Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis

Multimorbidity patterns of mental disorders and physical diseases of adults in northeast China: a cross-sectional network analysis

AIMS

Multimorbidity, especially physical-mental multimorbidity, is an emerging global health challenge. However, the characteristics and patterns of physical-mental multimorbidity based on the diagnosis of mental disorders in Chinese adults remain unclear.

METHODS

A cross-sectional study was conducted from November 2004 to April 2005 among 13,358 adults (ages 18-65years) residing in Liaoning Province, China, to evaluate the occurrence of physical-mental multimorbidity. Mental disorders were assessed using the Composite International Diagnostic Interview (version 1.0) with reference to the Diagnostic and Statistical Manual of Mental Disorders (3rd Edition Revised), while physical diseases were self-reported. Physical-mental multimorbidity was assessed based on a list of 16 physical and mental morbidities with prevalence ≥1% and was defined as the presence of one mental disorder and one physical disease. The chi-square test was used to calculate differences in the prevalence and comorbidity of different diseases between the sexes. A matrix heat map was generated of the absolute number of comorbidities for each disease. To identify complex associations and potential disease clustering patterns, a network analysis was performed, constructing a network to explore the relationships within and between various mental disorders and physical diseases.

RESULTS

Physical-mental multimorbidity was confirmed in 3.7% (498) of the participants, with a higher prevalence among women (4.2%, 282) than men (3.3%, 216). The top three diseases with the highest comorbidity rate and average number of comorbidities were dysphoric mood (86.3%; 2.86), social anxiety disorder (77.8%; 2.78) and major depressive disorder (77.1%; 2.53). A physical-mental multimorbidity network was visually divided into mental and physical domains. Additionally, four distinct multimorbidity patterns were identified: 'Affective-addiction', 'Anxiety', 'Cardiometabolic' and 'Gastro-musculoskeletal-respiratory', with the digestive-respiratory-musculoskeletal pattern being the most common among the total sample. The affective-addiction pattern was more prevalent in men and rural populations. The cardiometabolic pattern was more common in urban populations.

CONCLUSIONS

The physical-mental multimorbidity network structure and the four patterns identified in this study align with previous research, though we observed notable differences in the proportion of these patterns. These variations highlight the importance of tailored interventions that address specific multimorbidity patterns while maintaining broader applicability to diverse populations.

A Randomized Controlled Trial Assessing the Effect of Preoperative Ibuprofen Administration on Postoperative Pain Reduction Following Miniscrew Insertion

OBJECTIVE

To evaluate the impact of preoperative oral ibuprofen premedication as a preemptive analgesia protocol on postoperative pain following the insertion of a single miniscrew insert.

METHODS

A randomized, single-blind, placebo-controlled parallel-group trial design was adopted. A total of 68 patients seeking miniscrew insert placement were recruited based on inclusion and exclusion criteria. Patients were randomly assigned in a 1:1 ratio to either the ibuprofen group or the control group, with 34 patients in each group. The ibuprofen group and the control group received 300 mg of ibuprofen sustained-release capsules and a placebo, respectively, 30 min before surgery. Postoperative analgesics were administered as needed. Pain scores at 2, 4, 6, 8, 12, and 24 h postoperatively were recorded using the Numerical Rating Scale (NRS), and the postoperative analgesic consumption was documented.

RESULTS

A total of 68 patients (34 in the control group and 34 in the preemptive analgesia group) completed the trial. No adverse events such as nausea or vomiting occurred in any of the patients. The preemptive analgesia group exhibited significantly lower pain scores at 2, 4, 6, and 8 h postoperatively [2 (0,3), 0 (0,2), 0 (0,0), 0 (0,0.25), respectively] compared to the control group [3 (2,5), 3 (2,4), 2 (0.75,4), 1 (0,3), respectively] (P = 0.0396, P = 0.0067, P = 0.0111, P = 0.0299). The proportions of patients requiring additional analgesics within 2-24 h postoperatively were 17.6% (6/34) in the preemptive analgesia group and 64.7% (22/34) in the control group, with a statistically significant difference between the two groups (P = 0.013).

CONCLUSION

Preemptive analgesia with ibuprofen can effectively reduce postoperative pain following miniscrew insert placement and represents a safe and effective perioperative pain management strategy.

TRIAL REGISTRATION

The UK's Clinical Study Registry; ISRCTN68332234 (Retrospectively registered); 20/12/2024.

Intravenously Administered Nonsteroidal Anti-Inflammatory Drugs in Clinical Practice: A Narrative Review

Intravenously administered nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a crucial component of multimodal analgesia strategies in surgical settings. This narrative review aims to provide an up-to-date evaluation of the efficacy, safety, and clinical use of intravenous (IV) NSAIDs for perioperative pain management in adults and children. The NSAIDs and selective COX-2 inhibitors (coxibs) approved in Europe for the short-term symptomatic treatment of acute, moderate perioperative pain via IV infusion in adults and/or children have been influenced by US and global guidelines and practice: the drugs primarily reviewed here are ibuprofen, ketorolac, ketoprofen, naproxen, paracetamol, and acetylsalicylic acid. Furthermore, intravenous ibuprofen is authorized for the short-term symptomatic treatment of fever. In contrast to intravenous ketoprofen, intravenous ibuprofen is authorized for administration to children over 6 years of age or weighing more than 20 kg. Overall, IV ibuprofen had a more favorable profile with regard to peri- and postoperative opioid sparing and pain relief. Oral ibuprofen and IV ibuprofen have similar levels of efficacy, although IV ibuprofen has a shorter onset of action and is required in patients who are unable to take oral medications. The frequency of significant adverse events appears to be similar for ibuprofen and paracetamol. Systematic reviews and meta-analyses report that intravenous NSAIDs reduce postoperative opioid consumption by approximately 20-60%, improving pain management with fewer opioid-related side effects. In indications in infants, the choice of medication is limited, and the oral route is not always feasible; IV formulations of ibuprofen are preferred in this setting. Topics for further research should include head-to-head trials of IV NSAIDs.

A real-world disproportionality analysis of the FDA adverse event reporting system events for ibuprofen

INTRODUCTION

Ibuprofen is commonly used as an over-the-counter (OTC) antipyretic and analgesic. As the frequency of its use has increased, there has been a corresponding increase in reports of associated adverse events (AEs). However, these events have not been systematically reported in the literature. Meanwhile, the importance of effective pharmacovigilance in evaluating the benefits and risks of drugs is being recognized.

METHODS

The data was obtained indirectly from FAERS using the OpenVigil 2 database, lexically mapped using software such as MySQL, Microsoft Excel, and the R language, and then subjected to four more rigorous algorithms to detect risk signals associated with ibuprofen AEs.

RESULTS

By analyzing data from the past 18 years, 878 ibuprofen-related AEs were identified as primary AEs. Notably, unexpected reproductive system and breast diseases, etc., which were unexpected, were observed as important system organ classes (SOCs) associated with ibuprofen. Among the 651 preferred terms (PTs) that simultaneously satisfy the four arithmetic methods, renal tubular acidosis and lip oedema are proposed as new signals for ibuprofen AEs.

CONCLUSION

This study explores the important and valuable potential AEs and ADRs of ibuprofen at the SOC and PT levels, respectively. To provide a reference on decision-making for ibuprofen to promote rational clinical dosing.

Ibuprofen delays ovulation by several hours: prospective controlled study in natural cycles with HCG-triggered ovulation

RESEARCH QUESTION

Does ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), delay ovulation?

DESIGN

Two-stage, proof-of-concept, controlled study, assessing the percentage of non-ovulated follicles 42 h after HCG injection in patients taking ibuprofen. The intervention group consisted of women undergoing natural cycle IVF treatment taking ibuprofen 3 × 400 mg per day. The control group consisted of women undergoing timed sexual intercourse or intrauterine insemination. The proportion of patients with non-ovulated follicles in the ibuprofen group was first compared against a reference of 50% using a one-sample binomial test, and second against the proportion observed in the control group using an adjusted logistic regression.

RESULTS

A total of 26 women were recruited in the ibuprofen intervention group. Twenty-five patients were recruited in the control group. The proportion of patients with delayed ovulation observed (22/26 [84.6%]; 95% CI 65.1% to 95.6%) was significantly higher than the reference of 50% (P < 0.001). In the control group, the proportion of patients with delayed ovulation was 20.0% ([5/25], 95% CI 6.8% to 40.7%). Compared with the ibuprofen group, a significantly increased probability of a delayed ovulation was found in the ibuprofen intervention group (adjusted OR 22.72, 95% CI 5.77 to 115; P < 0.001). Of the 22 women with delayed ovulation, oocytes were retrieved in 20 women (90.9%) and all oocytes were mature (metaphase II).

CONCLUSIONS

Women trying to conceive should avoid non-selective NSAIDs around the time of ovulation. Ibuprofen or other NSAID can be used to delay ovulation for several hours in assisted reproductive technology and other infertility treatments if required.

Pantoprazole and Vonoprazan Performed Well in Preventing Peptic Ulcer Recurrence in Low-Dose Aspirin Users

BACKGROUND

Low-dose aspirin (LDA) administration is associated with an elevated risk of recurring peptic ulcer (PU) and gastrointestinal (GI) hemorrhage.

AIMS

This systematic review and Bayesian network meta-analysis aimed to comprehensively assess the effectiveness of diverse medications in preventing the recurrence of PU and GI hemorrhage in patients with a history of PU receiving long-term LDA therapy.

METHODS

This systematic review and network meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered on PROSPERO (CRD42023406550). We searched relevant studies in main databases from inception to March 2023. All statistical analyses were performed using R (version 4.1.3), with the "Gemtc" (version 1.0-1) package. The pooled risk ratio (RR), corresponding 95% credible interval (95% CrI), and the surface under the cumulative ranking curve (SUCRA) were calculated.

RESULTS

11 Randomized clinical trials (RCTs) were included. The analysis underscored pantoprazole was the most efficacious for reducing the risk of PU recurrence (RR [95% CrI] = 0.02 [0, 0.28]; SUCRA: 90.76%), followed by vonoprazan (RR [95% CrI] = 0.03 [0, 0.19]; SUCRA: 86.47%), comparing with the placebo group. Pantoprazole also performed well in preventing GI hemorrhage (RR [95% CrI] = 0.01[0, 0.42]; SUCRA: 87.12%) compared with Teprenone.

CONCLUSIONS

For patients with a history of PU receiving LDA, pantoprazole and vonoprazan might be the optimal choices to prevent PU recurrence and GI hemorrhage.

Low Frequency of Upper Gastrointestinal Bleeding Despite Non-Steroidal Anti-Inflammatory Drugs and Corticosteroids in Patients with Rheumatoid Arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disease. It has been identified that non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids can be essential risk factors for developing complications such as upper gastrointestinal bleeding (UGIB).

OBJECTIVE

This study aimed to describe the safety profile of drugs used to treat RA focused in UGIB.

METHODS

A cross-sectional study of patients with RA between 2015 and 2021, a description of the population, and an evaluation of the relationship with UGIB through bivariate analysis and logistic regression.

RESULTS

Of 405 individuals, 16 presented UGIB (93.8% women, mean age was 65±13.6 years). No statistically significant differences were found regarding UGIB and medication use, except for the mean dose of corticosteroids. In the multivariate analysis, it was found that the presence of anemia in the last three months had an adjusted OR (AOR) of 16.1 (95% CI 2.74- 24.23) and higher HAQ values during the previous three months had an AOR of 6.17 (95% CI 1.79- 21.24).

CONCLUSION

This study found a low frequency of UGIB in patients with RA. More significant disability and anemia in the previous months were independently associated with UGIB. The low frequency of NSAID use in this population is noteworthy. In general, reasonable medication use related to this complication is recommended.

USE OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS IN PATIENTS WITH ADVANCED ACTIVE RHEUMATOID ARTHRITIS

This study aimed to determine whether patients with active rheumatoid arthritis (RA) regularly take non-steroidal anti-inflammatory drugs (NSAIDs) and to clarify whether their decision to take NSAIDs depends on disease activity, intensity of pain, or functional status. The study also aimed to identify the risk factors for gastrointestinal side effects. Over 6 months, we conducted a cross-sectional single-center study of consecutively hospitalized patients with confirmed RA. Activities of daily living, pain intensity, and disease activity were evaluated by the Health Assessment Questionnaire, visual analog scale, and disease activity score, respectively, in 28 joints. Of 73 patients diagnosed with RA, 48 (66%) regularly took NSAIDs. Compared to non-users, NSAID users used glucocorticoids less frequently. The decision to use NSAIDs was independent of disease activity, pain intensity, degree of functional impairment, or presence of gastrointestinal risk factors. However, a higher degree of functional impairment was associated with a longer duration of continuous NSAID and glucocorticoid use. NSAIDs are still relevant for RA treatment. The decision to use them is not necessarily affected by disease activity or pain intensity, but their prolonged use is required in patients with a higher degree of functional disability. NSAIDs enable exclusion of glucocorticoid use, sparing patients of glucocorticoid-related side effects.

Interpreting the Benefit and Risk Data in Between-Drug Comparisons: Illustration of the Challenges Using the Example of Mefenamic Acid versus Ibuprofen

Evidence-based pain therapy should rely on precisely defined and personalized criteria. This includes balancing the benefits and risks not only of single drugs but often requires complex between-drug comparisons. Non-steroidal anti-inflammatory drugs (NSAIDs) have been available for several decades and their use is described in an abundance of guidelines. Most of these guidelines recommend that ‘the selection of a particular NSAID should be based on the benefit-risk balance for each patient’. However, head-to-head studies are often lacking or of poor quality, reflecting the lower standards for clinical research and regulatory approval at the time. The inconsistency of approved indications between countries due to national applications adds to the complexity. Finally, a fading research interest once drugs become generic points to a general deficit in the post-marketing evaluation of medicines. Far from claiming completeness, this narrative review aimed to illustrate the challenges that physicians encounter when trying to balance benefits and risks in a situation of incomplete and inconsistent data on longstanding treatment concepts. Ibuprofen and mefenamic acid, the most frequently sold NSAIDs in Austria, serve as examples. The illustrated principles are, however, not specific to these drugs and are generalizable to any comparison of older drugs in daily clinical practice.

Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This study aimed to assess the effectiveness of virtual reality (VR) in managing different types of pain in different age groups and to provide evidence for the clinical application of new alternative strategy for pain management.

METHODS

Electronic databases, including the Cochrane Library, PubMed, EMBASE, and the Web of Science, were searched for studies published up to October 2020. Randomized controlled trials that reported on VR for pain management were included.

RESULTS

A total of 31 randomized controlled trials were included. As for the pain intensity, the increase of visual analog scale score in the VR group was 1.62 scores less than that in the control group. In juvenile patients, the VR group had 1.79 scores lower than that in control group. For adult patients, the VR group had 1.34 scores lower than that in control group. As for other pain-related indicators, the VR group had lower levels of anxiety, lower pain unpleasantness, lower pulse rate, and shorter duration of dressing change and spent less time thinking about pain. Nevertheless, there was no statistical difference in pain tolerance. VR can effectively alleviate acute pain. In terms of chronic low back pain and cancer-related pain, there was no statistical difference between VR therapy and standard therapy.

CONCLUSIONS

VR is a feasible alternative therapy for both juveniles and adults in pain management, and it has a greater potential for juveniles. VR can effectively alleviate acute pain. Nevertheless, VR showed little effectiveness in increasing pain tolerance, which may explain in part the ineffectiveness of VR therapy in pain management for chronic pain.

Perioperative Pain Management Issues Unique to Older Adults Undergoing Surgery: A Narrative Review

INTRODUCTION

The older population is growing and with this growth there is a parallel rise in the operations performed on this vulnerable group. The perioperative pain management strategy for older adults is unique and requires a team-based approach for provision of high-quality surgical care.

METHODS

Literature search was performed using PubMed in addition to review of relevant protocols and guidelines from geriatric, surgical, and anesthesia societies. Systematic reviews and meta-analyses, randomized trials, observational studies, and society guidelines were summarized in this review.

MANAGEMENT

The optimal approach to a pain management strategy for older adults undergoing surgery involves addressing all phases of perioperative care. For example, preoperative assessment of a patient's cognitive function and presence of chronic pain may impact the pain management plan. Consideration should be also given to intraoperative strategies to improve pain control and minimize both the dose and side effects from opioids (e.g. regional anesthetic techniques). Postoperative pain control (e.g. under or over treatment of pain) may impact the development of elderly-specific complications such as postoperative delirium and functional decline. Finally, pain management does not stop after the older adult patient leaves the hospital. Both discharge planning and post-operative clinic follow-up provide important opportunities for collaboration and intervention.

CONCLUSIONS

An opioid-sparing pain management strategy for older adults can be accomplished with a comprehensive and collaborative interdisciplinary strategy addressing all phases of perioperative care.

Prevalence and Patterns of Multimorbidity in a Nationally Representative Sample of Older Chinese: Results From the China Health and Retirement Longitudinal Study

BACKGROUND

Multimorbidity has become a prominent problem worldwide; however, few population-based studies have been conducted among older Chinese with multimorbidity. This study aimed to examine the prevalence of multimorbidity and explore its common patterns among a nationally representative sample of older Chinese.

METHODS

This study used data from the China Health and Retirement Longitudinal Study and included 19,841 participants aged at least 50 years. The prevalence of individual chronic diseases and multimorbidity during 2011-2015 were evaluated among the entire cohort and according to residential regions and gender. The relationships between participants' demographic characteristics and multimorbidity were examined using logistic regression model. Patterns of multimorbidity were explored using hierarchical cluster analysis and association rule mining.

RESULTS

Multimorbidity occurred in 42.4% of the participants. The prevalence of multimorbidity was higher among women (odds ratio [OR] = 1.31, 95% confidence interval [CI]: 1.13-1.51) and urban residents (OR = 1.14, 95% CI: 1.02-1.27) than their respective counterparts after accounting for potential confounders of age, education, smoking, and alcohol consumption. Hierarchical cluster analysis revealed four common multimorbidity patterns: the vascular-metabolic cluster, the stomach-arthritis cluster, the cognitive-emotional cluster, and the hepatorenal cluster. Regional differences were found in the distributions of stroke and memory-related disease. Most combinations of conditions and urban-rural difference in multimorbidity patterns from hierarchical cluster analysis were also observed in association rule mining.

CONCLUSION

The prevalence and patterns of multimorbidity vary by gender and residential regions among older Chinese. Women and urban residents are more vulnerable to multimorbidity. Future studies are needed to understand the mechanisms underlying the identified multimorbidity patterns and their policy and interventional implications.

Prevention of Non-steroidal Anti-inflammatory Drug-induced Peptic Ulcers

Nonsteroidal anti-inflammatory drugs (NSAID) are some of the most commonly prescribed medications in clinical practice. The long-term use of NSAIDs is one of the main causes of peptic ulcers and the increased risk of upper gastrointestinal tract complications, such as perforation and bleeding. Thus, the prevention of NSAID-induced peptic ulcers is an important clinical issue. Previous studies have evaluated various strategies for preventing ulcers in patients requiring prolonged NSAID use. The Korean clinical practice guidelines have been published recently based on the evidence of the currently available data. This review describes the strategies for the prevention of peptic ulcers due to NSAID. An assessment of the risk factors for peptic ulcers from NSAID is recommended to identify patients who should be considered for primary prophylaxis. The risk of NSAID-induced peptic ulcers can be reduced by the concomitant use of proton pump inhibitors (PPI), misoprostol, and histamine-2 receptor antagonists. Selective cyclooxygenase-2 inhibitors can be used with caution due to concerns regarding cardiovascular toxicity. Attempts should be made to use the lowest dose and shortest duration of the NSAID.

Efficacy of Electronic Acupuncture Shoes for Chronic Low Back Pain: Double-Blinded Randomized Controlled Trial

BACKGROUND

Chronic low back pain is a common problem and is associated with high costs, including those related to health care and indirect costs due to absence at work or reduced productivity. Previous studies have demonstrated that acupuncture or electroacupuncture can relieve low back pain. Electronic acupuncture shoes (EAS) are a novel device designed in this study. This device combines the properties of acupuncture and transcutaneous electrical nerve stimulation for clinical use.

OBJECTIVE

The aim of this study was to evaluate the efficacy of EAS in patients with chronic low back pain.

METHODS

In this prospective double-blinded randomized controlled study, the data of 83 patients who experienced chronic low back pain were analyzed. Patients came to our clinic for 20 visits and underwent assessment and treatment. Patients were randomly allocated to receive either EAS plus placebo nonsteroidal anti-inflammatory drugs (NSAIDs) (EAS group, n=42) or sham EAS plus NSAIDs (NSAID group, n=41). The visual analog scale (VAS) score and range of motion were assessed at baseline, before and after each EAS treatment, and 2 weeks after the last treatment. The time for achieving pain remission was recorded. Quality of life was assessed at the 2nd, 14th, and 20th visits.

RESULTS

After 6 weeks of treatment, the treatment success rate in each visit in the EAS group was higher than that in the NSAID group, as revealed by the intention-to-treat (ITT) and per-protocol (PP) analyses, but significant differences were observed only during the 16th visit in the ITT analysis (EAS group: 31/37, 84% and NSAID group: 21/34, 62%; P=.04). The change in the VAS score from baseline in each visit in the EAS group was greater than that in the NSAID group, as revealed by the ITT and PP analyses, and significant differences were observed in the 5th visit and 9th visit in the ITT analysis (P=.048 and P=.048, respectively). Significant differences were observed in the left rotation in the 2nd visit and 4th visit (P=.049 and P=.03, respectively). No significant differences were observed in the VAS score before and after treatment in each visit and in the quality of life in both groups.

CONCLUSIONS

EAS might serve as a reliable alternative therapeutic tool for patients with chronic low back pain who are contraindicated for oral NSAIDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02468297 https://clinicaltrials.gov/ct2/show/NCT02468297.

Associations between Multimorbidity and Physical Performance in Older Chinese Adults

Background: Evidence on the association between physical performance and multimorbidity is scarce in Asia. This study aimed to identify multimorbidity patterns and their association with physical performance among older Chinese adults. Methods: Individuals aged ≥60 years from the China Health and Retirement Longitudinal Study 2011-2015 (N = 10,112) were included. Physical performance was measured by maximum grip strength (kg) and average gait speed (m/s) categorized as fast (>0.8 m/s), median (>0.6-0.8 m/s), and slow (≤0.6 m/s). Multimorbidity patterns were explored using exploratory factor analysis. Generalized estimating equation was conducted. Results: Four multimorbidity patterns were identified: cardio-metabolic, respiratory, mental-sensory, and visceral-arthritic. An increased number of chronic conditions was associated with decreased normalized grip strength (NGS). Additionally, the highest quartile of factor scores for cardio-metabolic (β = -0.06; 95% Confidence interval (CI) = -0.07, -0.05), respiratory (β = -0.03; 95% CI = -0.05, -0.02), mental-sensory (β = -0.04; 95% CI = -0.05, -0.03), and visceral-arthritic (β = -0.04; 95% CI = -0.05, -0.02) patterns were associated with lower NGS compared with the lowest quartile. Participants with ≥4 chronic conditions were 2.06 times more likely to have a slow gait speed. Furthermore, the odds ratios for the highest quartile of factor scores of four patterns with slow gait speed compared with the lowest quartile ranged from 1.26-2.01. Conclusion: Multimorbidity was related to worse physical performance, and multimorbidity patterns were differentially associated with physical performance. A shift of focus from single conditions to the requirements of a complex multimorbid population was needed for research, clinical guidelines, and health-care services. Grip strength and gait speed could be targeted to routinely measure clinical performance among older adults with multimorbidity, especially mental-sensory disorders, in clinical settings.

Frequency and Types of Pathological Upper Gastrointestinal Endoscopy Findings in Clinically Healthy Individuals

BACKGROUND AND OBJECTIVE

Beyond its application for diagnostics in patients, esophagogastroduodenoscopy (EGD) is used to assess gastrointestinal drug effects in clinical trials, where the interpretation of any pathological findings depends on the respective background variability. The objective of this analysis was to characterize the occurrence of pathological findings in the upper gastrointestinal tract in symptom-free healthy individuals.

METHODS

A baseline EGD was performed in clinically healthy individuals in three clinical trials aimed to assess gastrointestinal tolerability of drugs. Pathological findings were described by type (redness, erosion, ulcer or other), number, size and location, and by clinical relevance as assessed by the endoscopist. Characteristics of volunteers were tested as potential covariates.

RESULTS

A total of 294 EGDs were assessed. Characteristics of individuals were as follows: 257 (87.4%) males, age (mean ± SD) 32.0 ± 8.1 years, body weight 76.0 ± 10.6 kg, body mass index (BMI) 24.0 ± 2.5 kg/m2, 200 consumed alcohol, 250 (of 290 where this information was available) consumed caffeine and 39 (of 152) were smokers, 30 (of 151) tested positive for H. pylori. Any pathological finding was present in 79.6%. Clinically relevant findings occurred in 44.2%, mainly erosions (39.1%). Nine stomach ulcers were observed. Only age and BMI had a statistically significant relationship to overall pathological findings [age 3.4 years higher (p = 0.027), and BMI 1.6 kg/m2 higher (p < 0.001); for clinically relevant vs no findings].

CONCLUSION

Upper gastrointestinal tract mucosal lesions, including those assessed as clinically relevant, are frequent in clinically healthy individuals, impeding the assessment of causality for both disease and drug effects on gastrointestinal health.

Rhoifolin regulates oxidative stress and proinflammatory cytokine levels in Freund's adjuvant-induced rheumatoid arthritis via inhibition of NF-κB

Rheumatoid arthritis (RA) is an autoimmune disease of knee joints involving pain and inflammation. Rhoifolin is a plant flavonoid known to have antioxidant and anti-inflammatory properties. This study was taken to identify the effect of rhoifolin on complete Freund’s adjuvant (CFA)-induced arthritis in the rat model. Treatment with rhoifolin (10 and 20 mg/kg) showed a significant improvement in the overall health parameters such as paw edema and weight loss. This improvement in morphological parameters corroborated the findings with gross morphological changes observed in the histopathological analysis. Rhoifolin treatment also caused a significant decrease in oxidative stress, evident from changes in intracellular levels of glutathione, glutathione peroxidase, malondialdehyde, and superoxide dismutase in the articular cartilage tissue. Moreover, proinflammatory cytokines, tumor necrosis factor (TNF)-α, interleukin(IL)-1β, and IL-6 showed a significant downregulation of gene expression and intracellular protein concentration levels. The NF-κB pathway showed a significant attenuation as evident in the significant reduction in the levels of NF-κB p65 and p-IκB-α. These results indicated that rhoifolin can be a natural therapeutic alternative to the extant regimens, which include non-steroidal anti-inflammatory drugs and immunosuppressants. Additionally, the antioxidant and anti-inflammatory action of rhoifolin was probably mediated by the NF-κB pathway. However, the exact target molecules of this pathway need to be determined in further studies.

Associations Between Somatic Multimorbidity Patterns and Depression in a Longitudinal Cohort of Middle-Aged and Older Chinese

OBJECTIVES

Depressive symptoms are commonly seen among patients with multiple chronic somatic conditions, or somatic multimorbidity (SMM); however, little is known about the relationships between depressive symptoms and different SMM combinations. Our study aimed to delineate the patterns of SMM and their longitudinal associations with depressive symptoms among a nationally representative sample of middle-aged and older Chinese adults.

DESIGN

We employed a longitudinal design.

SETTING AND PARTICIPANTS

Older adults (N = 10,084) aged ≥45 years from the China Health and Retirement Longitudinal Study 2011-2015 participated (mean age = 57.7 years at baseline; 53.3% men).

METHODS

Sixteen chronic somatic conditions were ascertained at baseline via questionnaires. Depression was assessed with the Center for Epidemiological Studies Depression Scale at baseline and during follow-up. Patterns of SMM were identified via exploratory factor analyses. Generalized estimating equations were used to evaluate the longitudinal associations between patterns of SMM and the presence of depressive symptoms at follow-up.

RESULTS

Compared with participants with no somatic condition, those with 1, 2, and 3 or more somatic conditions had a 21%, 66%, and 111% greater risk, respectively, for the presence of depressive symptoms. Increased factor scores for 4 patterns identified, cardio-metabolic pattern [adjusted odds ratio (AOR) 1.12, 95% confidence interval (CI) 1.06, 1.20], respiratory pattern (AOR 1.25, 95% CI 1.17, 1.33), arthritic-digestive-visual pattern (AOR 1.29, 95% CI 1.22, 1.37), and hepatic-renal-skeletal pattern (AOR 1.09, 95% CI 1.02, 1.16), were all associated with a higher risk of having depressive symptoms.

CONCLUSIONS AND IMPLICATIONS

All SMM patterns were independently associated with depression among middle-aged and older Chinese adults, with greater odds for people with comorbid arthritic-digestive-visual conditions and respiratory conditions. Clinical practitioners should treat the middle-aged and older population under a multiple-condition framework combining SMM and mental disorders.

Ibuprofen Safety at the Golden Anniversary: Are all NSAIDs the Same? A Narrative Review

Ibuprofen first came to market about 50 years ago and rapidly moved to over-the-counter (OTC) sales. In April 2019, the National Agency for the Safety of Medicines and Health Products (ANSM) of France issued a warning for NSAID uses by patients with infectious diseases based on an analysis of 20 years of real-world safety data on ibuprofen and ketoprofen. Nevertheless, ibuprofen remains a mainstay in the analgesic armamentarium and with numerous randomized clinical trials, head-to-head studies, and decades of clinical experience. The authors offer a review of the safety of ibuprofen and how it may differ from other NSAIDs. Ibuprofen is associated with certain well-known gastrointestinal adverse effects that are related to dose and patient population. Among nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen has a comparatively low risk of cardiovascular adverse effects. It has been associated with renal and hepatic adverse effects, which appear to depend on dose, concomitant medications, and patient population. The association of ibuprofen with infections is more complex in that it confers risk in some situations but benefits in others, the latter in cystic fibrosis. Emerging interest in the literature is providing evidence of the role of ibuprofen as a possible endocrine disrupter as well as its potential antiproliferative effects for cancer cells. Taken altogether, ibuprofen has a favorable safety profile and is an effective analgesic for many acute and chronic pain conditions, although it-like other NSAIDs-is not without risk. After 50 years, evidence is still emerging about ibuprofen and its unique safety profile among NSAIDs. FUNDING: The Rapid Service Fee was funded by Abbott Established Pharmaceuticals Division (EPD).

Comparison of Effectiveness of Etoricoxib and Diclofenac on Pain and Perioperative Sequelae After Surgical Avulsion of Mandibular Third Molars: A Randomized, Controlled, Clinical Trial

OBJECTIVE

The objective of this analysis was to compare the efficacy of etoricoxib and diclofenac in the management of perioperative sequelae following impacted mandibular third molar surgery.

MATERIALS AND METHODS

Ninety-seven patients who needed surgical avulsion of an impacted mandibular third molar were chosen for the study. All patients were randomly allocated to receive one of the following treatments, twice a day for 5 days after surgery: placebo (n=33), diclofenac (n=32), or etoricoxib (n=32). The primary outcome evaluated was postoperative pain, recorded by each patient and evaluated using the Visual Analogue Scale score. The secondary outcomes chosen were, compared with preoperative ones, changes in postoperative swelling and maximum mouth opening.

RESULTS

Compared with placebo, treatment with etoricoxib and diclofenac demonstrated an enhancement in the primary outcome. Furthermore, when compared with the other groups, patients who had undergone etoricoxib presented a significant median reduction in postoperative pain at 2 hours (P<0.001), 12 hours (P=0.025), and at 48 hours (P=0.018) after surgery. Moreover, the linear regression analysis showed that diclofenac and etoricoxib determined a significant influence on Visual Analogue Scale at 2, 6, 12, 24, 48 hours and at 10 days after surgery. There were no differences in swelling and maximum mouth opening values between groups.

DISCUSSION

This study demonstrated that both treatments were effective. However, treatment with etoricoxib showed a greater reduction in the incidence and severity of postoperative pain following third molar surgery compared with diclofenac and placebo.

Evaluation of the efficacy of celecoxib and ibuprofen on postoperative pain, swelling, and mouth opening after surgical removal of impacted third molars: a randomized, controlled clinical trial

The objective of this study was to compare the efficacy of celecoxib and ibuprofen in reducing postoperative sequelae following the surgical removal of impacted mandibular third molars. Ninety-eight subjects who needed surgical extraction of an impacted mandibular third molar were selected for the study. All subjects were randomly allocated to receive one of the following treatments twice a day for 5days after surgery: placebo (n=32), ibuprofen (n=33), or celecoxib (n=33). The primary outcome chosen was postoperative pain, which was evaluated using the visual analogue scale (VAS) score recorded by each patient. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with celecoxib and ibuprofen resulted in improvements in the primary outcome. Furthermore, when compared to the other groups, patients in the celecoxib group showed a significant reduction in postoperative pain scores at 6h (P<0.001), 12h (P=0.011), and 24h (P=0.041) after surgery. Regarding swelling and maximum mouth opening values, there were no significant differences between the groups at each follow-up session. This study demonstrated that treatment with celecoxib decreased the incidence and severity of postoperative pain following third molar surgery compared to ibuprofen and placebo.

Safety of naproxen compared with placebo, ibuprofen and acetaminophen: a pooled analysis of eight multiple-dose, short-term, randomized controlled studies

Objective: To quantify the rate of adverse events reported with naproxen compared with placebo, ibuprofen and acetaminophen at non-prescription doses in multiple-dose, multi-day (7-10 days) duration clinical trials and further contribute towards current knowledge regarding the safety profile of naproxen. Methods: Safety data were retrospectively collected from eight randomized, controlled trials that included subjects exposed to a fixed dosing regimen of 220-750 mg naproxen per day over 7-10 days. All data on adverse events and their duration, severity and possible relationship to the study drug were taken from the clinical study reports. The data were used in a post-hoc pooled analysis of participants exposed to naproxen 220-750 mg/day (N = 1494) and grouped according to age (<65 and ≥65 years), daily dose, race and gender. Results: The safety profile of naproxen closely resembled that of placebo, with similar rates of adverse events across treatment groups as the active comparators. There was no dose effect of naproxen, and there were no differences in older versus younger participants. Most events were mild to moderate. The most frequently reported adverse events in all groups were related to the gastrointestinal system (most commonly dyspepsia with naproxen), with no differences between groups. Conclusions: Our pooled analysis did not find an increased risk of adverse events with short-term use of non-prescription doses of naproxen compared with placebo, or compared to other common analgesics.

Carboranyl Analogues of Ketoprofen with Cytostatic Activity against Human Melanoma and Colon Cancer Cell Lines

Ketoprofen is a widely used nonsteroidal anti-inflammatory drug (NSAID) that also exhibits cytotoxic activity against various cancers. This makes ketoprofen an attractive structural lead for the development of new NSAIDs and cytotoxic agents. Recently, the incorporation of carboranes as phenyl mimetics in structures of established drugs has emerged as an attractive strategy in drug design. Herein, we report the synthesis and evaluation of four novel carborane-containing derivatives of ketoprofen, two of which are prodrug esters with an nitric oxide-releasing moiety. One of these prodrug esters exhibited high cytostatic activity against melanoma and colon cancer cell lines. The most pronounced activity was found in cell lines that are sensitive to oxidative stress, which was apparently induced by the ketoprofen analogue.

Efficacy of a drug composed of herbal extracts on postoperative discomfort after surgical removal of impacted mandibular third molar: a randomized, triple-blind, controlled clinical trial

OBJECTIVES

This study investigated and compared the effectiveness of a phytotherapeutic drug composed of herbal extracts on postsurgical discomfort after mandibular third molar surgery.

MATERIALS AND METHODS

Eighty-two patients requiring the surgical removal of a mandibular third molar were randomly assigned to receive placebo (group 1), ibuprofen (group 2), and a phytotherapeutic drug (composed of baicalin, 190 mg; bromelain, 50 mg; escin, 30 mg) (group 3). Drugs were administered after tooth extraction twice a day for 5 days. The primary outcome, pain, was evaluated using a visual analogue scale at 2 h, 6 h, 12 h, 24 h, 48 h, and 7 and 10 days after surgery. The secondary outcomes were the changes in maximum mouth opening and facial contours (mm) between baseline and at 24 h, 72 h, and 7 and 10 days after surgery.

RESULTS

Compared to the baseline, all treatments demonstrated an improvement in the primary and secondary outcomes. Moreover, compared to groups 1 and 2, patients in group 3 yielded a significant reduction of the postoperative pain score at 12 h (p < 0.001), 24 h (p = 0.010), and 48 h (p = 0.048) after surgery. The mean reduction of the swelling and trismus was similar between groups.

CONCLUSIONS

The results of this study suggest that a postoperative administration of a phytotherapeutic drug was found to be effective in postoperative pain management after the surgical removal of impacted mandibular third molars.

CLINICAL RELEVANCE

The phytotherapeutic drug composed of herbal extract determined a decrease in the severity of postoperative pain compared to ibuprofen and placebo.

Ibuprofen in the treatment of children's inflammatory pain: a clinical and pharmacological overview

Unlike fever, which is often over-treated especially in children, pain is underestimated and under-treated in pediatric age. The pharmacological agents approved for treating pain in these patients are few, also considering the recent limitation for codeine in children younger than 12 years. Paracetamol and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen are the most used at this purpose. The aim of this overview was to analyze the therapeutic appropriateness of ibuprofen in children based on its pharmacological properties. This work is a critical review of the pediatric literature over the last 20 years on efficacy and adverse events associated with the use of ibuprofen as analgesic in the pediatric population. Ibuprofen resulted effective in several pain conditions in children such as musculoskeletal pain, ear pain and acute otitis media, toothache and the inflammatory disease of the oral cavity and pharynx. The drug is a reasonable and efficacious alternative in postoperative pain, including tonsillectomy and adenoidectomy. It remains the treatment of choice for pain in chronic inflammatory diseases such as arthritis. Side effects and adverse events associated with ibuprofen are mild. It has the lowest gastrointestinal (GI) toxicity among NSAIDs, although some cases of GI toxicity may occur. Its renal effects are minimal, but dehydration plays an important role in triggering renal damage, so ibuprofen should not be given to patients with vomiting and diarrhea. Ibuprofen showed a good safety profile and provided evidence of effectiveness for mild-moderate pain of different origin in children. In case of fever or pain, the choice about the drug to be used should fall on ibuprofen in a clinical context where there is an inflammatory pathogenesis.

Analysis of the Effectiveness of Lornoxicam and Flurbiprofen on Management of Pain and Sequelae Following Third Molar Surgery: A Randomized, Controlled, Clinical Trial

The aim of this study was to analyze the effectiveness of Lornoxicam and Flurbiprofen in reducing perioperative sequelae after impacted mandibular third molar surgery. Ninety-one patients who needed surgical extraction of an impacted mandibular third molar were selected for the study. All subjects were randomly allocated to receive one of the following treatments twice a day for 5 days after surgery: placebo (n = 29), Flurbiprofen (n = 31), or Lornoxicam (n = 31). The primary outcome was postoperative pain, evaluated using the visual analogue scale (VAS) score at 30 min, 2, 6, 12, 24, 48 h, 7 and 10 days following surgery. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with Flurbiprofen and Lornoxicam was characterised by an improvement in the primary outcome. Moreover, the treatment with Lornoxicam presented significantly lower median pain scores at 2 h (p < 0.001) and at 6 h (p = 0.016) compared to Flurbiprofen and at 2 h (p < 0.001), 6 h (p = 0.01), and at 24 h (p = 0.018) after surgery compared with placebo. Swelling and maximum mouth opening values were not significantly different between the groups at each follow-up session. This trial demonstrated that treatment with Lornoxicam showed a decrease in the incidence and severity of pain in the first postoperative phase following third molar surgery compared to Flurbiprofen and placebo.

Attitude and Awareness of Dentists Practicing in Southern India Toward Non-steroidal Anti-inflammatory Drugs

Background:

Pain management is an everyday challenge in dentistry. Analgesics are the group of drugs prescribed for effective pain management, of which nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed drugs. Selection of NSAIDs must be judiciously made considering their pharmacological properties and adverse effects.

Aim:

This study aimed to analyze the attitude toward analgesic prescription among practicing dentists and the awareness to update their knowledge about them.

Materials and Methods:

The study was carried out among 100 dental practitioners, where a questionnaire consisting of 16 questions was formulated based on the awareness of indication and contraindication, actual practice, and required future trends for updating the knowledge. The questionnaire was distributed among the practitioners; the answered questionnaire was collected and tabulated. Statistical analysis included χ² test to evaluate the significance.

Results:

Of 100 dental practitioners, 63% prescribed drugs based on the diagnosis. Aceclofenac was found to be the effective drug in postoperative pain management, whereas paracetamol was considered to be the safest among NSAIDs in clinical conditions such as bleeding disorders, gastric irritation, chronic kidney disease, and during pregnancy. All practicing dentists showed their willingness to participate in awareness programs in updating their knowledge.

Conclusion:

This study showed that dental clinical practitioners are well aware of the drugs to be prescribed in different clinical conditions but pitfalls have been observed in areas of systemic complication, where continuous educational programs are needed to overcome the same.

Pharmacoepidemiology

At the time of their marketing authorization, the effects of drugs and especially their efficacy have been mostly studied in randomized controlled clinical trials (RCT), comparing them to placebo or to existing drugs. However, RCT are by nature limited in their extent, and the often stringent inclusion and exclusion criteria destined to provide for homogeneous study populations reduce the generalizability of RCT results.The post-authorization evaluation of drugs (pharmacoepidemiology or real-world evidence (RWE)) covers the description of drug utilization and population risks or benefits of these drugs after they have been marketed and provided to their target populations. Though field studies have existed for a long time, modern pharmacoepidemiology has been made possible essentially by the emergence of large population databases compiled from claims data or electronic health records. The methods can be exposure or disease-based cohorts or event-driven case-based studies, tailored to the specific questions to be answered. They rely on scrupulous analysis and execution of impeccable methodology, to ensure the most reliable results possible.Pharmacoepidemiology requires knowledge of the pharmacology of drugs, of the clinical aspects of diseases and disease management, and of the epidemiological methods that can apply.

Efficacy of Ketoprofen With or Without Omeprazole for Pain And Inflammation Control After Third Molar Removal

In view of the gastrointestinal problems generated by the ketoprofen use, the ketoprofen association with omeprazole is available on the market. However, this association efficacy in acute pain control has not been established. Bilateral extraction of lower third molars in similar positions is currently the most used model for the evaluation and investigation of the efficacy and pharmacological effects of new compounds for the treatment of acute postoperative pain. The randomized and crossover study consisted in evaluating the clinical efficacy of therapy performed by ketoprofen 100 mg (twice daily-b.i.d.) versus ketoprofen 200 mg + omeprazole 20 mg (once daily-q.d.) to pain, swelling and trismus control in the bilateral extraction model of lower third molars in similar positions in two different appointments, in 50 volunteers. Volunteers reported significantly less postoperative pain at various post-operative periods and consumed less rescue analgesic medication (acetaminophen 750 mg) throughout the study when they took the combination of ketoprofen 200 mg + omeprazole 20 mg (q.d.). Following administration of both study drugs, no gastrointestinal adverse reactions were reported by volunteers. Furthermore, the evaluations of the drugs in pain control by the volunteers were significantly favorable to ketoprofen 200 mg + omeprazole 20 mg (q.d.). For swelling and trismus control, the treatments presented similar results. In conclusion, when volunteers took ketoprofen 200 mg + omeprazole 20 mg (q.d.), they reported significantly less postoperative pain at various post-surgical periods and consumed less rescue analgesic medication throughout the study compared with ketoprofen 100 mg (b.i.d).

A simple model to solve a complex drug toxicity problem

Linear drug toxicity models like therapeutic index (TI), physicochemical rules (rule of five, 3/75), ligand efficiency indices (LEI), ideal pharmacokinetic (PK) and pharmacodynamic (PD) profiles are widely used in drug discovery and development. In spite of this, predicting drug toxicity at various stages remains challenging and the overall productivity (<20%) and ultimate benefit to the patients remain low. A simple drug toxicity model, "Drug Toxicity Index" (DTI), is developed here using 711 oral drugs. DTI redefines drug toxicity as scaled biphasic and exponential functions of PD, PK and physicochemical parameters. PD, PK and physicochemical toxicity contributions were estimated from the on and off target IC₅₀, maximum unbound plasma drug concentration (free C _max), and log D values, respectively. These contributions are then scaled by molar dose and oral bioavailability and the logarithm of the sum of scaled contributions is DTI. Drugs with DTI above the WHO ATC drug category specific average values consistently have toxic profiles, while drugs with DTI below this average are relatively safe. DTI performs better than standard rules for lead optimization, LEI and exposure based TIs in identifying safe and toxic drugs. DTI classifies 392 drugs reported in the US-FDA's Liver Toxicity Knowledge Base (LTKB) with an AUC for ROC curves of 0.91-0.64 for different WHO ATC categories. DTI has been used to predict network meta-analysis results on relative toxicity within/across eight different therapeutic areas. It is useful in understanding PD, PK and physicochemical toxicity contributions and identifying potentially toxic drugs and the toxicity of recently approved drugs. Decision trees are proposed for applying the DTI concept in preclinical drug discovery and clinical trial settings. DTI can potentially reduce failure in drug discovery and might be useful in therapeutic drug monitoring and in xenobiotic and environmental toxicity studies.

Pharmacoepidemiology of non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are reversible inhibitors of cyclo-oxygenase (COX), mainly used for the symptomatic relief of pain, whether traumatic, infectious, episodic or rheumatologic. Use for the long-term relief of inflammation is waning with the emergence of specific biotherapies. Their effects are related to potency, dosage, and pharmacokinetic or galenic considerations. Adverse reactions are mostly related to COX inhibition, and to the relative COX1 and COX2 inhibition. Over the years have resulted in the withdrawal of some NSAIDs. The most common adverse reactions are: gastrointestinal (COX1) which have declined over time with the emergence of more COX1 sparing drugs and gastroprotection; renal, with an impact on renal function and sodium extraction that is associated with hypertension, heart failure exacerbation, and stress-related renal failure; allergic skin reactions; increased transaminases and acute liver injury which may be idiosyncratic or immunoallergic; increased risk of acute coronary syndromes, initially associated with high-dose long-term use of COX2 specific inhibitors in controlled clinical trials, though more recently there have been indications from poorly controlled observational studies that they could occur with most NSAIDs. Event rates in patients with no overt coronary heart disease are vanishingly low, and the real magnitude of the issue in the treatment of common pain is still unknown. Considering their purely symptomatic effects, they should be used at the lowest possible dose for the shortest possible time, based on the symptomatic relief of pain or fever.

Analgesic Efficacy of an Acetaminophen/Ibuprofen Fixed-dose Combination in Moderate to Severe Postoperative Dental Pain: A Randomized, Double-blind, Parallel-group, Placebo-controlled Trial

PURPOSE

Acute pain is a significant burden to the individual and to society. There is a clear need for a pain medication that provides improved analgesia over common analgesics, without compromising tolerability. The goal of this study was to determine the efficacy of a new fixed-dose combination of acetaminophen 975 mg and ibuprofen 292.5 mg (FDC 975/292.5) relative to acetaminophen or ibuprofen monotherapy, or placebo.

METHODS

This prospective, multicenter, randomized, double-blind, placebo-controlled, Phase III trial included 408 adult volunteers aged 18 to 60 years experiencing moderate to severe pain after surgical removal of at least 2 impacted third molars. Subjects were randomized in a 3:3:3:2 ratio to the following interventions: FDC 975/292.5, acetaminophen 975 mg, ibuprofen 292.5 mg, and placebo. Self-reported pain intensity scores were recorded over a 48-hour double-blind treatment period using a 100-mm visual analog scale. In addition, time to perceptible and meaningful pain relief was assessed by using the two-stopwatch method; use of rescue medication (oxycodone) was recorded; and patients rated their pain relief on a 5-point categorical scale. All adverse events during the 30-day study period were assessed.

FINDINGS

The majority of participants were female (67.4%) and white (90.0%), with a mean age of 24.8 years. Demographic and baseline characteristics were balanced across treatment groups, with a mean baseline pain score of 56.4 mm. The primary end point was the time-adjusted sum of pain intensity differences over 48 hours, which was found to be significantly greater for FDC 975/292.5 than for both monotherapies and placebo (all, P < 0.001). The robustness of the procedures used in the calculation of the primary end point was confirmed in a series of sensitivity analyses. Statistical superiority of the combination was evident in all secondary end points (time to meaningful pain relief, maximum pain score, response rate, participants using supplementary analgesia, time to rescue, oxycodone consumption, and categorical pain relief score) with the exception of time to perceptible pain relief versus monotherapies and the time to peak response versus ibuprofen. The percentage of patients reporting adverse events was 37.3% in the FDC 975/292.5 group, with no significant differences between treatment groups. Nausea was the most common adverse event across all groups.

IMPLICATIONS

Overall, the fixed-dose combination of acetaminophen and ibuprofen provided greater and more rapid analgesia than comparable doses of either agent alone or placebo in adults after removal of impacted third molars. ClinicalTrials.gov identifier: NCT01420653.

Use of Non-Steroidal Anti-Inflammatory Drugs and Associated Gastroprotection in a Cohort of Workers

BACKGROUND

This study describes the prevalence of non-steroidal anti-inflammatory drug (NSAID) use, and analyses prescribing patterns of NSAIDs and associated gastroprotection.

METHODS

The study population consisted of 5650 workers at the General Motors automobile assembly plant in Zaragoza, Spain. NSAID prescription data for 2014 were obtained from the prescription database of Aragon (Spain). NSAID consumption was determined based on the number of defined daily doses purchased per year. Heavy NSAIDs users were identified using Lorenz curves.

RESULTS

NSAID use in the cohort was high (40.7% of workers, 95% CI 39.4⁻41.9). The prescription of proton pump inhibitors increased with age. Gastrointestinal protection was lacking in some participants who were being treated with drugs associated with a high risk of gastrointestinal bleeding. Heavy NSAID users (defined as those above the 95th percentile of consumption), accounted for 26% of total DDDs, and consumed a greater proportion of coxibs than non-heavy users.

CONCLUSIONS

The rate of NSAID consumption in the cohort was high. To reduce the risk of gastrointestinal complications, monitoring and adequate gastroprotection are essential in patients who are prescribed NSAIDs for long periods of time or who are treated concomitantly with drugs that increase the risk of gastrointestinal bleeding.

Molecular docking and pharmacological/toxicological assessment of a new compound designed from celecoxib and paracetamol by molecular hybridization

Nonsteroidal anti-inflammatory drugs are commonly used worldwide; however, they have several adverse effects, evidencing the need for the development of new, more effective and safe anti-inflammatory and analgesic drugs. This research aimed to design, synthesize and carry out a pharmacological/toxicological investigation of LQFM-102, which was designed from celecoxib and paracetamol by molecular hybridization. To evaluate the analgesic effect of this compound, we performed formalin-induced pain, hot plate and tail flick tests. The anti-inflammatory effect of LQFM-102 was evaluated in carrageenan-induced paw oedema and pleurisy tests. The biochemical markers indicative of toxicity-AST, ALT, GSH, urea and creatinine-as well as the index of gastric lesion after prolonged administration of LQFM-102 were also analyzed. In addition, the interaction of LQFM-102 with COX enzymes was evaluated by molecular docking. In all experimental protocols, celecoxib or paracetamol was used as a positive control at equimolar doses to LQFM-102. LQFM-102 reduced the pain induced by formalin in both phases of the test. However, this compound did not increase the latency to thermal stimuli in the hot plate and tail flick tests, suggesting an involvement of peripheral mechanisms in this effect. Furthermore, LQFM-102 reduced paw oedema, the number of polymorphonuclear cells, myeloperoxidase activity and TNF-α and IL-1β levels. Another interesting finding was the absence of alterations in the markers of hepatic and renal toxicity or lesions of gastric mucosa. In molecular docking simulations, LQFM-102 interacted with the key residues for activity and potency of cyclooxygenase enzymes, suggesting an inhibition of the activity of these enzymes.

Risk factors associated with nonsteroidal anti-inflammatory drugs (NSAIDs)-induced gastrointestinal bleeding resulting on people over 60 years old in Beijing

Gastrointestinal (GI) bleeding is an unwanted side effect common to all chemical types of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in elderly people. However, the risk factors of GI bleeding associated with NSAIDs for elderly people remain unknown. This study aims to evaluate the risks of GI bleeding associated with NSAIDs in 4728 elderly people over 60 years old based on database from a hospital in Beijing.This retrospective hospital-based study included 4728 patients over 60 years old prescribed with NSAIDs, of which 928 patients had GI bleeding and 3800 did not have. Odds ratios (OR) for the risk of GI bleeding associated with NSAIDs were determined by logistic regression analysis. Mean Decrease Gini (MDG) involved in random forest algorithm was used to rank the associated factors with GI bleeding.In multivariate analysis, family history of GI bleeding (OR, 3.348; P = .000), history of peptic ulcers (OR, 4.068; P = .000), history of cardiovascular and cerebrovascular disease (OR, 1.476; P = .001), diabetes mellitus (OR, 1.408; P = .000), antiplatelet drugs (OR, 3.106; P = .000), Helicobacter pylori infection (OR, 1.312; P = .001), cholesterol level (OR, 0.516; P = .000), upper abdominal discomfort (OR, 3.467; P = .000), anorexia (OR, 2.038; P = .000), and NSAIDs used for 0.5 to 3 months (OR, 0.780; P = .000) were associated with GI bleeding. After ranked the MDG of each factor, the top 5 ranked factors associated with GI bleeding were melena, hematemesis, antiplatelet drugs, cholesterol level, and upper abdominal discomfort.We found that family history of GI bleeding, history of peptic ulcers, history of cardiovascular and cerebrovascular disease, diabetes mellitus, antiplatelet drugs, Helicobacter pylori infection, hypocholesterolemia, and NSAIDs used for 0.5 to 3 months were independent risk factors for GI bleeding on people over 60 years old. Meanwhile, upper abdominal discomfort might be the predictor of GI bleeding associated with NSAIDs elderly users.

The implementation of academic detailing and its effectiveness on appropriate prescribing of pain relief medication: a real-world cluster randomized trial in Belgian general practices

BACKGROUND

In Belgium, the debate about the effect of the national academic detailing service (ADS) on prescribing quality in general practice is ongoing. In order to evaluate both the implementation strategies of the ADS and its effectiveness on appropriate prescribing of pain relief medication, we conducted a real-world cluster randomized controlled trial (cRCT).

METHODS

In a pragmatic cRCT, all Belgian general practices previously visited by Farmaka were assessed for eligibility and randomized. Only practices randomized to the intervention group were invited for an academic detailing visit on appropriate prescribing of pain relief medication. GPs were unaware of the study, ensuring the production of real-world evidence but were given the option to opt out from the analysis. An objective outcome assessment was obtained using routinely collected reimbursement data. Primary outcomes were the proportion of patients reimbursed for an analgesic or NSAID, the defined daily dose of paracetamol per patient per month, the proportion of patients reimbursed for a recommended NSAID among those reimbursed for any NSAID and the proportion of patients reimbursed for both an NSAID and a proton pump inhibitor among those reimbursed for an NSAID. The impact of practice, GP and academic detailer characteristics were also assessed.

RESULTS

Three thousand five hundred twenty-nine general practices (4530 GPs) were eligible and randomized. One thousand six hundred ninety-eight practices (2171 GPs) in the intervention group and one thousand seven hundred three (2163 GPs) in the control group were included in the analysis. The intervention had a significant impact on the proportion of patients reimbursed for a recommended NSAID among those reimbursed for any NSAID (increase in odds (95% CI): 19% (10-29%)). A clear impact on other outcomes could not be detected. Additionally, we showed that the characteristics of the academic detailers might impact the effectiveness of the visit.

CONCLUSIONS

National implementation of academic detailing in Belgian general practices provided by Farmaka significantly improved the proportion of recommended NSAIDs prescribed by GPs, but not other outcomes related to appropriate prescribing of pain relief medication.

TRIAL REGISTRATION

NCT01761864 . Registered 2 January 2013.

Effects of aspirin and non-aspirin nonsteroidal anti-inflammatory drugs on the incidence of recurrent colorectal adenomas: a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials

BACKGROUND

Beneficial effects of aspirin and non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) against recurrent colorectal adenomas have been documented in systematic reviews; however, the results have not been conclusive. Uncertainty remains about the appropriate dose of aspirin for adenoma prevention. The persistence of the protective effect of NSAIDs against recurrent adenomas after treatment cessation is yet to be established.

METHODS

Our objective was to update and systematically evaluate the evidence for aspirin and other NSAIDs on the incidence of recurrent colorectal adenomas taking into consideration the risks of random error and to appraise the quality of evidence using GRADE (The Grading of Recommendations, Assessment, Development and Evaluation) approach. Retrieved trials were evaluated using Cochrane risk of bias instrument. Meta-analytic estimates were calculated with random-effects model and random errors were evaluated with trial sequential analysis (TSA).

RESULTS

In patients with a previous history of colorectal cancer or adenomas, low-dose aspirin (80-160 mg/day) compared to placebo taken for 2 to 4 years reduces the risk of recurrent colorectal adenomas (relative risk (RR), 0.80 [95% CI (confidence interval), 0.70-0.92]). TSA indicated a firm evidence for this beneficial effect. The evidence indicated moderate GRADE quality. Low-dose aspirin also reduces the recurrence of advanced adenomas (RR, 0.66 [95% CI, 0.44-0.99]); however, TSA indicated lack of firm evidence for a beneficial effect. High-dose aspirin (300-325 mg/day) did not statistically reduce the recurrent adenomas (RR, 0.90 [95% CI, 0.68-1.18]). Cyclooxygenase-2 (COX-2) inhibitors (e.g. celecoxib 400 mg/day) were associated with a significant decrease in the recurrence of both adenomas (RR, 0.66 [95% CI, 0.59-0.72]) and advanced adenomas (RR, 0.45 [95% CI, 0.33-0.57]); however, this association did not persist and there was a trend of an increased risk of recurrent adenomas observed 2 years after the withdrawal.

CONCLUSION

Our findings confirm the beneficial effect of low-dose aspirin on recurrence of any adenomas; however, effect on advanced adenomas was inconclusive. COX-2 inhibitors seem to be more effective in preventing recurrence of adenomas; however, there was a trend of an increased risk of recurrence of adenomas observed after discontinuing regular use.

Topical Administration of Ibuprofen for Injured Athletes: Considerations, Formulations, and Comparison to Oral Delivery

Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of drugs commonly used to treat both the acute and chronic injuries sustained by athletes during training and competition. In many parts of the world, NSAIDs can be purchased over-the-counter and used without any physician oversight. However, the chronic nature of overuse injuries requires NSAIDs to be taken orally for an extended period of time. As a result, they can have significant adverse effects on athletes, namely gastrointestinal (GI), renal, and cardiovascular damage. Dyspepsia and upper GI ulceration and bleeding are of great concern in chronic NSAID use, and as such oral NSAIDs are generally contraindicated in those with a history of peptic ulcers or irritable bowel disease. In the setting of chronic overuse soft tissue or joint disease, topically administered NSAIDs offer an alternate route of administration that has the potential to deliver a similar level of pain and anti-inflammatory relief while bypassing the harmful side effects associated with oral intake. Topically applied NSAIDs are able to achieve high concentrations within the targeted site of action while simultaneously keeping plasma concentrations low, offering several advantages over oral administration. One commonly used generic NSAID is ibuprofen (2-(4-isobutylphenyl)propanoic acid). First synthesized in the 1960s, ibuprofen has since become widely available as an over-the-counter pharmaceutical. In this review, we outline new and different techniques that have been used to deliver ibuprofen into diseased tissues, including supersaturations, microemulsions, gels, nanosystems, and microneedles. We also review relevant clinical trials comparing transdermally delivered ibuprofen to placebo and orally administered ibuprofen.

Pain relief of sore throat with a new anti-inflammatory throat lozenge, ibuprofen 25 mg: A randomised, double-blind, placebo-controlled, international phase III study

OBJECTIVE

The aim of this study was to compare the efficacy and safety of a new oromucosal ibuprofen form, ibuprofen 25 mg lozenge, in single and repeat dosing for up to 4 days, to the matched placebo, in the treatment of acute sore throat pain in adults.

METHODS

In this randomised, double-blind, placebo-controlled trial, adult patients with non-streptococcal sore throat and signs of moderate-to-severe associated pain (≥5 on the objective Tonsillo-Pharyngitis Assessment 21-point scale and ≥60 mm on the subjective 0-100 mm visual analogue Sore Throat Pain Intensity Scale [STPIS]) were assigned ibuprofen 25 mg (n=194) or matching placebo (n=191) lozenge treatment. Efficacy was assessed (at the investigating centre up to 2 hours after first dosing, then on an ambulatory basis) by parameters derived from patient's scores on scales of pain relief, pain intensity, and global efficacy assessment. The primary efficacy end-point was the time-weighted TOTal PAin Relief (TOTPAR) over 2 hours after first dosing using the Sore Throat Relief Scale (STRS). Safety and local tolerability were assessed.

RESULTS

Ibuprofen 25 mg was superior to placebo on numerous pain relief parameters; TOTPAR was significantly higher with ibuprofen 25 mg over 2 hours after first dosing (P<.05), the effect being apparent from the first evaluation at 15 minutes (P<.05). The STPIS reduction in favour of ibuprofen 25 mg was not significant vs placebo. Mean STRS scores and patient's global efficacy assessment both reflected a higher efficacy of ibuprofen 25 mg over the 4-day treatment period with tests of statistical significance up to day 1 evening (P<.05), and, in patients with still clinically significant pain (n=128), after an average 4 days (P<.01). Ibuprofen 25 mg lozenge was well tolerated with a safety profile similar to placebo.

CONCLUSION

Low-dose ibuprofen 25 mg lozenge in repeat dosing provides in adults more efficacious and rapid relief of sore throat pain and is as well tolerated as placebo.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01785862.