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Yaxley J. Common Analgesic Agents and Their Roles in Analgesic Nephropathy: A Commentary on the Evidence. Korean J Fam Med 2016; 37:310-316. [PMID: 27900067 PMCID: PMC5122661 DOI: 10.4082/kjfm.2016.37.6.310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/11/2016] [Accepted: 08/24/2016] [Indexed: 11/03/2022] Open
Abstract
An association between non-opioid analgesic agents and chronic kidney disease has long been suspected. The presumed development of chronic renal impairment following protracted and excessive use of non-opioid analgesia is known as analgesic nephropathy. Many clinicians accept analgesic nephropathy as a real entity despite the paucity of scientific evidence. This narrative review aims to summarize the literature in the field. The weight of available observational literature suggests that long-term ingestion of paracetamol and combination mixtures of aspirin and paracetamol are likely to contribute to chronic renal impairment. However, there is no convincing data to implicate non-steroidal anti-inflammatory drugs or aspirin monotherapy in the development of analgesic nephropathy. In the absence of high-level evidence, while controversy persists, it may be prudent for physicians to consider all non-narcotic analgesics to be nephrotoxic with long-term use.
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Affiliation(s)
- Julian Yaxley
- Department of Medicine, Redcliffe Hospital, Redcliffe, QLD, Australia
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Aminoshariae A, Kulild JC, Donaldson M. Short-term use of nonsteroidal anti-inflammatory drugs and adverse effects: An updated systematic review. J Am Dent Assoc 2015; 147:98-110. [PMID: 26562732 DOI: 10.1016/j.adaj.2015.07.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/21/2015] [Accepted: 07/31/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND In this article, the authors examine the available scientific evidence regarding adverse effects of short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). Short-term use was defined as 10 days or fewer. METHODS The authors reviewed randomized controlled clinical trials and cohort and case-controlled clinical studies published between 2001 and June 2015 in which the investigators reported on the safety of nonselective cyclooxygenase inhibitors and of cyclooxygenase-2 selective inhibitor NSAIDs. RESULTS The systematic review process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines allowed the authors to identify 40 studies that met the inclusion criteria. CONCLUSIONS On the basis of the available scientific evidence, NSAIDs may be considered relatively safe drugs when prescribed at the most effective dose and for the shortest duration of time, which was defined to be 10 days or fewer. PRACTICAL IMPLICATIONS Although the US Food and Drug Administration recommends the use of NSAIDs beyond 10 days to be accompanied by a consultation with a health care provider, the use of NSAIDs may be considered relatively safe when prescribed at the most effective dose and for the shortest duration of time, which was defined as 10 days or fewer. Exceptions would be for patients at risk of developing NSAID-exacerbated respiratory disease, patients with prior myocardial infarction who are receiving antithrombotic therapy, patients with asthma, and patients with a history of renal disease.
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Bellei E, Monari E, Bergamini S, Cuoghi A, Tomasi A, Guerzoni S, Ciccarese M, Pini LA. Validation of potential candidate biomarkers of drug-induced nephrotoxicity and allodynia in medication-overuse headache. J Headache Pain 2015; 16:559. [PMID: 26272683 PMCID: PMC4536253 DOI: 10.1186/s10194-015-0559-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/21/2015] [Indexed: 12/15/2022] Open
Abstract
Background Medication-overuse headache (MOH) is a chronic disorder that results from the overuse of analgesics drugs, triptans or other acute headache compounds. Although the exact mechanisms underlying MOH remain still unknown, several studies suggest that it may be associated with development of “central sensitization”, which may cause cutaneous allodynia (CA). Furthermore, the epidemiology of drug-induced disorders suggests that medication overuse could lead to nephrotoxicity. The aim of this work was to confirm and validate the results obtained from previous proteomics studies, in which we analyzed the urinary proteome of MOH patients in comparison with healthy non-abusers individuals. Methods MOH patients were divided into groups on the basis of the drug abused: triptans, non-steroidal anti-inflammatory drugs (NSAIDs) and mixtures, (mainly containing indomethacin, paracetamol and, in some cases, caffeine). Healthy subjects, with a history of normal renal function, were used as controls. In this study, four proteins that were found differentially expressed in urine, and, on the basis of the literature review, resulted related to kidney diseases, were verified by Western Blot and Enzyme-linked Immunosorbent Assay (ELISA); Prostaglandin-H2 D-synthase (PTGDS), uromodulin (UROM), alpha-1-microglobulin (AMBP) and cystatin-C (CYSC). Results Western blot analysis allowed to validate our previous proteomics data, confirming that all MOH patients groups show a significant over-excretion of urinary PTGDS, UROM, AMBP and CYSC (excluding triptans group for this latter), in comparison with controls. Moreover, the expression of PTGDS was further evaluated by ELISA. Also by this assay, a significant increase of PTGDS was observed in all MOH abusers, according to 2-DE and Western blot results. Conclusions In this study, we confirmed previous findings concerning urinary proteins alterations in MOH patients, identified and demonstrated the over-expression of PTGDS, UROM, AMBP, and CYSC, particularly in NSAIDs and mixtures abusers. Over-expression of these proteins have been related to renal dysfunction and probably, PTGDS, to the development of CA. The detection and confirmation of this proteins pattern represent a promising tool for a better understanding of potential nephrotoxicity induced by drugs overuse and may enhance awareness related to the MOH-associated risks, even in absence of clinical symptoms.
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Affiliation(s)
- Elisa Bellei
- Department of Diagnostic Medicine, Clinic and Public Health, Proteomic Lab, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy,
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Wehling M. Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects. Eur J Clin Pharmacol 2014; 70:1159-72. [PMID: 25163793 DOI: 10.1007/s00228-014-1734-6] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/14/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs, and this widespread use is complicated by safety issues. METHOD A Literature review was conducted. RESULTS NSAIDs are a leading cause of drug-related morbidity, especially in the elderly and patients with comorbidities. Most adverse effects are related to generalized inhibition of the major targets of NSAIDs: cyclooxygenases I and II. These enzymes are not only involved in pain and inflammation pathogenesis but are also required in the gastrointestinal (GI) tract for mucosal protection and gut motility, and in the kidneys for functional integrity. Thus, the mechanisms of NSAID toxicity are well understood, but the consequences are largely uncontrolled in clinical practice. GI ulcers, including bleeding ulcers, may occur in several percent of all chronic unprotected, high-dose NSAID users. Renal side effects may precipitate renal failure, resulting in acute dialysis and chronic retention. This includes sodium retention, resulting in arterial hypertension, heart failure, and atherosclerotic events. Cardiovascular risk may be tripled by chronic high-dose NSAID use in long-term clinical trials though "real-life studies" indicate lower risk ratios. Off-target side effects include allergic reactions, drug-induced liver injury, and central nervous system effects. CONCLUSIONS Management of pain and inflammation must consider those risks and find alternative drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity. Alternative drugs, low-dose/short-term use, but especially non-pharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies, need to be further utilized. The appalling equation "less pain-more deaths/morbidity" ultimately necessitates treatment optimization in the individual patient.
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Affiliation(s)
- Martin Wehling
- Institute of Experimental and Clinical Pharmacology and Toxicology, Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University of Heidelberg, Maybachstrasse 14, 68169, Mannheim, Germany,
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Nderitu P, Doos L, Jones PW, Davies SJ, Kadam UT. Non-steroidal anti-inflammatory drugs and chronic kidney disease progression: a systematic review. Fam Pract 2013; 30:247-55. [PMID: 23302818 DOI: 10.1093/fampra/cms086] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are widely regarded as one risk factor, which influences chronic kidney disease (CKD) progression. However, previous literature reviews have not quantified the risk in moderate to severe CKD patients. OBJECTIVE To estimate the strength of association between chronic NSAID use and CKD progression. METHODS We conducted a systematic review and meta-analysis of observational general practice or population studies featuring patients aged 45 years and over. The electronic databases searched were MEDLINE, EMBASE, Cochrane, AMED, BNI and CINAHL until September 2011 without date or language restrictions. Searches included the reference lists of relevant identified studies, WEB of KNOWLEDGE, openSIGLE, specific journals, the British Library and expert networks. For relevant studies, random effects meta-analysis was used to estimate the association between NSAID use and accelerated CKD progression (estimated glomerular filtration rate decline ≥ 15 ml/min/1.73 m2). RESULTS From a possible 768 articles, after screening and selection, seven studies were identified (5 cohort, 1 case-control and 1 cross-sectional) and three were included in the meta-analysis. Regular-dose NSAID use did not significantly affect the risk of accelerated CKD progression; pooled odds ratio (OR) = 0.96 (95%CI: 0.86-1.07), but high-dose NSAID use significantly increased the risk of accelerated CKD progression; pooled OR = 1.26 (95%CI: 1.06-1.50). CONCLUSIONS The avoidance of NSAIDs in the medium term is unnecessary in patients with moderate to severe CKD, if not otherwise contraindicated. As the definition of high-dose of NSAID use remains unclear, the lowest effective dose of NSAIDs should be prescribed where indicated.
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Affiliation(s)
- Paul Nderitu
- Health Services Research Unit, Institute of Science and Technology in Medicine, Keele University, Keele, UK.
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Kelkar M, Cleves MA, Foster HR, Hogan WR, James LP, Martin BC. Acute and chronic acetaminophen use and renal disease: a case-control study using pharmacy and medical claims. JOURNAL OF MANAGED CARE PHARMACY : JMCP 2012; 18:234-46. [PMID: 22468732 PMCID: PMC4000171 DOI: 10.18553/jmcp.2012.18.3.234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Studies have examined the association between acetaminophen (APAP) use and renal disease; however, their interpretation is limited by a number of methodological issues. OBJECTIVE To study the association between acute and chronic prescription-acquired APAP use and renal disease. METHODS This was a retrospective case-control study of medical and pharmacy claims of a 10% random sample of the enrollees from the IMS LifeLink Health Plans commercial claims dataset for dates of service from January 1, 1997, through December 31, 2009. Subjects were continuously enrolled and aged 18 years or older. Cases had at least 1 incident claim of renal disease defined by ICD-9-CM codes in the primary diagnosis field. Controls were randomly selected from individuals without evidence of renal disease, liver disease, or asthma in medical claims and matched to cases in a 3-to-1 ratio based on 3 variables (age, gender, and geographic region). APAP exposure, dosage, and duration of use were measured in the 7 and 30 days (acute) and in the 1-year (chronic) look-back periods. Multivariable conditional logistic regression was used to estimate the risk of APAP exposure adjusted for comorbidities, use of other nephrotoxic drugs, and health system factors. RESULTS There were 4,724 cases and 14,172 controls with a mean (SD) age of 60.8 (17.8) years, and 52.6% were males; 10.9% of cases and 4.2% of controls had APAP exposure in the 30 days pre-index with mean potential maximum daily dosages of 3,846.5 mg and 3,190.8 mg, respectively. Acute APAP exposure was significantly associated with renal disease, and the risk decreased with longer look-back periods (7 days: adjusted odds ratio [OR] = 1.93, 95% CI = 1.61-2.30); 30 days: OR = 1.71, 95% CI = 1.48-1.97). Cumulative APAP dosage greater than 1 kg and APAP use for longer than 30 days in the pre-index year were not significantly associated with an increased risk of renal disease (both P values = 0.900). CONCLUSIONS Acute prescription-acquired APAP use was associated with renal disease, while chronic use was not. Because this study assessed APAP use in pharmacy claims, further research accounting for over-the-counter APAP use is warranted before the safety of chronic APAP consumption can be firmly established.
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Affiliation(s)
- Mugdha Kelkar
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
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Straube A, Aicher B, Fiebich BL, Haag G. Combined analgesics in (headache) pain therapy: shotgun approach or precise multi-target therapeutics? BMC Neurol 2011; 11:43. [PMID: 21453539 PMCID: PMC3080296 DOI: 10.1186/1471-2377-11-43] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 03/31/2011] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Pain in general and headache in particular are characterized by a change in activity in brain areas involved in pain processing. The therapeutic challenge is to identify drugs with molecular targets that restore the healthy state, resulting in meaningful pain relief or even freedom from pain. Different aspects of pain perception, i.e. sensory and affective components, also explain why there is not just one single target structure for therapeutic approaches to pain. A network of brain areas ("pain matrix") are involved in pain perception and pain control. This diversification of the pain system explains why a wide range of molecularly different substances can be used in the treatment of different pain states and why in recent years more and more studies have described a superior efficacy of a precise multi-target combination therapy compared to therapy with monotherapeutics. DISCUSSION In this article, we discuss the available literature on the effects of several fixed-dose combinations in the treatment of headaches and discuss the evidence in support of the role of combination therapy in the pharmacotherapy of pain, particularly of headaches. The scientific rationale behind multi-target combinations is the therapeutic benefit that could not be achieved by the individual constituents and that the single substances of the combinations act together additively or even multiplicatively and cooperate to achieve a completeness of the desired therapeutic effect.As an example the fixed-dose combination of acetylsalicylic acid (ASA), paracetamol (acetaminophen) and caffeine is reviewed in detail. The major advantage of using such a fixed combination is that the active ingredients act on different but distinct molecular targets and thus are able to act on more signalling cascades involved in pain than most single analgesics without adding more side effects to the therapy. SUMMARY Multitarget therapeutics like combined analgesics broaden the array of therapeutic options, enable the completeness of the therapeutic effect, and allow doctors (and, in self-medication with OTC medications, the patients themselves) to customize treatment to the patient's specific needs. There is substantial clinical evidence that such a multi-component therapy is more effective than mono-component therapies.
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Affiliation(s)
- Andreas Straube
- Department of Neurology, Klinikum Großhadern, Ludwig-Maximilians-University, D-81377 Munich, Germany
| | - Bernhard Aicher
- Boehringer Ingelheim Pharma GmbH&Co. KG, Binger-Str. 173, D-55216 Ingelheim am Rhein, Germany
| | - Bernd L Fiebich
- Dept. of Psychiatry and Psychotherapy, Universitätsklinikum Freiburg, Hauptstr. 5, D-79104 Freiburg, Germany
| | - Gunther Haag
- Michael-Balint Klinik, Hermann-Voland Str. 10, D-78126 Königsfeld im Schwarzwald, Germany
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Abstract
Chronic headaches represent a significant burden for the affected individuals and for the society, and a major challenge for successful care. Among the various types of chronic headaches, those that are associated with medication overuse (medication-overuse headache, MOH) are of particular importance because of the large proportion of patients who complain of this condition and their poor outcome. Most patients with MOH had migraine as primary headache. Practically, almost all drugs used for the symptomatic relief of migraine, including triptans and analgesics can cause MOH. Although the pathophysiology of MOH is unknown, recent studies hypothesize that plastic changes in specific pain areas of the central nervous system are main contributors to establishing MOH. Not infrequently, drug overuse is associated with habituation and failure of previously effective medications. Finally, treatment of MOH is poorly evidence based and mostly relies on clinical experience and belief.
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Affiliation(s)
- Pierangelo Geppetti
- Headache Center, Careggi University Hospital, University of Florence, Florence, Italy.
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Sparkes AH, Heiene R, Lascelles BDX, Malik R, Sampietro LR, Robertson S, Scherk M, Taylor P. ISFM and AAFP consensus guidelines: long-term use of NSAIDs in cats. J Feline Med Surg 2010; 12:521-38. [PMID: 20610311 PMCID: PMC11148988 DOI: 10.1016/j.jfms.2010.05.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
UNLABELLED NSAIDS AND CATS: Non-steroidal anti-inflammatory drugs (NSAIDs) are an important class of drug in feline medicine, having analgesic, anti-inflammatory and antipyretic activity. While most published data on their use in this species relate to short-term (often perioperative) therapy, there is increasing evidence of the value of these drugs in treating chronic pain in cats (for example, that associated with degenerative joint disease), and some NSAIDs have now become licensed for long-term use in cats in some geographies. Most of our knowledge of therapeutic mechanisms or adverse drug reactions associated with NSAIDs is extrapolated from work in other species, and there is a paucity of published data relating to cats. GUIDELINES These guidelines have been drawn together by an expert panel, which have reviewed the current literature on long-term NSAID use in cats and other species, and developed guidance on their use based on this information. The aim is to provide practical information for veterinarians to encourage appropriate NSAID therapy whenever cats will benefit from the use of these drugs.
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Abstract
Chronic analgesic nephropathy, particularly chronic interstitial nephritis and renal papillary necrosis, results from daily use for many years of mixtures containing at least two analgesics and caffeine or dependence-inducing drugs. Computed tomography scan can accurately diagnose this disease even in the absence of reliable information on previous analgesic use. The occasion to moderate regular use of aspirin and nonsteroidal anti-inflammatory drugs is without renal risk when renal function is normal. Paracetamol use is less clear although the risk is not great. The continued use of non-phenacetin-combined analgesics with or without nonsteroidal anti-inflammatory drugs is associated with faster progression toward renal impairment. As long as high-risk analgesic mixtures are available over the counter, analgesic nephropathy will continue to be a problem.
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Affiliation(s)
- Marc E De Broe
- Department of Nursing Sciences, Laboratory of Pathophysiology, University of Antwerp, Antwerp, Belgium.
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Michielsen P, Heinemann L, Mihatsch M, Schnülle P, Graf H, Koch KM. Non-phenacetin analgesics and analgesic nephropathy: clinical assessment of high users from a case-control study. Nephrol Dial Transplant 2008; 24:1253-9. [PMID: 19037086 DOI: 10.1093/ndt/gfn643] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND A recent large-scale case-control study on analgesic nephropathy (SAN) [1] found no increased risk of end-stage renal disease (ESRD) in users of combined or single formulations of phenacetin-free analgesics. In a subgroup of 22 high users, however, a dose-dependent increased risk was found, which raised the question if these patients presented or not with analgesic nephropathy (AN). METHODS The individual questionnaires of this subgroup of high users were reviewed, and the total lifetime intake of different types of analgesics was calculated. For evidence of AN, the following data were considered: (1) the amount and type of analgesics consumed, (2) the cause of ESRD, as diagnosed by the nephrologist in charge of the patient and (3) renal imaging and other relevant laboratory data. RESULTS This group of ESRD patients consumed on average 7.8 kg of antipyretic analgesics (range 30.8-2.7 kg) over an average of 21.5 years (range 35-6 years). Single analgesics were exclusively used by 12 patients (54.5%) and combined analgesics by 5 patients (22.7%), while 5 patients used both. None of the patients was diagnosed as having AN, and a review of the questionnaires did not disclose evidence suggestive of AN. The possibility that, irrespective of AN, the analgesic (ab)use contributed to the progression of existing renal diseases cannot be answered in the absence of well-defined criteria. The data supporting the existence of such an analgesic-associated nephropathy (AAN) are, however, not consistent and most likely due to confounding by indication. CONCLUSION In a group of ESRD patients with high use of non-phenacetin analgesics, no evidence of AN was found. There is no evidence that (ab)use of analgesics or NSAIDs other than phenacetin leads to a pathologically or clinically defined renal disease that could be named AN or AAN.
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