Adverse Reactions to Selective Cyclooxygenase-2 Inhibitors (Coxibs)

Natural products as inhibitors of prostaglandin E2 and pro-inflammatory 5-lipoxygenase-derived lipid mediator biosynthesis

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit prostanoid formation and represent prevalent therapeutics for treatment of inflammatory disorders. However, NSAIDs are afflicted with severe side effects, which might be circumvented by more selective suppression of pro-inflammatory eicosanoid biosynthesis. This concept led to dual inhibitors of microsomal prostaglandin E₂ synthase (mPGES)-1 and 5-lipoxygenase that are crucial enzymes in the biosynthesis of pro-inflammatory prostaglandin E₂ and leukotrienes. The potential of their dual inhibition in light of superior efficacy and safety is discussed. Focus is placed on natural products, for which direct inhibition of mPGES-1 and leukotriene biosynthesis has been confirmed.

Tolerance to alternative cyclooxygenase-2 inhibitors in nonsteroidal anti-inflammatory drug hypersensitive patients

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) frequently cause adverse drug reactions. Many studies have shown that drugs which selectively inhibit the cyclooxygenase-2 enzyme (COX-2) are safe alternatives in the majority of patients. However, hypersensitivity reactions to COX-2 inhibitors have been published. Hardly any data are available regarding the safety of alternatives in case of COX-2 inhibitor hypersensitivity. We aimed to investigate the tolerance to COX-2 inhibitors in patients with non-selective NSAID hypersensitivity. Furthermore, in COX-2 hypersensitive patients tolerance of a second COX-2 inhibitor was investigated.

METHODS

We retrospectively analyzed 91 patients with proven non-selective NSAID hypersensitivity that underwent oral challenges with a COX-2 inhibitor. Patients with intolerance to the first challenged COX-2 inhibitor received a second challenge with a different COX-2 inhibitor.

RESULTS

19 out of 91 (21%) patients had a positive reaction to the first oral challenge with a COX-2 inhibitor. 14 of them underwent a second challenge with a different COX-2 inhibitor and 12 (86%) did not react.

CONCLUSIONS

A relatively high percentage (21%) of the non-selective NSAID hypersensitive patients did not tolerate a COX-2 inhibitor and oral challenge is advised prior to prescription of a COX-2 inhibitor. For the majority of patients reacting to a COX-2 inhibitor an alternative can be found.

Clinical Management of Nonsteroidal Anti-inflammatory Drug Hypersensitivity

Hypersensitivity diseases caused by nonsteroidal anti-inflammatory agents are relatively common in the population. This article summarizes the present understanding on the various allergic and nonallergic clinical pictures produced through hypersensitivity to these drugs using the pathogenic classification of hypersensitivity reactions recently proposed by the Nomenclature Committee of the World Allergy Organization to guide clinicians in the diagnosis and management of patients with these conditions.

Management options for patients with aspirin and nonsteroidal antiinflammatory drug sensitivity

OBJECTIVE

To evaluate and provide management strategies for patients with aspirin or nonselective nonsteroidal antiinflammatory drug (NSAID) sensitivity.

DATA SOURCES

Literature retrieval was accessed through MEDLINE (1966-March 2007) using the terms acetaminophen, aspirin, antiinflammatory agents nonsteroidal, urticaria, angioedema, asthma, leukotriene antagonists, desensitization, and tacrolimus. Article references retrieved were hand-searched for other relevant articles.

STUDY SELECTION AND DATA EXTRACTION

All studies published in English were evaluated. Studies, review articles, and commentaries on aspirin-induced asthma and aspirin- or NSAID-induced urticaria/angioedema were included in the review.

DATA SYNTHESIS

Aspirin sensitivity is most often manifested as respiratory reactions (eg, bronchospasm, profuse rhinorrhea, conjunctival injection) or urticaria/angioedema. The primary mechanism is believed to be inhibition of the cyclooxygenase 1 (COX-1) enzyme; as such, patients with aspirin sensitivity often display cross-reactions to nonselective NSAIDs that inhibit the COX-1 enzyme. Management strategies include avoidance of aspirin and cross-reacting nonselective NSAIDs. However, desensitization to aspirin is a viable option for patients with aspirin-induced respiratory reactions, especially for those who require aspirin for thromboembolic prophylaxis. Aspirin desensitization is maintained indefinitely with a daily aspirin dose. There is limited evidence of the use of leukotriene modifiers in preventing aspirin-induced asthma. COX-2 selective NSAIDs, especially in patients with aspirin-induced asthma, have not been found to cross-react. However, approximately 4% of patients with a history of aspirin-induced skin reactions may experience a cutaneous reaction following a challenge to a COX-2 selective NSAID. Since acetaminophen is a weak inhibitor of the COX-1 enzyme, patients with aspirin-induced asthma should not take more than 1000 mg of acetaminophen in a single dose.

CONCLUSIONS

Management of patients with aspirin/NSAID sensitivity includes avoidance of aspirin/nonselective NSAIDs, use of COX-2 selective NSAIDs, acetaminophen in doses less than 1000 mg, and desensitization. The role of leukotriene modifiers requires further study before they can be recommended for patients.

Transcriptional profiling of the human monocyte-to-macrophage differentiation and polarization: new molecules and patterns of gene expression

Comprehensive analysis of the gene expression profiles associated with human monocyte-to-macrophage differentiation and polarization toward M1 or M2 phenotypes led to the following main results: 1) M-CSF-driven monocyte-to-macrophage differentiation is associated with activation of cell cycle genes, substantiating the underestimated proliferation potential of monocytes. 2) M-CSF leads to expression of a substantial part of the M2 transcriptome, suggesting that under homeostatic conditions a default shift toward M2 occurs. 3) Modulation of genes involved in metabolic activities is a prominent feature of macrophage differentiation and polarization. 4) Lipid metabolism is a main category of modulated transcripts, with expected up-regulation of cyclo-oxygenase 2 in M1 cells and unexpected cyclo-oxygenase 1 up-regulation in M2 cells. 5) Each step is characterized by a different repertoire of G protein-coupled receptors, with five nucleotide receptors as novel M2-associated genes. 6) The chemokinome of polarized macrophages is profoundly diverse and new differentially expressed chemokines are reported. Thus, transcriptome profiling reveals novel molecules and signatures associated with human monocyte-to-macrophage differentiation and polarized activation which may represent candidate targets in pathophysiology.

Safety of etoricoxib, a new cyclooxygenase 2 inhibitor, in patients with nonsteroidal anti-inflammatory drug-induced urticaria and angioedema

BACKGROUND

The use of selective inhibitors of cyclooxygenase 2 (COX-2) has been shown to be safe in patients with aspirin-induced asthma. However, a few individuals with cutaneous reactions to nonsteroidal anti-inflammatory drugs (NSAIDs) experience urticaria or angioedema when challenged with various coxibs.

OBJECTIVE

To investigate the clinical tolerance of NSAID-sensitive individuals to the selective COX-2 inhibitors etoricoxib and celecoxib.

METHODS

Patients with NSAID-induced urticaria or angioedema were challenged in a double-masked, placebo-controlled design protocol with etoricoxib (120 mg) and celecoxib (200 mg). Cutaneous, respiratory, and general symptoms; vital signs; and pulmonary function were monitored hourly for 3 hours.

RESULTS

Fifty-eight patients (46 females and 12 males) with a mean +/- SD age of 31.7 +/- 14.1 years (range, 13-66 years) who showed urticaria or angioedema when challenged with NSAIDs were included in this study. A cutaneous clinical pattern was observed in 34 patients (59%), and a mixed pattern (cutaneous and respiratory) was seen in 24 (41%). Celecoxib provocation of 54 patients induced urticaria in 3, urticaria and angioedema in 2, and urticaria, rhinorrhea, and conjunctival erythema in 1 (reaction rate, 11.1%). Etoricoxib challenges performed in 56 patients induced urticaria in 3 and angioedema in 1 (reaction rate, 7.1%).

CONCLUSIONS

These results confirm that most NSAID-sensitive individuals with cutaneous reactions to classic NSAIDs will tolerate specific COX-2 inhibitors, supporting the use of thesedrugs after careful oral provocation in such patients.

Risk of skin reactions when using ibuprofen-based medicines

Adverse reactions to drugs are a frequent cause of morbidity and medical consultation; it is no surprise that nonsteroidal anti-inflammatory drugs (NSAIDs) run second, after antibiotics, mainly of the beta-lactam group (penicillins and cephalosporins). Numerous clinical pictures involving the skin--various morbilliform rashes, urticaria and angioedema as the most common--due to hypersensitivity to a particular NSAID (i.e., ibuprofen) have been described; other clinically defined skin diseases such as vasculitis, Steven-Johnson's syndrome, photosensitivity, fixed drug eruptions, livedo-like dermatitis, linear drug eruption, lichenoid drug eruption, exanthematous pustulosis, eczematous eruption, contact dermatitis and pemphigoid have received the attention of physicians. Extensive use around the world makes it interesting to investigate adverse cutaneous reactions to ibuprofen and other members of the propionic acid derivative group, to ascertain their prevalence, clinical presentation and prevention. This paper presents a review of published literature concerning cutaneous hypersensitivity reactions to ibuprofen and related arylpropionic acids.