Gastro-intestinal blood loss during administration of indoprofen, aspirin and ibuprofen

In silico analysis suggests repurposing of ibuprofen for prevention and treatment of EBOLA virus disease

The large 2014/2015 Ebola virus outbreak in West Africa points out the urgent need to develop new preventive and therapeutic approaches that are effective against Ebola viruses and  can be rapidly utilized. Recently, a simple theoretical criterion for the virtual screening of molecular libraries for candidate inhibitors of Ebola virus infection was proposed. Using this method the ‘drug space’ was screened and 267 approved and 382 experimental drugs as candidates for treatment of the Ebola virus disease (EVD) have been selected. Detailed analysis of these drugs revealed the non-steroidal anti-inflammatory drug ibuprofen as an inexpensive, widely accessible and minimally toxic candidate for prevention and treatment of EVD. Furthermore, the molecular mechanism underlying this possible protective effect of ibuprofen against EVD is suggested in this article.

Over-the-counter ibuprofen and risk of gastrointestinal bleeding complications: a systematic literature review

BACKGROUND

Exposure to over-the-counter (OTC) ibuprofen and other OTC non-steroidal anti-inflammatory drugs (NSAIDs) is substantial. Although the literature on gastrointestinal (GI) safety of NSAID therapy is extensive, the risk profiles of OTC and prescription dosing are seldom separated, and few studies provide risks specific to OTC ibuprofen.

OBJECTIVE

To conduct a literature review to evaluate the risk of GI bleeding events related to OTC ibuprofen use.

METHODS

Published clinical trials, observational studies, and meta-analyses of OTC ibuprofen use, defined as up to 1200 mg/day or stated as 'over the counter,' reporting endpoints of incidence rates and proportions of GI bleeding events (e.g., GI bleeding-related hospitalizations and deaths) were identified via MEDLINE through 2010. Data from these studies were summarized.

RESULTS

Twenty studies (nine observational, ten clinical trials, one meta-analysis) reporting incidence rates and proportions of a GI bleeding-related event associated with OTC or OTC-specific doses of ibuprofen were included. The frequency of a GI-related hospitalization was <0.2% for patients on OTC-comparable doses. Incidence rates among those using OTC-comparable doses ranged from 0 to 3.19 per 1000 patient-years. The incidence of a GI bleeding-related event increased with age and the use of concomitant medications, and there was a general, though not always statistically significant, ibuprofen dose-response relationship. The relative risk of any GI bleeding-related event ranged from 1.1 to 2.4 for users of OTC-specific doses of ibuprofen compared to non-users.

CONCLUSIONS

Studies reported low incidence of GI bleeding events with use of OTC ibuprofen. Few published studies that specifically investigated OTC ibuprofen use were identified. Varying methodologies and definitions of exposure and outcomes prevented direct comparison of many results. Only studies that used the methods herein described were identified. Further research evaluating the risk of GI bleeding events in patients taking OTC-specific ibuprofen use may be useful.

Indoprofen upregulates the survival motor neuron protein through a cyclooxygenase-independent mechanism

Most patients with the pediatric neurodegenerative disease spinal muscular atrophy have a homozygous deletion of the survival motor neuron 1 (SMN1) gene, but retain one or more copies of the closely related SMN2 gene. The SMN2 gene encodes the same protein (SMN) but produces it at a low efficiency compared with the SMN1 gene. We performed a high-throughput screen of approximately 47,000 compounds to identify those that increase production of an SMN2-luciferase reporter protein, but not an SMN1-luciferase reporter protein. Indoprofen, a nonsteroidal anti-inflammatory drug (NSAID) and cyclooxygenase (COX) inhibitor, selectively increased SMN2-luciferase reporter protein and endogenous SMN protein and caused a 5-fold increase in the number of nuclear gems in fibroblasts from SMA patients. No other NSAIDs or COX inhibitors tested exhibited this activity.

Unaltered ibuprofen-induced faecal blood loss upon coadministration of moclobemide

The influence of moclobemide on ibuprofen-induced faecal blood loss was investigated in 24 volunteers. The subjects were randomly assigned to one of two groups and received from day 1 until day 14 either moclobemide 150 mg t.i.d. (group A) or placebo t.i.d. (group B). On days 8-14, when moclobemide concentrations in group A were at steady state, all volunteers additionally received ibuprofen (600 mg t.i.d). From day 15 to 21, all subjects received placebo alone. Faecal blood loss (FBL) was quantified daily by the 51Cr-labelled erythrocyte method. As expected for ibuprofen, a significant increase in FBL during the second week of the study was observed. There was no difference in FBL between the two treatment groups (moclobemide or placebo). Similar FBL values were observed in both groups (group A vs B): during the first week the FBL values were (mean +/- SD) 0.40 +/- 0.23 ml/day vs 0.55 +/- 0.53 ml/day on days 1-3 and 0.40 +/- 0.21 ml/day vs 0.37 +/- 0.13 ml/day on days 4-7. The increase in FBL during the second week was comparable in both groups, with and without moclobemide (days 8-10: 0.78 +/- 0.59 ml/day vs 0.80 +/- 0.58 ml/day; days 11-14: 1.49 +/- 0.95 ml/day vs 1.28 +/- 0.62 ml/day). A decline in FBL was observed during the third week under placebo in both groups, but baseline values were not reached during the observation period. Again there was no difference between the two groups (days 15-17: 0.91 +/- 0.52 ml/day vs 0.92 +/- 0.47 ml/day; days 18-21: 0.74 +/- 0.30 ml/day vs 0.68 +/- 0.48 ml/day). No statistically significant interaction was found between week and type of treatment, indicating that no significant influence of moclobemide on the ibuprofen-induced faecal blood loss occurred. No notable pharmacokinetic interaction between moclobemide and ibuprofen was observed. Moclobemide plasma concentration-time profiles with and without concomitantly administered ibuprofen were superimposable. The results demonstrate that the concomitant administration of ibuprofen and moclobemide to healthy volunteers does not result in a clinically significant interaction, either at the pharmacodynamic (faecal blood loss) or at the pharmacokinetic level.

Influence of moclobemide on ibuprofen-induced faecal blood loss

In a pharmacological screen on drug-drug interactions performed in laboratory animals moclobemide potentiated at high doses the antiphlogistic/anti-inflammatory activity of ibuprofen. Therefore, a study was undertaken to determine in healthy volunteers the faecal blood loss induced by multiple doses of ibuprofen (600 mg t.i.d.) in presence and absence of steady-state concentrations of concomitantly administered moclobemide (150 mg t.i.d.). The results show that multiple doses of moclobemide do not change faecal blood loss induced by ibuprofen. Furthermore, no clinically relevant pharmacokinetic interaction between the two drugs studied was detected.

Etodolac, a new nonsteroidal anti-inflammatory drug: gastrointestinal microbleeding and endoscopic studies

A review of the literature is presented on the gastrointestinal effects of etodolac, a new nonsteroidal anti-inflammatory drug (NSAID), as evaluated in both microbleeding and endoscopic studies. In four microbleeding studies, gastrointestinal blood loss in healthy subjects was estimated by a 51Cr-erythrocyte labeling method before drug treatment, after 7 days of treatment with NSAIDs including etodolac, and 1 week after the last day of treatment. In these 7-day studies, the gastrointestinal blood loss seen with etodolac (600 to 1200 mg/day) was similar to that seen with placebo and significantly (p less than 0.05) less than that seen with aspirin (2600 mg/day), naproxen (750 mg/day), ibuprofen (2400 mg/day), or indomethacin (200 mg/day). Naproxen, ibuprofen, and indomethacin caused mean daily blood losses in excess of 1 ml/day over baseline values. The increase with aspirin was 4 to 5 ml/day. In contrast, the greatest mean daily increase in blood loss with etodolac therapy was 0.2 ml. In a 4-week study of etodolac (600 and 1000 mg/day) and piroxicam (20 mg/day) given to patients with osteoarthritis or rheumatoid arthritis, blood loss seen with etodolac was comparable to that seen with placebo and significantly less than that seen with piroxicam. Gastrointestinal irritation was also assessed by endoscopy after 1 week of NSAID or placebo treatment. Endoscopy scores after etodolac treatment (up to 1200 mg/day) were similar to scores at baseline and after placebo and were significantly lower than scores following treatment with aspirin (3900 mg/day), indomethacin (200 mg/day), ibuprofen (2400 mg/day), or naproxen (100 mg/day). The effects of etodolac (600 or 1000 mg/day) and diclofenac (150 mg/day) were not different from each other or from baseline. These data indicate that etodolac, in these studies, did not cause clinically significant gastrointestinal microbleeding or visible gastric injury. By the criteria used in these studies, etodolac is less irritating to the gastrointestinal tract than aspirin, indomethacin, ibuprofen, naproxen, or piroxicam, and compares favorably with diclofenac.

Review: acute human models of gastric mucosal injury

The use of acute human models of gastric mucosal injury has been stimulated by a need to understand more fully the problems of non-steroidal anti-inflammatory drugs but such models have other applications. None is ideal and they all share certain drawbacks. For none of them has a precise relationship to clinical events been established and they have all tended to be employed on a population of young healthy subjects who are not those at greatest clinical risk. Of individual methods mucosal potential difference is an indirect measure which is too often affected by other influences to be acceptable as a measure of mucosal injury when used alone, although it has some value as an adjunct to other measurements. Assay of DNA in gastric washings is a suitable technique for quantifying desquamation of gastric epithelial cells occurring in response to acute injury; on present evidence its significance is much more difficult to assess in the context of continuing challenge over several days. By contrast, measurement of microbleeding is more suitable for quantifying injury over several days of NSAID ingestion; little bleeding is recorded with a single acute challenge. Endoscopy can demonstrate macroscopic lesions which result from mucosal injury--injury which is quantified more easily and sensitively by measurements of cellular exfoliation or bleeding. Paradoxically, endoscopy's strength has been to underline the scientific weakness of acute models because it shows that it is rare for ulcers, which are the lesions of clinical concern to develop in these studies.

A double-blind comparison of ibuprofen, ASA-codeine-caffeine compound and placebo in the treatment of dental surgery pain

A double-blind randomized clinical trial was conducted in eighty-seven patients with mild, moderate or severe dental surgery pain to evaluate the analgesic activity of a single dose of the following compounds: (i) ibuprofen 400 mg, (ii) ACC-30 (a compound containing ASA 375 mg; codeine phosphate 30 mg; caffeine citrate 30 mg), (iii) placebo. Ibuprofen was significantly better than ACC-30 and placebo on almost all pain intensity, degree of relief and duration of analgesia parameters. ACC-30 was not significantly different from placebo on any analgesic measurement. No serious side-effects were reported with any of the study medications.

The effects of ibuprofen, indomethacin, aspirin, naproxen, and placebo on the gastric mucosa of normal volunteers: a gastroscopic and photographic study

The effects of various nonsteroidal antiinflammatory drugs on the gastric mucosa were endoscopically evaluated in 40 normal volunteers. Eight groups, each containing five subjects were designed: aspirin (3600 mg/d); placebo; ibuprofen (1600 mg/d); ibuprofen (2400 mg/d); indomethacin (100 mg/d); indomethacin (150 mg/d); naproxen (500 mg/d); and naproxen (750 mg/d). All volunteers took medication for seven days and gastroscopy was carried out on day one and day eight. All findings were documented by photography. Severe gastric mucosal injury occurred with aspirin (P less than 0.05), both doses of indomethacin, and the higher dose of naproxen. Lesser changes were seen with the lower dose of naproxen, both doses of ibuprofen and placebo. The higher doses of ibuprofen, indomethacin, and naproxen caused a greater degree of gastric mucosal injury, but statistical significance was achieved only with naproxen (P less than 0.01). Subjective gastrointestinal complaints generally correlated with endoscopic pathology; however, nine volunteers had evidence of severe injury to the gastric mucosa with no symptomatology. This was confined to the patients on indomethacin, naproxen, and ibuprofen. Aspirin patients all had some degree of symptomatology but to a lesser degree than expected in view of the endoscopic findings.

Indoprofen, a new non-steroidal anti-inflammatory drug, in the treatment of osteoarthrosis: report on a multi-centre study in 1629 patients

A multi-centre trial was carried out in 1629 patients with osteoarthrosis in 233 clinical centres to investigate the therapeutic efficacy and tolerability of indoprofen in this clinical condition. The results from assessments of both subjective and objective variables were comparable to those obtained in Phase 3 studies. Moreover, 87.2% of patients expressed a 'good' or 'very good' opinion on the product's efficacy after treatment, usually with 3 tablets (600 mg) daily for 4 weeks. The benefit/risk relationship was confirmed as very favourable on account of the marked activity of the drug and the acceptable frequency of adverse reactions, which were mainly subjective and slight and confined to the gastro-intestinal tract.