Double-bind cross-over tiral of flurbiprofen and phenylbutazone in ankylosing spondylitis

Non-steroidal anti-inflammatory drugs (NSAIDs) for axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis)

BACKGROUND

Axial spondyloarthritis (axSpA) comprises ankylosing spondylitis (radiographic axSpA) and non-radiographic (nr-)axSpA and is associated with psoriasis, uveitis and inflammatory bowel disease. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line drug treatment.

OBJECTIVES

To determine the benefits and harms of NSAIDs in axSpA.

SEARCH METHODS

We searched CENTRAL, MEDLINE and EMBASE to 18 June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of NSAIDs versus placebo or any comparator in adults with axSpA and observational cohort studies studying the long term effect (≥ six months) of NSAIDs on radiographic progression or adverse events (AEs). The main comparions were traditional or COX-2 NSAIDs versus placebo. The major outcomes were pain, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), radiographic progression, number of withdrawals due to AEs and number of serious AEs

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed the risk of bias, extracted data and assessed the quality of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 39 studies (35 RCTs, two quasi-RCTs and two cohort studies); and 29 RCTs and two quasi-RCTs (n = 4356) in quantitative analyses for the comparisons: traditional NSAIDs versus placebo, cyclo-oxygenase-2 (COX-2) versus placebo, COX-2 versus traditional NSAIDs, NSAIDs versus NSAIDs, naproxen versus other NSAIDs, low versus high dose. Most trials were at unclear risk of selection bias (n = 29), although blinding of participants and personnel was adequate in 24 trials. Twenty-five trials had low risk of attrition bias and 29 trials had low risk of reporting bias. Risk of bias in both cohort studies was high for study participation, and low or unclear for all other criteria. No trials in the meta-analyses assessed patients with nr-axSpA.Traditional NSAIDs were more beneficial than placebo at six weeks. High quality evidence (four trials, N=850) indicates better pain relief with NSAIDs (pain in control group ranged from 57 to 64 on a 100mm visual analogue scale (VAS) and was 16.5 points lower in the NSAID group (95% confidence interval (CI) -20.8 to -12.2), lower scores indicate less pain, NNT 4 (3 to 6)); moderate quality evidence (one trial, n = 190) indicates improved disease activity with NSAIDs (BASDAI in control group was 54.7 on a 100-point scale and was 17.5 points lower in the NSAID group, 95% CI -23.1 to -11.8), lower scores indicate less disease activity, NNT 3 (2 to 4)); and high quality evidence (two trials, n = 356) indicates improved function with NSAIDs (BASFI in control group was 50.0 on a 100-point scale and was 9.1 points lower in the NSAID group (95% CI -13.0 to -5.1), lower scores indicate better functioning, NNT 5 (3 to 8)). High (five trials, n = 1165) and moderate (three trials, n = 671) quality evidence (downgraded due to potential imprecision) indicates that withdrawals due to AEs and number of serious AEs did not differ significantly between placebo (52/1000 and 2/1000) and NSAID (39/1000 and 3/1000) groups after 12 weeks (risk ratio (RR) 0.75, 95% CI 0.46 to 1.21; and RR 1.69, 95% CI 0.36 to 7.97, respectively). BASMI and radiographic progression were not reported.COX-2 NSAIDS were also more efficacious than placebo at six weeks. High quality evidence (two trials, n = 349) indicates better pain relief with COX-2 (pain in control group was 64 points and was 21.7 points lower in the COX-2 group (95% CI -35.9 to -7.4), NNT 3 (2 to 24)); moderate quality evidence (one trial, n = 193) indicates improved disease activity with COX-2 (BASDAI in control groups was 54.7 points and was 22 points lower in the COX-2 group (95% CI -27.4 to -16.6), NNT 2 (1 to 3)); and high quality evidence (two trials, n = 349) showed improved function with COX-2 (BASFI in control group was 50.0 points and was 13.4 points lower in the COX-2 group (95% CI -17.4 to -9.5), NNT 3 (2 to 4)). Low and moderate quality evidence (three trials, n = 669) (downgraded due to potential imprecision and heterogeneity) indicates that withdrawals due to AEs and number of serious AEs did not differ significantly between placebo (11/1000 and 2/1000) and COX-2 (24/1000 and 2/1000) groups after 12 weeks (RR 2.14, 95% CI 0.36 to 12.56; and RR 0.92, 95% CI 0.14 to 6.21, respectively). BASMI and radiographic progression were not reported.There were no significant differences in benefits (pain on VAS: MD -2.62, 95% CI -10.99 to 5.75; three trials, n = 669) or harms (withdrawals due to AEs: RR 1.04, 95% CI 0.60 to 1.82; four trials, n = 995) between NSAID classes. While indomethacin use resulted in significantly more AEs (RR 1.25, 95% CI 1.06 to 1.48; 11 studies, n = 1135), and neurological AEs (RR 2.34, 95% CI 1.32 to 4.14; nine trials, n = 963) than other NSAIDs, these findings were not robust to sensitivity analyses. We found no important differences in harms between naproxen and other NSAIDs (three trials, n = 646), although other NSAIDs appeared more effective for relieving pain (MD 6.80, 95% CI 3.72 to 9.88; two trials, n = 232). We found no clear dose-response effect on benefits or harms (five studies, n = 1136). Single studies suggest NSAIDs may be effective in retarding radiographic progression, especially in certain subgroups of patients, e.g. patients with high CRP, and that this may be best achieved by continuous rather than on-demand use of NSAIDs.

AUTHORS' CONCLUSIONS

High to moderate quality evidence indicates that both traditional and COX-2 NSAIDs are efficacious for treating axSpA, and moderate to low quality evidence indicates harms may not differ from placebo in the short term. Various NSAIDs are equally effective. Continuous NSAID use may reduce radiographic spinal progression, but this requires confirmation.

Should non-steroidal anti-inflammatory drugs be used continuously in ankylosing spondylitis?

OBJECTIVE

The 2010 update of ASAS/EULAR recommendations for managing ankylosing spondylitis (AS) specify that continuous non-steroidal anti-inflammatory drug (NSAID) treatment should be preferred in patients with persistently active, symptomatic disease. Here, our objective was to assess whether continuous NSAID therapy improves disease control and influences radiographic progression compared to on-demand therapy. We also assessed the safety profiles of both regimens.

METHODS

We performed a review by searching the PubMed and Embase databases using two MeSH term combinations to compare continuous and on-demand NSAID therapy in terms of disease control, radiographic progression, and safety.

RESULTS

The only study evaluating the impact of continuous NSAID therapy on disease control showed no significant difference with on-demand therapy. In four studies, continuous treatment was associated with slower radiographic progression, as assessed in three studies using the modified Stoke Ankylosing Spondylitis Spinal Score (m-SASSS). Three studies compared the safety of continuous and on-demand celecoxib, two in osteoarthritis and one in AS, and found no significant differences regarding the usual side effects of Cox-2 inhibitors.

CONCLUSIONS

Several studies showed slower radiographic progression with continuous NSAID therapy in AS. No studies demonstrated superiority of continuous NSAID therapy regarding symptom control. Continuous NSAID therapy (at least with Cox-2 inhibitors) does not modify safety compared to on-demand therapy.

Evidence-based recommendations for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists

OBJECTIVE

Recommendations and/or guidelines represent a popular way of integrating evidence-based medicine into clinical practice. The 3E Initiatives is a multi-national effort to develop recommendations for the management of rheumatic diseases, which involves a large number of experts combined with practising rheumatologists addressing specific questions relevant to clinical practice.

METHODS

Ten countries participated in three rounds of discussions and votes concerning the management of AS. A set of nine questions was formulated in the domains of diagnosis, monitoring and treatment, after a Delphi procedure. A literature search in MedLine was conducted. Predefined outcome parameters for the domains of diagnosis, monitoring and treatment were assessed. The evidence to support each proposition was evaluated and scored. After discussion and votes, the final recommendations were presented using brief statements by each national group, following which the final international recommendations were formulated.

RESULTS

A total of 2699 papers were found and 467 were selected for analysis. Twelve key recommendations were developed: three in the domain of diagnosis addressing general diagnostic considerations, early AS diagnosis and general practitioners' referral recommendations; three concerning monitoring of AS disease activity, severity and prognosis; six concerning pharmacological treatment (except biologics): non-steroidal anti-inflammatory drugs/COX-II inhibitors, bisphosphonates and treatment of enthesitis. The compiled agreement among experts ranged from 72% to 93%.

CONCLUSION

Recommendations for the management of AS were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement. Involvement of a larger and more representative group of rheumatologists may improve their dissemination and implementation in daily clinical practice.

Pharmacotherapy (excluding biotherapies) for ankylosing spondylitis: Development of recommendations for clinical practice based on published evidence and expert opinion

OBJECTIVES

To develop recommendations about pharmacotherapy (excluding biotherapeutic agents) in patients with axial forms of ankylosing spondylitis (AS) seen in everyday clinical practice.

METHODS

The recommendations were based on evidence from the literature. First, a scientific committee used a Delphi procedure to select five focal points about which recommendations were needed. Then, a literature task force looked for relevant publications in the following: Cochrane, PubMed, and Ovid databases; and abstracts from the French Society for Rheumatology, European League against Rheumatism, and American College of Rheumatology. Based on the data in these publications, recommendations were drafted then validated by a group of experts. The strength of each recommendation was determined, as well as the extent of agreement among the experts.

RESULTS

The four focal points were the best strategy for using nonsteroidal anti-inflammatory drugs, role for systemic glucocorticoid therapy, role for glucocorticoid injections into the sacroiliac joints and entheses, and role for slow-acting drugs (e.g., methotrexate, sulfasalazine, leflunomide, thalidomide, and pamidronate). Of the 661 promising publications identified by the literature search, 173 were found to be relevant. The evidence in these 173 papers was reported to experts during interactive workshops. At the end of the workshops, the experts drafted recommendations, which were then validated by having all panel participants vote during a final meeting. There were seven recommendations, whose strength ranged from A to D.

CONCLUSION

Seven recommendations about pharmacotherapy in patients with AS were developed. They can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of patients with AS in France.

Developments and current pharmacotherapeutic recommendations for ankylosing spondylitis

The introduction of anti-TNFalpha therapy into the field of rheumatology has led to dramatic improvements in patient care, perhaps the most remarkable being in the management of ankylosing spondylitis. As experience with these compounds grows, their place in therapeutic strategy is becoming clearer, and it has been possible to develop evidence- and expertise-based recommendations for the management of ankylosing spondylitis to aid the clinician in patient care. This review outlines treatment advances in ankylosing spondylitis, including the use of anti-TNFalpha agents, and how these have been incorporated into clinical recommendations for daily use.

Nonsteroidal antiinflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial

OBJECTIVE

A 2-year randomized controlled trial was performed to test the hypothesis that long-term, continuous treatment with nonsteroidal antiinflammatory drugs (NSAIDs), in comparison with NSAID treatment on demand only, influences radiographic progression in patients with ankylosing spondylitis (AS).

METHODS

Patients with AS (n = 215), who had previously participated in a 6-week, randomized, double-blind clinical trial that compared celecoxib, ketoprofen, and placebo, were randomly allocated to receive either continuous treatment with NSAIDs or on-demand treatment with NSAIDs for a period of 2 years. All patients began treatment with celecoxib, at a starting dosage of 100 mg twice daily; patients could increase this dosage to 200 mg twice daily or could switch to another NSAID while maintaining the same treatment strategy. Structural changes were assessed by radiographs of the lumbar and cervical spine and scored according to the modified Stoke Ankylosing Spondylitis Spine Score by one observer who was blinded to the treatment strategy and temporal order of the radiographs. Statistical analyses included a between-group comparison of 1) radiographic progression scores (by Mann-Whitney U test), 2) time-averaged values of variables reflecting signs and symptoms of AS (by linear regression analysis), and 3) the frequency of reported site-specific adverse events (by chi-square test or Fisher's exact test, as appropriate).

RESULTS

Complete sets of radiographs were available for 76 of the 111 patients in the continuous-treatment group and for 74 of the 104 patients in the on-demand group. The mean +/- SD scores for radiographic progression were 0.4 +/- 1.7 in the continuous-treatment group and 1.5 +/- 2.5 in the on-demand treatment group (P = 0.002). Parameters reflecting signs and symptoms were not statistically significantly different between groups. The between-group difference in radiographic progression did not disappear after adjusting for baseline values of radiographic damage or disease activity variables and for time-averaged values of disease activity variables, nor after input of missing data. Relevant adverse events tended to occur more frequently in the continuous-treatment group than in the on-demand group (for hypertension, 9% versus 3%; for abdominal pain, 11% versus 6%; for dyspepsia, 41% versus 38%), but the differences were not statistically significant.

CONCLUSION

A strategy of continuous use of NSAIDs reduces radiographic progression in symptomatic patients with AS, without increasing toxicity substantially.

Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis

OBJECTIVE

To assess available management strategies in ankylosing spondylitis (AS) using a systematic approach, as a part of the development of evidence based recommendations for the management of AS.

METHODS

A systematic search of Medline, Embase, CINAHL, PEDro, and the Cochrane Library was performed to identify relevant interventions for the management of AS. Evidence for each intervention was categorised by study type, and outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated for each intervention where possible. Results from randomised controlled trials were pooled where appropriate.

RESULTS

Both pharmacological and non-pharmacological interventions considered to be of interest to clinicians involved in the management of AS were identified. Good evidence (level Ib) exists supporting the use of non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs for symptomatic treatment. Non-pharmacological treatments are also supported for maintaining function in AS. The use of conventional antirheumatoid arthritis drugs is not well supported by high level research evidence. Tumour necrosis factor inhibitors (infliximab and etanercept) have level Ib evidence supporting large treatment effects for spinal pain and function in AS over at least 6 months. Level IV evidence supports surgical interventions in specific patients.

CONCLUSION

This extensive literature review forms the evidence base considered in the development of the new ASAS/EULAR recommendations for the management of AS.

Conventional treatments for ankylosing spondylitis

Management of ankylosing spondylitis (AS) is challenged by the progressive nature of the disease. To date, no intervention is available that alters the underlying mechanism of inflammation in AS. Currently available conventional treatments are palliative at best, and often fail to control symptoms in the long term. Current drug treatment may perhaps induce a spurious state of "disease remission," which is merely a low level of disease activity. Non-steroidal anti-inflammatory drugs are first line treatment, but over time, the disease often becomes refractory to these agents. Disease modifying antirheumatic drugs are second line treatment and may offer some clinical benefit. However, conclusive evidence of the efficacy of these drugs from large placebo controlled trials is lacking. Additionally, these drugs can cause treatment-limiting adverse effects. Intra-articular corticosteroid injection guided by arthrography, computed tomography, or magnetic resonance imaging is an effective means of reducing inflammatory back pain, but controlled studies are lacking. A controlled study has confirmed moderate but significant efficacy of intravenous bisphosphonate (pamidronate) treatment in patients with AS; further evaluation of bisphosphonate treatment is warranted. Physical therapy and exercise are necessary adjuncts to pharmacotherapy; however, the paucity of controlled data makes it difficult to identify the best way to administer these interventions. Surgical intervention may be required to support severe structural damage. Thus, for patients with AS, the future of successful treatment lies in the development of pharmacological agents capable of both altering the disease course through intervention at sites of disease pathogenesis, and controlling symptoms.

Spondylarthropathy treatment: progress in medical treatment, physical therapy and rehabilitation

The monitoring and treatment of the diseases belonging to the concept of spondylarthropathy are related more to their clinical presentation, for example axial versus peripheral involvement, than to the precise diagnosis, for example, ankylosing spondylitis versus psorìatic arthritis. For each clinical presentation the treatment comprises local and systemic routes of administration but also drug and non-drug therapies.

Current guidelines for the drug treatment of ankylosing spondylitis

Ankylosing spondylitis (AS) is a systemic inflammatory rheumatic disease involving spinal and sacroiliac joints. This condition is responsible for back pain, stiffness and discomfort. Several drugs are currently available in the management of AS, and may be divided into 3 groups. The first includes nonsteroidal anti-inflammatory drugs (NSAIDs), which are the main drug group used in AS because they reduce pain and stiffness in most patients. Several NSAIDs are available but phenylbutazone is considered the NSAID of choice in AS. However, other NSAIDs give similar beneficial results and the medication of preference in specific to each patient. All NSAIDs share common gastrointestinal toxicity, and they should be administered during periods of flare-up of the disease. The second drug group that has been used in the treatment of patients with AS comprises analgesics, muscle relaxants and low dose corticosteroids. They can be considered as adjuvant therapy. These drugs are helpful when NSAIDs are poorly tolerated or ineffective. Second-line treatments or disease modifying antirheumatic drugs (DMARDs) are included in the third group. These drugs are required in cases of longstanding severe or refractory AS. Sulfasalazine has proven to be effective in such cases, leading to improvement in clinical and laboratory indices of disease activity. Beneficial results are mainly evident in patients with AS who have peripheral disease involvement. Other medications (such as methotrexate or gold salts, for instance) require properly designed controlled studies to evaluate their effectiveness in the treatment of this disorder, while immunosuppressive agents have little to offer in the management of patients with AS and require further studies. Some specific clinical features are observed in AS: enthesopathy may be treated with local injection of corticosteroids; sacroiliac joint pain may be managed by corticosteroid injection performed under fluoroscopic control or guided by computed tomography. The management of patients with AS includes some other procedures such as patient education, rest, a programme of physical exercise and physiotherapy. In parallel with pharmacotherapy, these procedures are of great importance in reducing stiffness and spinal ankylosis, and thus improve the patient's quality of life.

Clinical pharmacokinetics of flurbiprofen and its enantiomers

Flurbiprofen is a chiral nonsteroidal anti-inflammatory drug (NSAID) of the 2-arylpropionic acid class. Although it possesses a chiral centre, with the S-(+)-enantiomer possessing most of the beneficial anti-inflammatory activity, both enantiomers may possess analgesic activity and all flurbiprofen preparations to date are marketed as the racemate. Flurbiprofen exhibits stereoselectivity in its pharmacokinetics. Stereoselectivity is exhibited at the level of protein binding and metabolite formation. Hence, the data generated using nonstereoselective assays may not be used to explain the pharmacokinetics of individual enantiomers. The absorption of flurbiprofen is rapid and almost complete when given orally. The area under the plasma concentration-time curve of flurbiprofen is proportional to the dose administered to patients. Sustained release dosage forms are available, which may be beneficial due to the short terminal phase elimination half-life of conventional immediate release flurbiprofen (3 to 6 hours). They may also decrease local gastrointestinal adverse effects. Although with these preparations the peak plasma drug concentration is reduced and time taken to achieve peak concentrations is prolonged, the bioavailability is the same as that with regular release counterparts. Flurbiprofen binds extensively to plasma albumin, apparently in a stereoselective manner. Substantial concentrations of the drug are attained in synovial fluid, which is the proposed site of action of NSAIDs. There is negligible R to S inversion after oral administration. Flurbiprofen is eliminated following extensive biotransformation to glucuro-conjugated metabolites. Conjugates are excreted in urine, and approximately 20% of flurbiprofen is eliminated unchanged. The excretion of conjugates may be tied to renal function as accumulation of conjugates occurs in end-stage renal disease, but not in young individuals or elderly patients. Although flurbiprofen is excreted into breast milk, the amount of drug transferred comprises only a small fraction of the maternal exposure. Significant drug interactions have been demonstrated for aspirin (acetylsalicylic acid), coumarins and propranolol. The relationship between concentration and anti-inflammatory and analgesic effect has yet to be elucidated for this drug.

Ankylosing spondylitis. Current drug treatment

The administration of drugs constitutes an important component of the therapeutic programme in ankylosing spondylitis (AS). The main objective of initiating such therapy is to reduce pain, stiffness and discomfort. There are at present 3 groups of drugs available for the management of AS. The first group is represented by drugs thought to influence the disease process itself. In this group, sulfasalazine is the only drug which is controlled trials has been shown to suppress disease activity in AS. We recommend the use of sulfasalazine in patients with high disease activity, with peripheral arthritis and in those with AS of short duration. The second group of drugs includes nonsteroidal anti-inflammatory drugs (NSAIDs), which suppress inflammation without influencing the disease process. These drugs should be administered selectively during periods of high disease activity. Moreover, 1 drug should be used in appropriate dosage before it is assumed to be inefficient. High doses of NSAIDs may be prescribed before bedtime in patients suffering from severe pain and stiffness during the night. The toxicity profile of NSAIDs includes gastrointestinal and renal side effects. The third group comprises analgesics and muscle relaxants. Such drugs should be used rather frequently in patients with longstanding AS refractory to treatment with NSAIDs. Peripheral arthritis and enthesopathy are generally managed by local injections of corticosteroids, while AS complicated by psoriasis or inflammatory bowel disease is treated as primary AS. AS occurring in juveniles is best treated with aspirin and an NSAID, although careful observation is necessary for the development of Reye's syndrome (with aspirin) and gastric irritation (with NSAIDs). When patients with AS undergo surgery, the possibility of silent gastrointestinal bleeding due to the use of NSAIDs and salicylates should not be ignored. Patients treated with oral corticosteroids should receive a bolus injection of soluble corticosteroid prior to surgical intervention. NSAIDs may be administered pre- and postoperatively to relieve stiffness induced by immobility. Rapid treatment of intervening infections and use of NSAIDs is recommended in AS complicated by renal amyloidosis. During pregnancy and lactation, ibuprofen may be the preferred drug in AS.

A comparison of diflunisal and phenylbutazone in the treatment of ankylosing spondylitis

A 12-week double-blind randomized drug trial followed by an open extension period of 36 weeks was carried out in 38 male patients with ankylosing spondylitis (AS) to compare the efficacy and safety of diflunisal (500 mg twice daily) and phenylbutazone (200 mg twice daily). Both drugs proved to be effective in improving the severity of symptoms associated with AS, and this improvement was maintained throughout the open extension period. Initially diflunisal had a more pronounced and rapid analgesic action, whereas phenylbutazone was more effective in increasing axial mobility. During the study 9 patients dropped out: 3 in each treatment group due to side effects and 1 in each group due to lack of efficacy; another patient was lost to follow-up. The two drugs were similarly safe as judged by the occurrence of adverse clinical effects, mainly gastrointestinal. This study again demonstrates the value of phenylbutazone in AS but, taking into account the possible haematological side effects, the use of other NSAIDs is stressed. Diflunisal is an alternative capable of improving the painful stiffness associated with AS.

Flurbiprofen in the treatment of ankylosing spondylitis. A comparison with indomethacin

In this randomized, double-blind study, 57 patients with ankylosing spondylitis were evaluated after 26 weeks of treatment with either flurbiprofen (Ansaid, Upjohn) or indomethacin. Flurbiprofen administered four times a day in a total daily dose of 200 mg was effective in controlling the pain and associated symptoms of ankylosing spondylitis. Pain was adequately controlled in some patients following a total daily dose of 100 mg of flurbiprofen administered twice a day. Flurbiprofen was as effective as indomethacin in most key efficacy measurements analyzed. The drug was well tolerated in doses of up to 300 mg per day, and no clinically significant laboratory abnormalities were detected. Flurbiprofen is an excellent treatment for the control of pain and inflammation in patients with ankylosing spondylitis.

Treatment of acute shoulder syndrome with flurbiprofen

A multi-dose, double-blind, randomized, placebo-controlled, multicenter study was conducted to evaluate 68 patients with acute bursitis or tendinitis following treatment with flurbiprofen (Ansaid, Upjohn) or placebo. Flurbiprofen was administered in a total daily dosage of 200 to 300 mg four times daily. Based on efficacy rating scales, flurbiprofen-treated patients had the greatest proportion of improvement at almost all time periods. They also showed statistically significant improvement compared with placebo-treated patients, according to investigators' overall assessments at all time periods. Most patients showed improvement within three to four days of treatment. Flurbiprofen was both well tolerated and effective for the relief of pain caused by bursitis or tendinitis of the shoulder.

European experience with flurbiprofen. A new analgesic/anti-inflammatory agent

Numerous European clinical trials begun more than 12 years ago have clearly demonstrated flurbiprofen's safety and efficacy as an analgesic, anti-inflammatory, and antipyretic agent. In preclinical studies, flurbiprofen was at least as potent as indomethacin, and approximately 200 times more potent than aspirin. For patients with rheumatoid arthritis, a review of several trials found flurbiprofen often superior to aspirin and naproxen, and equivalent to indomethacin and ibuprofen in efficacy. Acetaminophen appeared no more effective than placebo for patients with rheumatoid arthritis. For patients with ankylosing spondylitis, flurbiprofen was also shown to be equivalent or superior to indomethacin and phenylbutazone. For patients with osteoarthritis of the peripheral joints, spine, hip, and knee, flurbiprofen was again found equal to ibuprofen, diclofenac, indomethacin, and naproxen. Side effects with flurbiprofen were few and predominantly related to the gastrointestinal tract.

Flurbiprofen in the treatment of ankylosing spondylitis. A comparison with phenylbutazone

Flurbiprofen (Ansaid, Upjohn), a potent new analgesic and anti-inflammatory agent, was compared with phenylbutazone in 90 patients with ankylosing spondylitis. In this double-blind, randomized, 26-week study, a total daily dose of 200 mg of flurbiprofen, administered three times daily, was as effective as 300 mg of phenylbutazone in controlling the pain and other symptoms of ankylosing spondylitis. In some patients, symptoms were adequately controlled by 150 mg of flurbiprofen per day, administered twice daily. There were no statistically significant differences between flurbiprofen and phenylbutazone in the investigators' and patients' assessments of improvement at all key follow-up periods. In addition, there were no consistently significant differences between drugs in the efficacy pain scales and quantitative measurements studied. Flurbiprofen was well tolerated in doses of up to 300 mg per day, and no clinically significant laboratory abnormalities were detected. Flurbiprofen appears to be an excellent alternative to phenylbutazone in the management of patients with ankylosing spondylitis.

Flurbiprofen: a review of its pharmacological properties and therapeutic use in rheumatic diseases

Flurbiprofen, a phenylalkanoic acid derivative, is a non-steroidal anti-inflammatory, antipyretic, analgesic agent advocated for use in rheumatoid arthritis, degenerative joint disease, ankylosing spondylitis and allied conditions. Published data suggest that flurbiprofen 120 to 150 mg daily is comparable in effectiveness with therapeutic doses of aspirin (3 to 4 g) in rheumatoid arthritis, but generally causes fewer side effects. Flurbiprofen 150 to 300 mg appears to be comparable with 75 to 150 mg of indomethacin in rheumatoid arthritis and degenerative joint disease, and comparable with phenylbutazone or indomethacin in ankylosing spondylitis. In comparison with other non-steroidal agents, flurbiprofen appears to be at least as effective as naproxen, ibuprofen or sulindac, but generally causes more side effects than these drugs. However, as no one of the non-steroidal anti-inflammatory agents is the most suitable drug for all patients requiring such therapy, flurbiprofen should be considered along with other drugs of its type in the arthritic patient.

Treatment of ankylosing spondylitis with flurbiprofen or phenylbutazone

Flurbiprofen (150-200 mg daily) and phenylbutazone (300-400 mg daily) were compared in the management of 27 patients with active ankylosing spondylitis. This was a parallel, double-blind, and randomized trial of 6 weeks duration. Both drugs were equally effective in the relief of pain and tenderness of the affected joints. Overall subjective improvement, assessed by the patient and the investigator at the end of the trial, favored phenylbutazone, but it did not reach a statistically significant level. The mean values of the endpoint parameters of spinal motion showed statistically significant improvement in both groups, except in the Schober test in the flurbiprofen group and chest expansion in the phenylbutazone group. Untoward effects characteristic of these drugs were found in a few patients.

Steroid-sparing action of flurbiprofen: use of an additional parameter of joint scans with 99m technetium

A double-blind placebo controlled trial was carried out in 14 steroid-dependent patients with rheumatoid arthritis to assess the effectiveness and steroid-sparing action of flurbiprofen over a 4-week period. During the first week, the patients' steroid dosage was stabilized at the minimum necessary to control symptoms. They were then treated with either 100 mg flurbiprofen or placebo 3-times daily for 3 weeks. Steroid dosage was initially reduced to 50% of the stabilized dose and reduced further if practicable, depending on therapeutic response. Clinical assessments were made, at weekly intervals, of pain, swelling, tenderness, erythema, range of movement, grip strength, walking time, and duration of morning stiffness. Joint scanning of 99mTc uptake was also measured before and after treatment in 11 patients. The results showed that whereas 3 out of 6 patients on placebo has distinct inflammatory flare-up, this did not occur in any of the 8 patients on flurbiprofen. Moreover, 3 of the flurbiprofen group showed improvement and a further reduction in steriod dosage was possible in 3 patients. Improvements in joint scans correlated well with the clinical findings in 6 of 11 patients.

Treatment of rheumatoid arthritis with flurbiprofen or ibuprofen

Flurbiprofen and ibuprofen were compared in a six-week double-blind randomized study in 208 patients with rheumatoid arthritis. Daily dosages were 120 mg flurbiprofen and 2400 mg ibuprofen for six weeks. Both drugs were effective in providing partial control of RA symptoms. Either or both drugs produced statistically significant improvement in mean values of time of onset of fatigue, grip strength and tender and swollen joint counts. All other standard endpoints of efficacy (except ESR) were improved but not at a statistically significant level. Slightly more than half of the patients improved during the trial. There was no statistically significant difference in the efficacy of the drugs. The incidence of side effects was low with both drugs. Most side effects were related to gastrointestinal tract irritation.

Treatment of ankylosing spondylitis with flurbiprofen and indomethacin

In a parallel, double-blind and randomized trial of 6-weeks' duration, flurbiprofen (150 mg to 200 mg daily) was compared with indomethacin (75 mg to 100 mg daily) in the management of 26 patients with active ankylosing spondylitis. None of the patients in either group withdrew from the study because of lack of efficacy of the drugs. Both drugs were equally effective in the relief of pain and tenderness of the affected joints. Overall subjective improvement, assessed by the patient and the investigator at the end of the trial, was present in 90% of the patients in the flurbiprofen group and in 75% of those in the indomethacin group. The mean values of all the spinal motion tests improved in the flurbiprofen group but not in the indomethacin group. Statistically significant improvement in the Schober test was achieved in the flurbiprofen group and in chest expansion in the indomethacin group. Characteristic untoward effects related to the central nervous system and gastro-intestinal tract were present in a few patients in both groups.

Response of osteoarthritis to ibuprofen or flurbiprofen

Flurbiprofen and ibuprofen, two propionic acid derivatives with anti-inflammatory and analgesic activity, were compared in a double-blind multiclinic study in 195 patients with osteoarthritis of the peripheral joints. The patients were given 80 mg/day flurbiprofen or 1600 mg/day ibuprofen for six weeks. Pain, subjective evaluation and functional tests improved significantly in both groups. There were no statistically significant differences between the two treatments in any of the responses. Gastro-intestinal side-effects, generally mild, developed in 5-6% of the patients.

Prostaglandins, nonsteroidal anti-inflammatory agents and eye disease

The prostaglandins produce elevation of intraocular pressure and breakdown of the blood-aqueous barrier. They act via the secondary messenger system, cyclic AMP. Although the pathogenesis of many forms of ocular inflammation, both external and internal, is unclear, it is evident that some forms of ocular inflammation are prostaglandin-mediated, at least in part. Others may be totally mediated by prostaglandin synthesis. At present the corticosteroids are the mainstay of therapy of these conditions. However, the corticosteroids are poor inhibitors of prostaglandin synthesis and have many deleterious side effects such as induction of ocular hypertension, cataract, and infection. The search for new agents that will obviate these side effects and be more specific for the disease process is crucial. The discovery that the mode of action of many nonsteroidal anti-inflammatory agents is via inhibition of prostaglandin synthesis places a premium on elucidating which of these agents is most effective and least toxic in the eye and by which route of administration. The arachidonic acid screening model is ideal for initially choosing which agent has the greatest potential clinically. Arachidonic acid, a PGE2 precursor, when given topically also elevates intraocular pressure and aqueous humor protein, and these effects are blocked by the nonsteroidal anti-inflammatory drugs. This occurs if the arachidonic acid is injected into the vitreous humor, too, providing evidence that this in vivo model involves intraocular mechanisms. Utilizing the arachidonic acid system, a comparative study of nonsteroidal inhibitors of prostaglandin synthesis shows that the most effective of 14 agents were flurbiprofen solution and suspensions of polysorbate-dispersed indoxole, meclofenamic acid, indomethacin, and clonixin. Animal uveitis is not an ideal model for the human condition. Nevertheless, proving the superior efficacy of a screened drug in this system will identify those drugs to be tested in the human disease states. Only after the very few best drugs of this nature are identified should the ultimate steps of human testing be initiated.