Response of osteoarthritis to ibuprofen or flurbiprofen

Nonsteroidal anti-inflammatory drugs and hepatic toxicity: a systematic review of randomized controlled trials in arthritis patients

BACKGROUND & AIMS

Nonsteroidal anti-inflammatory drugs (NSAIDs) might cause hepatic side effects, but the frequency of these laboratory and clinical side effects is uncertain.

METHODS

Searches of bibliographic databases MEDLINE and EMBASE and of public archives of the Food and Drug Administration were conducted to identify randomized controlled trials of diclofenac, naproxen, ibuprofen, celecoxib, rofecoxib, valdecoxib, or meloxicam in adults with osteoarthritis or rheumatoid arthritis that provided information on aminotransferase elevations >3 x upper limit of normal, liver-related discontinuations, hepatic serious adverse events, liver-related hospitalizations, or liver-related deaths. The proportion of patients with each of the hepatic toxicity outcomes was calculated separately by using sample size weighted pooling for each NSAID.

RESULTS

Sixty-seven articles from the bibliographic database and 65 studies from the Food and Drug Administration archives met inclusion criteria. Diclofenac (3.55%; 95% confidence interval [CI], 3.12%-4.03%) and rofecoxib (1.80%; 95% CI, 1.52%-2.13%) had higher rates of aminotransferase >3 x upper limit of normal than placebo (0.29; 95% CI, 0.17-0.51) and the other NSAIDs (all < or = 0.43%). The 95% CIs for liver-related discontinuations of all NSAIDs except diclofenac (2.17%; 95% CI, 1.78%-2.64%) overlapped with placebo. Only 1 liver-related hospitalization (among 37,671 patients) and 1 liver-related death (among 51,942 patients) occurred, with naproxen.

CONCLUSIONS

Diclofenac and rofecoxib had higher rates of aminotransferase elevations than placebo and other NSAIDs studied. No NSAID studied had increased rates of liver-related serious adverse events, hospitalizations, or deaths.

Analgesic efficacy of flurbiprofen as compared to acetaminophen and placebo after periodontal surgery

The purpose of the present investigation was to compare the analgesic efficacy of flurbiprofen, a nonsteroidal anti-inflammatory drug, which is a phenyl propionic acid derivative, with acetaminophen and placebo in 63 adult outpatients with moderate to severe dental pain following periodontal surgery. After surgery was completed under local anesthesia, the patients received under double-blind conditions an envelope containing four tablets of either flurbiprofen 100 mg, acetaminophen 500 mg, or placebo and they were instructed to take one tablet every 6 hours when postoperative pain reached moderate to severe intensity. To determine analgesic efficacy and patients recorded pain intensity on a scale of 0 to 3. Patients were allowed to remedicate after 1 hour if pain was not reduced. Flurbiprofen was shown to possess an adequate analgesic effect superior to either placebo (P less than 0.005) or acetaminophen (P less than 0.01) in the parameters studied. Our results seem to further support earlier data obtained with the drug in dental patients with postoperative pain after the surgical removal of impacted third molars; therefore, it is concluded that flurbiprofen used as directed is a new alternative for the proper treatment of pain following periodontal surgery.

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, aspirin, codeine, and placebo for postpartum uterine pain

Flurbiprofen (Ansaid, Upjohn), a substituted phenyl propionic acid, is a new analgesic/anti-inflammatory agent. To evaluate its relative efficacy in noninflammatory pain, 159 hospitalized women with moderate or severe postpartum uterine cramps were given single oral doses of 50 mg of flurbiprofen, 650 mg of aspirin, 60 or 120 mg of codeine sulfate, or placebo in a parallel, stratified, randomized block, placebo-controlled, double-blind trial. Patients rated pain intensity, pain relief, and side effects in uniform interviews for six hours after treatment. All measures of peak and summed analgesia exhibited significant differences among the five treatments. Flurbiprofen and aspirin showed the greatest analgesic response and were significantly superior to placebo. Results of codeine treatment were equivocal with no evidence of a positive dose response. Side effects were unremarkable except for dizziness and drowsiness after the 120-mg codeine dose. These findings suggest that flurbiprofen as an analgesic for patients with postpartum uterine pain is equivalent to aspirin and superior to codeine.

A review of selected investigational nonsteroidal antiinflammatory drugs of the 1980s

We reviewed the literature on 7 investigational nonsteroidal antiinflammatory drugs (NSAIDs): fenbufen, flurbiprofen, tiaprofenic acid, diclofenac, fenclofenac, etodolac and proquazone. These drugs all appear to be at least as effective as currently marketed NSAIDs. Toxicity reported with these newer agents is similar to that seen with other drugs in this class, with gastrointestinal complaints being most commonly reported. The frequency of gastritis and the extent of gastrointestinal microbleeding are less than what occur with aspirin therapy. Fenclofenac may affect thyroid function tests, an effect not noted with other NSAIDs. Proquazone and fenclofenac may have some effect on immunologic function similar to those of slow-acting antirheumatic drugs. These drugs decrease immunoglobulins, rheumatoid factor and C-reactive protein. The place for these drugs in the management of rheumatic diseases has yet to be defined. They may prove to be more beneficial than currently marketed drugs for some patients.

Review of ibuprofen for osteoarthritis

Pain is the predominant reason for seeking treatment in patients with osteoarthritis. Management is multifactorial, involving psychological, physical, pharmaceutical, and sometimes surgical measures. Nonsteroidal anti-inflammatory agents play a valuable role in the overall treatment program. A review of 28 clinical trials involving ibuprofen for osteoarthritis shows sometimes conflicting results in efficacy, often because of inadequacies in study design or dosage. In fact, 17 of these 28 studies employed doses of less than 1,600 mg/day. Nonetheless, several trends are clear. Ibuprofen at a dose of over 1,200 mg daily was superior to placebo and at doses of 1,200 to 1,800 mg/day was as effective or more effective than 3,200 to 3,600 mg/day of aspirin or 4,500 mg/day of aspirin plus acetaminophen. In trials with a wide variety of other nonsteroidal anti-inflammatory drugs, ibuprofen was often as effective as the comparison agent. Tolerability was consistently excellent with ibuprofen, and adverse reactions were few.

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.

Diflunisal: six-month experience in osteoarthritis

1 The analgesic efficacy and tolerance of diflunisal in patients with osteoarthritis has been compared with ibuprofen and acetylsalicylic acid (ASA) in two clinical studies carried out double-blind for 12 weeks and then continued single-blind for a further 12 weeks. The studies involved 115 patients and 695 patients, respectively.

2 Diflunisal was superior to ibuprofen in overall response, as assessed by both patients and investigators (P < 0.01), improvement in disease activity and by improvement in internal rotation of the hip (P < 0.05).

3 Diflunisal was superior to ASA in overall response, as assessed by both patients and investigators, therapeutic index (P < 0.01), reduction in morning stiffness, and by improvement in performance of daily activities (P < 0.05).

4 In the first study, the mean daily dose of diflunisal during the double-blind period was 702 mg and of ibuprofen 1 161 mg. In the second study, the mean daily dose of diflunisal was 612 mg and of ASA 2 461 mg.

5 Diflunisal produced fewer gastrointestinal side-effects after 24 weeks of therapy than did ibuprofen (P < 0.01).

6 Diflunisal produced fewer general side-effects and fewer gastrointestinal side-effects during the double-blind and the single-blind phases of the study (P < 0.01). Fewer patients discontinued therapy because of side-effects in the diflunisal group than in the ASA group (P < 0.05).

7 Both ASA and diflunisal decreased serum uric acid, with diflunisal being more uricosuric than aspirin (P < 0.01).

A double-blind comparative study of 150 mg flurbiprofen daily and 75 mg indomethacin daily in the treatment of osteoarthrosis of the hip joint

Thirty patients with osteoarthrosis of the hip were studied in a double-blind crossover comparison of 150 mg flurbiprofen daily and 75 mg indomethacin daily, each drug being given for 2 weeks separated by a wash-out period of 1 week on placebo. Statistical analysis of the results from 26 patients with complete records showed that both drugs produced statistically significant improvements over baseline after 1 and 2 weeks in assessments of severity of pain, night pain, duration of morning stiffness, and intermalleolar straddle. No statistical differences, however, were found between the two drugs. There were no reports of side-effects with flurbiprofen, but 6 reports from 3 patients whilst receiving indomethacin.

Diflunisal: efficacy in postoperative pain

1. Seven hundred and forty patients complaining of pain after oral or orthopaedic surgery or episiotomy were studied in five single dose or short-term double-blind, controlled, randomized studies comparing efficacy and safety of diflunisal with that of acetylsalicylic acid, glafenin or placebo. 2. Diflunisal was found to be effective in relieving postoperative pain in 75-85% of patients. A twice day dosage schedule seems to be clinically adequate, 375 mg twice daily proving to be equally effective as glafenin 200 mg three times daily. No serious drug-related clinical or laboratory adverse experiences were encountered in any of the five studies.

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.