Recent Advances in NSAIDs-Induced Enteropathy Therapeutics: New Options, New Challenges

Antioxidant Effects of Resveratrol in Intervertebral Disk

Intervertebral disk (IVD) degeneration (IVDD) can cause various spinal degenerative diseases. Cumulative evidence has indicated that IVDD can result from inflammation, apoptosis, autophagy, biomechanical changes and other factors. Currently, lack of conservative treatment for degenerative spinal diseases leads to an urgent demand for clinically applicable medication to ameliorate the progression of IVDD. Resveratrol (3,5,4'-trihydroxy-trans-stilbene), a polyphenol compound extracted from red wine or grapes, has shown protective effects on IVD, alleviating the progression of IVDD. Resveratrol has been demonstrated as a scavenger of free radicals both in vivo and in vitro. The antioxidant effects of resveratrol are likely attributed to its regulation on mitochondrial dysfunction or the elimination of reactive oxygen species. This review will summarize the mechanisms of the reactive oxygen species production and elaborate the mechanisms of resveratrol in retarding IVDD progression, providing a comprehensive understanding of the antioxidant effects of resveratrol in IVD.

Gene expression analysis in NSAID-induced rat small intestinal disease model with the intervention of berberine by the liquid chip technology

Objective

Investigate the effect and mechanism of berberine on the small intestinal mucosa of non-steroidal anti-inflammatory drugs (NSAIDs) related small intestinal injury.

Materials and methods

Twenty-four SD rats were randomly divided into control group, model group and intervention group. The model group and intervention group were treated with diclofenac (7.5 mg/kg·d, 2/d), a total of 4 days tube feeding, and the intervention group was treated with 50 mg/kg·d intragastric administration of berberine after 2 days. The control group was treated with 7.5 mg/kg·d, 2/d 0.9% saline tube feeding. Then we screened differential expression of colonic mucosal gene by the liquid chip technology.

Results

Compared with the control group, macroscopic and histology score of the model group increased significantly (P < 0.05), HTR4, HTR1a, F2RL3, CALCA, NPY, CRHR2, IL1b, P2RX3, TPH1, HMOX1, TRPV1, VIP, F2RL1, SLC6A4, TFF2, AQP8 content were significantly increased (P < 0.05), NOS1 content decreased significantly (P < 0.05); Compared with the model group, macroscopic and histology score of the intervention group improved significantly (P < 0.05), and HTR4, F2RL3, NPY, CRHR2, IL1b, VIP, AQP8 content were significantly lower (P < 0.05), NOS1 content increased significantly (P < 0.05).

Conclusion

Berberine has a protective effect on NSAID-associated small intestinal injury, the mechanism may be that berberine decreases the expression of intestinal mucosa HTR4, F2RL3, NPY, CRHR2, IL1b, VIP, AQP8, and increases the expression of NOS1, that to reduce intestinal permeability and protect intestinal mucosal barrier.

Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain

Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39–45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient’s recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.

[Gastrointestinal Bleeding in Patients with Coronary Heart Disease: Preventive Options]

Extensive use of antithrombotic drugs (ATD) in patients with ischemic heart disease (IHD), on the one hand, provides a considerable decrease in the risk for development of life-threatening cardiovascular complications but on the other hand, is associated with a risk of gastrointestinal bleedings (GIB), which may develop in 0.5-1.0 % of patients. In such cases, the major measures for prevention of GIB are strict adherence to indications for the ATD treatment, detection and analysis of risk factors for GIB and their elimination as far as feasible. For evaluation of GIB risk in patients with IHD, the PRECISE-DAPT and DAPT, HAS-BLED scales should be used. If the risk factors are non-modifiable the therapeutic tactics for further management of these patients should be strictly individual with determining the nature of damage, degree of a risk for present and possible complications, and the range of required therapeutic and diagnostic measures. The use of ATD requires monitoring of the patient's condition to timely detect and treat GI complications.

COMPARING OF FAECAL CALPROTECTIN LEVELS IN PATIENTS WITH OSTEOARTHRITIS TAKING NSAID TREATMENT AND PATIENTS WITHOUT NSAIDS THERAPY

Faecal calprotectin (FC) level can be increased in several conditions, which are characterised by neutrophilic inflammation. Some medications, particularly NSAIDs, can elevate its level as well. NSAIDs are taken by patients in many chronic conditions, including osteoarthritis (OA). On the other hand, there is growing evidence that osteoarthritis is not only a degenerative disease, but it has a significant inflammatory component. The role of systemic inflammation is well-known in inflammatory joint diseases, but there is some evidence that it can play an essential role in the OA as well. It can suggest that in the OA, the inflammatory changes could be found in the different organs and systems. The aim of this study was to investigate the FC level in patients with osteoarthritis depending on the NSAIDs intake and to compare it to the FC levels in healthy adults. Materials and methods. In this small observational study, we evaluated the FC levels in patients suffering from OA (36 persons), divided them into two groups depending on their NSAIDs intake, and compared it to FC levels in healthy participants (12 persons). We compared the FC levels depending on the selectivity of the NSAIDs taken by our participants, as well. Results. The median calprotectin level in our patients was 72.57 (IQR 20.55-221.57) mg/kg, 95 %CI 26,18-109.01. OA patients had higher levels than the healthy group (p<0.001). OA patients who took NSAIDs had the highest FC levels – 221.57 (IQR 91.56-448.61) – higher, than those who did not take it – 72.57 (IQR 35.26-164.79) (p=0.03) and than healthy participants, who has normal FC levels (p<0.001); the FC levels of patients who did not take NSAIDs also exceeds healthy subject’s levels (p<0.001). The FC levels in the collective group have a sufficient positive correlation with the duration of NSAIDs intake, VAS score and strong correlation with Lequesne index values. We found that both NSAIDs groups have a significantly greater prevalence of elevated or high FC levels than the control group (p<0.001) and that NSAIDs patients significantly more often have high FC levels than those who do not take NSAIDs (p=0.035). When comparing FC levels in patients depending on the type of NSAIDs they take, we found that those who take non-selective NSAIDs has significantly higher FC levels than those who do not take NSAIDs – 264.1 (IQR 89.72-464.67) to 25.65 (IQR 19.5-75.33) (p=0.0003). The FC levels of who take selective NSAIDs – 98.53 (91.56-105.5) – did not differ significantly to non-selective NSAIDs taker’s group values and non-selective NSAIDs taker’s values (p>0.05). Conclusions. Patients who suffer from OA have higher FC levels than healthy individuals, and patients with OA who take NSAIDs regularly have higher FC levels than those who do not. The intake of non-selective NSAIDs is associated with higher FC levels, than the intake of high-selective NSAIDs. FC levels of those who take high-selective NSAIDs do not differ statistically from those who do not intake NSAIDs. Further research is needed in this area.

NSAIDs disrupt intestinal homeostasis by suppressing macroautophagy in intestinal epithelial cells

Small intestinal damage induced by nonsteroidal anti-inflammatory drugs (NSAIDs) remains an under-recognized clinical disorder. The incomplete understanding of the pathophysiology has hampered the development of prevention and treatment strategies leading to the high morbidity and mortality rates. NSAIDs are known to modulate macroautophagy, a process indispensable for intestinal homeostasis. Whether NSAIDs stimulate or repress macroautophagy and how this correlates with the clinical manifestations of NSAID enteropathy, however, remains unknown. The objectives of this study were to determine whether NSAIDs impaired macroautophagy and how this affects macroautophagy-regulated intestinal epithelial cell (IEC) processes essential for intestinal homeostasis (i.e., clearance of invading pathogens, secretion and composition of mucus building blocks, and inflammatory response). We show that NSAID treatment of IECs inhibits macroautophagy in vitro and in vivo. This inhibition was likely attributed to a reduction in the area and/or distribution of lysosomes available for degradation of macroautophagy-targeted cargo. Importantly, IEC regulatory processes necessary for intestinal homeostasis and dependent on macroautophagy were dysfunctional in the presence of NSAIDs. Since macroautophagy is essential for gastrointestinal health, NSAID-induced inhibition of macroautophagy might contribute to the severity of intestinal injury by compromising the integrity of the mucosal barrier, preventing the clearance of invading microbes, and exacerbating the inflammatory response.

Detection of Crohn Disease in Patients with Spondyloarthropathy: The SpACE Capsule Study

OBJECTIVE

Inflammatory bowel disease (IBD) is generally reported to be associated with spondylarthropathies (SpA) in 5%-15% of cases. Systematic colonoscopic assessment by protocol demonstrated mucosal inflammation characteristic of Crohn disease (CD) in up to one-third of patients with SpA. Video capsule endoscopy (CE) is a superior diagnostic tool to detect small bowel mucosal disease. Our study compared the accuracy of CE to standard colonoscopy for detection of inflammatory bowel lesions in patients with SpA, and to describe predictors of small bowel inflammation (SBI) in this cohort.

METHODS

Prospective cross-sectional study of adult patients followed for SpA. Patients were evaluated by CE and standard colonoscopy with biopsies. SBI was quantified using the Lewis Score. Additional screening tests included fecal calprotectin (FCP), C-reactive protein (CRP), and a diagnostic panel of serologic, inflammatory and genetic tests (SGI).

RESULTS

There were 64 patients recruited (53% female, mean age 42 ± 13 yrs). Chronic gastrointestinal (GI) symptoms were present in 57%. CE revealed significant SBI in 27/64 (42.2%), compared to 7/64 (10.9%) by standard colonoscopy (p = 0.035). Elevated FCP was associated with small bowel CD (OR 4.5, 95% CI 1.01-19.9; p = 0.042). No correlation was observed with presence of GI symptoms, CRP, or SGI results. Finding CD led to a change in management in 65.2% of cases.

CONCLUSION

CE uncovered SBI consistent with CD in 42.2% of patients with SpA, with a significant incremental yield over colonoscopy of 31%. FCP levels were significantly correlated with CE results, while GI symptoms and SGI results were poor predictors of SBI.

Clinical importance of nonsteroidal anti-inflammatory drug enteropathy: the relevance of tumor necrosis factor as a promising target

The pathogenesis of nonsteroidal anti-inflammatory drug (NSAID) enteropathy is still unclear, and consequently, there is no approved therapeutic strategy for ameliorating such damage. On the other hand, molecular treatment strategies targeting tumor necrosis factor (TNF) exerts beneficial effects on NSAID-induced intestinal lesions in rodents and rheumatoid arthritis patients. Thus, TNF appears to be a potential therapeutic target for both the prevention and treatment of NSAID enteropathy. However, the causative relationship between TNF and NSAID enteropathy is largely unknown. Currently approved anti-TNF agents are highly expensive and exhibit numerous side effects. Hence, in this review, the pivotal role of TNF in NSAID enteropathy has been summarized and plant-derived polyphenols have been suggested as useful alternative anti-TNF agents because of their ability to suppress TNF activated inflammatory pathways both in vitro and in vivo.

Indomethacin injury to the rat small intestine is dependent upon biliary secretion and is associated with overgrowth of enterococci

NSAIDuse is limited due to the drugs' toxicity to the gastrointestinal mucosa, an action incompletely understood. Lower gut injury induced byNSAIDs is dependent on bile secretion and is reported to increase the growth of a number of bacterial species, including an enterococcal species,Enterococcus faecalis This study examined the relationships between indomethacin (INDO)-induced intestinal injury/bleeding, small bowel overgrowth (SBO) and dissemination of enterococci, and the contribution of bile secretion to these pathological responses. Rats received either a sham operation (SO) or bile duct ligation (BDL) prior to administration of two daily subcutaneous doses of saline orINDO, and 24 h later, biopsies of ileum and liver were collected for plating on selective bacterial media. Fecal hemoglobin (Hb) and blood hematocrit (Hct) were measured to assess intestinal bleeding. Of the four treatment groups, onlySO/INDOrats experienced a significant 10- to 30-fold increase in fecal Hb and reduction in Hct, indicating thatBDLattenuatedINDO-induced intestinal injury/bleeding. Ileal enterococcal colony-forming units were significantly increased (500- to 1000-fold) inSO/INDOrats. Of all groups, only theSO/INDOrats demonstrated gut injury, and this was associated with enterococcal overgrowth of the gut and dissemination to the liver. We also demonstrated thatINDO-induced intestinal injury andE. faecalisovergrowth was independent of the route of administration of the drug, as similar findings were observed in rats orally dosed with theNSAID Bile secretion plays an important role inINDO-induced gut injury and appears to support enterococcal overgrowth of the intestine.NSAID-induced enterococcalSBOmay be involved either as a compensatory response to gut injury or with the pathogenic process itself and the subsequent development of sepsis.

Current status and future perspectives of capsule endoscopy

Small bowel capsule endoscopy (CE) was first introduced 15 years ago, and a large amount of literature has since been produced, focused on its indication, diagnostic yields, and safety. Guidelines that have made CE the primary diagnostic tool for small bowel disease have been created. Since its initial use in the small bowel, CE has been used for the esophagus, stomach, and colon. The primary indications for small bowel CE are obscure gastrointestinal bleeding, unexplained iron deficiency anemia, suspected Crohn's disease, small bowel tumors, nonsteroidal anti-inflammatory drug enteropathy, portal hypertensive enteropathy, celiac disease, etc. Colon CE provides an alternative to conventional colonoscopy, with possible use in colorectal cancer screening. Guidelines for optimal bowel preparation of CE have been suggested. The main challenges in CE are the development of new devices with the ability to provide therapy, air inflation for better visualization of the small bowel, biopsy sampling systems attached to the capsule, and the possibility of guiding and moving the capsule by an external motion controller. We review the current status and future directions of CE, and address all aspects of clinical practice, including the role of CE and long-term clinical outcomes.

Geranylgeranylacetone protects against small-intestinal injuries induced by diclofenac in patients with rheumatic diseases: a prospective randomized study

BACKGROUND

We aimed to explore the effect of geranylgeranylacetone on small-intestinal mucosal injuries induced by diclofenac sodium in patients with rheumatic diseases.

METHODS

The patients were randomly divided into two groups in our prospective study. The patients in the geranylgeranylacetone group received diclofenac sodium plus geranylgeranylacetone, and those in the control group received only diclofenac sodium for 12 weeks. We examined small-intestinal mucosal injuries using capsule endoscopy before and after treatment.

RESULTS

There were no significant differences between geranylgeranylacetone (n = 21, male: 42.9%; age: 31.0 ± 9.0 year) and control (n = 19, male: 68.4%; age: 31.0 ± 11.0 year) groups in terms of the numbers of patients with petechiae/red spots, denuded areas and mucosal breaks at baseline capsule endoscopy. After treatment, the numbers of patients with denuded areas (χ(2) = 0.000, P = 1.000) and mucosal breaks (χ(2) = 1.750, P = 0.186) did not increase in the geranylgeranylacetone group. However, the numbers of patients with petechiae/red spots (χ(2) = 5.216, P = 0.022), denuded areas (χ(2) = 8.686, P = 0.003) and mucosal breaks (χ(2) = 7.795, P = 0.005) increased after treatment in the control groups. Geranylgeranylacetone improved both the Lewis score (Z = -2.459, P = 0.017) and degree (χ(2) = 5.414, P = 0.020) on capsule endoscopy 12 weeks later.

CONCLUSIONS

In patients with rheumatic diseases, geranylgeranylacetone is effective for protecting against small-intestinal mucosal injuries induced by diclofenac sodium.

Nonsteroidal anti-inflammatory drugs and inflammatory bowel disease: pathophysiology and clinical associations

Nonsteroidal anti-inflammatory drugs (NSAIDs) produce significant gastrointestinal (GI) adverse events. Laboratory and clinical studies suggest that NSAIDs have the potential to trigger the onset or relapse of inflammatory bowel disease. In this review, the currently available information on the mechanism of action of NSAID injury of the GI tract and the pathophysiology of GI effects of NSAIDs, including immune dysregulation will be assessed. A detailed description of NSAID effects on individual GI organs will be discussed. This is followed by a MEDLINE review of clinical literature on the relationship between NSAID ingestion and the development and worsening of inflammatory bowel disease.

New evidence on the impact of antithrombotics in patients submitted to small bowel capsule endoscopy for the evaluation of obscure gastrointestinal bleeding

Objectives. Small bowel capsule endoscopy (SBCE) plays a decisive role in the obscure gastrointestinal bleeding (OGIB) diagnosis. Antithrombotics may increase bleeding risk in patients with preexistent lesions or through direct mucosal aggression. We aimed to correlate antithrombotics usage with lesions with bleeding potential found in SBCE. Methods. Retrospective single-center study including 274 consecutive SBCE performed over 7 years for OGIB. The lesions were classified as P0 (no bleeding potential), P1 (uncertain bleeding potential: erosions), and P2 (high bleeding potential: angioectasias, ulcers, and tumors). We assessed antiplatelet and anticoagulant drug use during the 60 days preceding SBCE. Results. One-third of the patients were under antithrombotic therapy. The diagnostic yield of SBCE for P2 lesions was 30.0%. Angioectasias (20.4%) were the most frequently observed lesions. There was a significant correlation between anticoagulant drug use and a higher incidence of P2 lesions in the small bowel (43.2% versus 26.5%; OR = 2.11, P = 0.026). We found no significant correlation between antiplatelets and lesions with bleeding potential in SBCE. Conclusions. Small bowel lesions with high bleeding potential were more frequently detected when the patient was on anticoagulant drugs, resulting in a twofold risk. Antiplatelet drugs were not associated with small bowel lesions.

Drug-drug interaction between NSAIDS and low-dose aspirin: a focus on cardiovascular and GI toxicity

INTRODUCTION

The aging of the population in the US and other countries means that a large number of people will likely take NSAIDs for the relief of pain and low-dose aspirin (LD-ASA) for cardioprotection. However, the cardioprotective value of LD-ASA can be compromised in patients who take NSAIDs concomitantly, because some NSAIDs competitively bind to critical amino-acid residues on cyclooxygenase (COX) enzymes and interfere with the mechanism of antiplatelet activity of LD-ASA.

AREAS COVERED

A review of the literature was conducted to provide an overview of current issues surrounding the concomitant use of NSAIDs and LD-ASA, to explore potential mechanisms for this drug-drug interaction and to consider current and future treatment options that may mitigate the risk associated with their concomitant use.

EXPERT OPINION

NSAIDs offer effective pain relief for the most common forms of pain, such as low back pain, musculoskeletal pain associated with arthritis, postsurgical pain, headache, acute pain syndromes, menstrual pain and dental pain. The development of NSAID formulations that offer effective pain control with fewer or less serious adverse effects due to interference with ASA would be a valuable medical advance. Several promising treatment options and regimens may be available in the future.

Pharmacological evaluation and preparation of nonsteroidal anti-inflammatory drugs containing an N-acyl hydrazone subunit

A series of anti-inflammatory derivatives containing an N-acyl hydrazone subunit (4a-e) were synthesized and characterized. Docking studies were performed that suggest that compounds 4a-e bind to cyclooxygenase (COX)-1 and COX-2 isoforms, but with higher affinity for COX-2. The compounds display similar anti-inflammatory activities in vivo, although compound 4c is the most effective compound for inhibiting rat paw edema, with a reduction in the extent of inflammation of 35.9% and 52.8% at 2 and 4 h, respectively. The anti-inflammatory activity of N-acyl hydrazone derivatives was inferior to their respective parent drugs, except for compound 4c after 5 h. Ulcerogenic studies revealed that compounds 4a-e are less gastrotoxic than the respective parent drug. Compounds 4b-e demonstrated mucosal damage comparable to celecoxib. The in vivo analgesic activities of the compounds are higher than the respective parent drug for compounds 4a-b and 4d-e. Compound 4a was more active than dipyrone in reducing acetic-acid-induced abdominal constrictions. Our results indicate that compounds 4a-e are anti-inflammatory and analgesic compounds with reduced gastrotoxicity compared to their respective parent non-steroidal anti-inflammatory drugs.