation is possible.

Comparison of conventional NSAIDs and cyclooxygenase-2 inhibitors in outpatients

OBJECTIVES

To compare outpatients treated with conventional nonsteroidal antiinflammatory drugs (NSAIDs) versus cyclooxygenase-2 (COX2) inhibitors in June 2002 in the Ain district of France.

PATIENTS AND METHODS

A cross-sectional study was done in the 14,216 patients older than 19 years of age who were identified in the universal health insurance database as having received therapy with conventional NSAIDs or COX2 inhibitors. A logistic regression model was built to identify factors associated with the type of antiinflammatory agent.

RESULTS

COX2 inhibitor therapy was noted in 17% of patients. Factors significantly associated with COX2 inhibitor therapy were older age and concomitant use of symptomatic slow-acting drugs for osteoarthritis, disease-modifying antirheumatic drugs, anticoagulants, antiplatelet agents, diuretics, angiotensin-converting enzyme inhibitors, and angiotensin II receptor antagonists. Patients taking COX2 inhibitor therapy were significantly less likely to be taking concomitant gastroprotective therapy, compared to patients on conventional NSAIDs.

CONCLUSIONS

The powerful advertisement campaigns that surrounded the introduction of COX2 inhibitors rapidly affected practice patterns regarding the prescription of antiinflammatory drugs. The study reported here showed a significantly greater likelihood of receiving COX2 inhibitors in older patients taking multiple medications, a population known to be at increased risk for drug-induced cardiovascular events. Evidence obtained after the present study established that COX2 inhibitors carry a risk of cardiovascular side effects. Rofecoxib has been removed from the market, and new recommendations have been issued regarding other COX2 inhibitors.

Clinical perspectives of anti-inflammatory therapy in the elderly: the lipoxigenase (LOX)/cycloxigenase (COX) inhibition concept

Non steroidal anti-inflammatory drugs (NSAIDs) are one of the categories of drugs most frequently used by elderly people, and maybe the most self-prescribed drugs. Both coronary events, and stroke, can be prevented by daily aspirin assumption. Other NSAIDs, except selective COX-2 inhibitors (coxibs), seem to reduce the incidence of cardiovascular events, but a definitive judgement is yet impossible. Moreover, these drugs cause more than 100,000 serious gastric adverse events each year in the US, and the risk increases exponentially in the elderly. Coxibs cause less gastric damage, but their cost is very high. Moreover, NSAIDs inhibit renal function and reduce the efficacy of diuretics and angiotensin converting enzyme (ACE) inhibitors, often used by elderly patients. Recent studies show that even COX-2 is important in the renal physiology, so that even coxibs appear not to be avoided of renal toxicity. Both gastric and renal toxicity induced by traditional NSAIDs and coxibs seem to be related to the fact that these drugs inhibit the synthesis of prostaglandins (PGs), but not those of leukotrienes (LTs), important mediators of inflammation and of many other physiopatological events. Newly developed anti-inflammatory drugs block both COX and the 5-LOX metabolic pathways, inhibiting the formation of PGs, thromboxanes (TXs) and LTs. The inhibition of the LT synthesis increases the anti-inflammatory efficacy (especially in pneumological and rheumatological diseases), reducing the risk of gastric damage. Even if preliminary data seem to be very interesting, further clinical safety data on these drugs obtained from elderly oriented trials need to be available before to give a final evaluation.

Adverse Drug Events Involving COX-2 Inhibitors

OBJECTIVE

To describe the types and severity of adverse drug-related events (ADEs) observed in patients receiving cyclooxygenase-2 (COX-2) inhibitors and to increase the awareness of risk factors that predispose patients to ADEs associated with COX-2 inhibitors.

METHODS

A review of ADEs reported at the University of Pittsburgh Medical Center Presbyterian Hospital (UPMC-P) revealed significant events related to use of celecoxib or rofecoxib. A query of the internal ADE database was performed to identify ADEs involving COX-2 inhibitors from January 1999 to June 2002. A similar query was performed to identify ADEs involving nonselective nonsteroidal antiinflammatory drugs (NSAIDs) reported during this same time period. Utilization data were also collected.

RESULTS

Forty-eight ADEs involving 24 patients receiving COX-2 inhibitors were reported and validated via the UPMC-P ADE review process compared with 38 events in 33 patients receiving nonselective NSAIDs. The types of ADEs reported as related to COX-2 inhibitors were similar to those reported in association with nonselective NSAIDs. Forty-two percent of ADEs (n = 20) involving COX-2 inhibitors and 45% of events (n = 17) involving nonselective NSAIDs were classified as severe. All patients receiving COX-2 inhibitors and 91% of patients receiving nonselective NSAIDs exhibited risk factors that increased their risk to experience an ADE; all but 1 of these patients were receiving outpatient COX-2 inhibitor therapy.

CONCLUSIONS

The observed ADEs involving COX-2 inhibitors were similar to those associated with nonselective NSAIDs. Most events may have been preventable, highlighting the need for education regarding the appropriate use of COX-2 inhibitors.

Demographics and concomitant disorders in heart failure

Chronic heart failure is an increasingly common cause of premature death and poor quality of life. Community-based epidemiological studies have provided much-needed information on the demography of chronic heart failure, providing insight into its influence on public health. In most patients, chronic heart failure is accompanied by a range of concomitant disorders that both contribute to the cause of the disease and have a key role in its progression and response to treatment. Information on the most common comorbidities in chronic heart failure--ischaemic heart disease, hypertension, and diabetes mellitus--is presented for prespecified subgroups in the reports of many large-scale, multicentre trials; despite their limitations, these subanalyses provide guidance in therapeutic decision-making. Similarly, because chronic heart failure is commonly an endpoint in intervention trials of both hypertension and diabetes, such studies afford important information on the prevention of chronic heart failure in these common diseases.

The adverse renal effects of prostaglandin-synthesis inhibitors in the newborn rabbit

Nonsteroidal anti-inflammatory drugs are frequently used during pregnancy (premature labor, polyhydramnios) and the immediate postnatal period (closure of patent ductus arteriosus). This article evaluates the renal effect of 3 nonspecific COX inhibitors (aspirin, indomethacin, and ibuprofen) in newborn rabbits. Five groups of anesthetized, ventilated, normoxemic 6-day-old rabbits (n = 52) were administered intravenous aspirin (40 mg/kg), indomethacin (2 mg/kg), and ibuprofen (0.02, 0.2, 2.0 mg/kg, respectively). Renal function and hemodynamics as assessed by inulin and para-aminohippuric acid clearances were measured before and in the hour after drug administration. In all groups of animals, the nonselective COX inhibitors induced an increase in renal vascular resistance and a consequent decrease in glomerular filtration rate and renal blood flow. Urine flow rate decreased significantly in all groups, except in the group receiving the lowest dose of ibuprofen. In newborn rabbits, aspirin, indomethacin, and ibuprofen induced intense renal vasoconstriction, which resulted in impaired renal function. This observation illustrates the major renal protective role played by the vasodilatory prostaglandins during the neonatal period, when the kidney is perfused at very low perfusion pressure. We conclude that all COX inhibitors should be administered with the same caution to the preterm neonate.

The demographics of chronic pain management

Pain is the most common symptom for which patients seek care. The management of pain advanced considerably with the development of cyclooxygenase (COX)-2-specific inhibitors (coxibs). The clinical usefulness of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) is often limited by the occurrence of adverse effects, such as gastric toxicity and bleeding complications, which have been attributed to the inhibition of COX-1. At the recommended dosage by targeting only COX-2, coxibs offer patients anti-inflammatory and analgesic relief with reduced gastrotoxicity compared with traditional NSAIDs. Individualization of therapy based on a careful assessment of risks versus benefits of different agents is an important consideration in pain management. This review summarizes clinical evidence of the comparable efficacy but improved tolerability of the coxibs compared with conventional NSAIDs. Important patient considerations and risk factors involved in the selection of appropriate analgesic/anti-inflammatory treatments are highlighted.