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

Drug utilization, clinical and economic outcomes of patients with osteoarthritis of the hip and/or knee treated with long-term use of traditional NSAIDs, topical NSAIDs, and COX-2 inhibitors

OBJECTIVES

To describe and compare baseline characteristics, healthcare and drug utilization, and negative clinical outcomes of commercially-insured patients diagnosed with OA of the hip and/or knee who initiated treatment on traditional oral NSAIDs (tNSAIDs), topical NSAIDs, or cyclooxygenase-2 inhibitors (COX-2s).

METHODS

A commercial claims database (1/2012-3/2017) was used to identify patients ≥18 years old, with ≥2 diagnoses of hip and/or knee OA, and ≥90 days supply of NSAIDs. Patients were assigned to cohorts based on the type of NSAID initially prescribed and observed in the 6 months before (baseline) and 36 months after (follow-up) the date of their first NSAID prescription after the first OA diagnosis. Analyses estimated baseline demographic and clinical characteristics and follow-up period drug utilization. Logistic regressions assessed the risk of gastrointestinal (GI) and acute renal failure (ARF) events.

RESULTS

tNSAIDs were the most frequently prescribed treatment. During the follow-up period, less than 15% of patients prescribed tNSAIDs switched to either COX-2s or topical NSAIDs and 37% of patients prescribed a COX-2 and 56% of patients prescribed a topical NSAID switched to tNSAIDs. GI and ARF events during the follow-up period ranged from 7.3-8.1% and 8.0-11.0%, respectively, across cohorts. The tNSAIDs and COX-2s cohorts had increased risk of both types of events relative to patients prescribed topical NSAIDs, controlling for other characteristics.

CONCLUSIONS

Analyses characterize the long-term real-world utilization of NSAIDs and associated outcomes for patients with OA of the hip and/or knee. Study results highlight the likelihood of switching and the risk of negative clinical outcomes associated with long-term use.

New Insights Into the Pharmacological Management of Postoperative Pain: A Narrative Review

Postoperative pain is prevalent and often undertreated. There is a risk that untreated or suboptimally treated postoperative pain may transition into chronic postoperative pain, which can be challenging to treat. Clinical guidelines recommend the use of multimodal analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and, in some cases, opioids. NSAIDs are a broad class of drugs with different attributes such as cyclo-oxygenase (COX)-1 or COX-2 selectivity, onset of action, and analgesic potency. NSAIDs are associated with gastrointestinal and cardiovascular side effects and should be administered at the lowest effective dose for the shortest effective duration but can be effective in postoperative pain. The role of opioids in postoperative analgesia is long-standing but has recently come under scrutiny. Opioids are often used in multimodal analgesic combinations in such a way as to minimize the total consumption of opioids without sacrificing analgesic benefit. Special clinical considerations are required for surgical patients already on opioid regimens or with opioid use disorder. A particularly useful fixed-dose combination product for postoperative analgesia is dexketoprofen-tramadol, which confers safe and effective postoperative pain control and reduces the risk of persistent postoperative pain.

Is aspirin a substrate of MDR1/P-glycoprotein?

Aspirin (acetyl salicylic acid) is widely used co-medication in patients with cardiovascular and cerebrovascular diseases. Given the prevalence of acetyl salicylic acid's use as a co-medication and conflicting reports in the literature on it being a substrate of P-glycoprotein (P-gp). There is a potential risk for its interaction with compounds with P-gp liability, therefore, we have conducted a detailed investigation to determine substrate potential of acetyl salicylic acid towards P-gp. We observed significantly lower cellular uptake of acetyl salicylic acid in MDR1 transfected LLC-PK1 cells compared to LLC-PK1 wild-type (WT) cells, however, the in vitro efflux of acetyl salicylic acid in MDR1 transfected LLC-PK1 cells was not inhibited by known inhibitors under various conditions. Acetyl salicylic acid did not show active asymmetrical transport across MDR1 transfected LLC-PK1 cells compared to LLC-PK1-WT cells in transwell assay. Moreover, no difference in plasma and brain exposure of acetyl salicylic acid and its metabolite salicylic acid was observed between FVB-WT and Mdr1a/b knockout (KO) mice. Taken together, our findings indicate that acetyl salicylic acid is not a substrate of P-gp.

Low-Dose Aspirin for Primary Prevention of Cardiovascular Disease: Use Patterns and Impact Across Race and Ethnicity in the Southern Community Cohort Study

Background

Data are limited on use patterns of low‐dose aspirin and its role for primary prevention of cardiovascular disease (CVD) in different racial and ethnic groups.

Methods and Results

Overall, 65 231 non‐Hispanic black and white people aged 40 to 79 years with no history of CVD enrolled from 2002 through 2009 in the SCCS (Southern Community Cohort Study). At cohort entry, the simplified Framingham 10‐year CVD risk was calculated, and data related to low‐dose aspirin use and clinical and socioeconomic covariates were collected. Race‐ and ethnicity‐specific adjusted odds ratios for characteristics of low‐dose aspirin users and hazard ratios for ischemic cardiac death according to aspirin use were calculated using multivariate logistic and Cox regression models. Black participants were less likely to take low‐dose aspirin compared with white participants, regardless of CVD risk and covariates (adjusted odds ratio: 0.79; 95% CI, 0.75–0.82). Over a median follow‐up of 11.3 years, low‐dose aspirin use was associated with a trend toward decreased risk of ischemic cardiac death in white participants (adjusted hazard ratio: 0.86; 95% CI, 0.68–1.10), especially in women (adjusted hazard ratio: 0.72; 95% CI, 0.51–1.02), but not in black participants (adjusted hazard ratio: 1.18; 95% CI, 0.98–1.40). Similar trends were observed when the analysis was restricted to high‐risk individuals aged 50 to 69 or 50 to 59 years, ages for which guidelines consider aspirin for CVD primary prevention.

Conclusions

Low‐dose aspirin use for primary prevention of CVD is lower among black than white patients. Its use might be associated with a disparate impact on ischemic cardiac death according to race and ethnicity. Although additional studies are required, these findings provide no evidence of a beneficial effect of aspirin among black patients for CVD primary prevention.

Towards an Effective and Safe Treatment of Inflammatory Pain: A Delphi-Guided Expert Consensus

OBJECTIVE

The clinical management of inflammatory pain requires an optimal balance between effective analgesia and associated safety risks. To date, mechanisms associated with inflammatory pain are not completely understood because of their complex nature and the involvement of both peripheral and central mechanisms. This Expert Consensus document is intended to update clinicians about evolving areas of clinical practice and/or available treatment options for the management of patients with inflammatory pain.

METHOD

An international group of experts in pain management covering the pharmacology, neurology and rheumatology fields carried out an independent qualitative systematic literature search using MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials.

RESULTS

Existing guidelines for pain management provide recommendations that do not satisfactorily address the complex nature of pain. To achieve optimal outcomes, drug choices should be individualized to guarantee the best match between the characteristics of the patient and the properties of the medication. NSAIDs represent an important prescribing choice in the management of inflammatory pain, and the recent results on paracetamol question its appropriate use in clinical practice, raising the need for re-evaluation of the recommendations in the clinical practice guidelines.

CONCLUSIONS

Increasing clinicians' knowledge of the available pharmacologic options to treat different pain mechanisms offers the potential for safe, individualized treatment decisions. We hope that it will help implement the needed changes in the management of inflammatory pain by providing the best strategies and new insights to achieve the ultimate goal of managing the disease and obtaining optimal benefits for patients.

FUNDING

Dompé Farmaceutici SPA and Paolo Procacci Foundation.

[Pharmacology of non-opioid analgesics]

Due to high prescription rates as well as the frequent use as over the counter drugs, it is of interest to consider non-opioid analgesics when evaluating the quality and appropriateness of a given overall medication. This article sums up the basic pharmacology and main adverse effects of these analgesics. Non-opioids can be further classified according to their additional mechanisms of action besides analgesia. High-dose acetylsalicylic acid, traditional nonsteroidal anti-inflammatory drugs, and coxibs exhibit antipyretic and anti-inflammatory properties. Acetaminophen and metamizole (dipyrone) are analgesics and antipyretic agents, while metamizole exhibits also spasmolytic effects. Capsaicin and intrathecal ziconotide are pure analgesics.

Cancer prevention by aspirin in children with Constitutional Mismatch Repair Deficiency (CMMRD)

Constitutional MisMatch Repair Deficiency (CMMRD) is caused by homozygous or compound heterozygous germline variants in one of the mismatch repair (MMR) genes (MSH2, MSH6, PMS2, MLH1). This syndrome results in early onset colorectal cancer, leukemia and lymphoma, brain tumors and other malignancies. Children with CMMRD are at high risk of developing multiple cancers and cancer surveillance does not guarantee detection of cancer at a curable stage. The development of a preventive treatment strategy would be a major step forward. Long-term daily use of acetylsalicylic acid (ASA) has been shown to reduce cancer risk in individuals with Lynch syndrome (LS). LS is caused by heterozygous germline variants of MSH2, MSH6, PMS2 and MLH1 and characterized by an increased risk of developing colorectal and endometrial cancer at adult age. Here we discuss the potential use of ASA for cancer prevention in patients with CMMRD.

Inhibition of cyclooxygenase-2 sensitizes lung cancer cells to radiation-induced apoptosis

Radiotherapy resistance is an enduring major setback in lung cancer therapy, and is responsible for a large proportion of treatment failures. In previous years, cyclooxygenase-2 (COX-2) has frequently been reported to promote tumor occurrence and development, suggesting a potential role in radiotherapy resistance. To investigate whether COX-2 inhibitors can be applied in radiosensitization, an MTT assay was performed to examine cell viability after X-ray radiation in the presence or absence of the specific COX-2 inhibitor Celecoxib. Cell apoptosis and cell cycle changes were also detected through laser confocal scanning microcopy and flow cytometry. X-ray treatment only caused mild cell death in lung cancer A549 cells. However, combination treatment using celecoxib and X-ray radiation exhibited improved inhibitory effects and significantly suppressed cell proliferation. Therefore, COX-2 inhibitors combined with radiotherapy can counteract radiation-induced high COX-2 expression, demonstrating that celecoxib can function as a radiosensitizer of lung cancer cells. It is therefore reasonable to predict COX-2 inhibitors to be potential clinical radiotherapy synergists.

Analysis of the chemical toxicity effects using the enrichment of Gene Ontology terms and KEGG pathways

BACKGROUND

Chemical toxicity is one of the major barriers for designing and detecting new chemical entities during drug discovery. Unexpected toxicity of an approved drug may lead to withdrawal from the market and significant loss of the associated costs. Better understanding of the mechanisms underlying various toxicity effects can help eliminate unqualified candidate drugs in early stages, allowing researchers to focus their attention on other more viable candidates.

METHODS

In this study, we aimed to understand the mechanisms underlying several toxicity effects using Gene Ontology (GO) terms and KEGG pathways. GO term and KEGG pathway enrichment theories were adopted to encode each chemical, and the minimum redundancy maximum relevance (mRMR) was used to analyze the GO terms and the KEGG pathways. Based on the feature list obtained by the mRMR method, the most related GO terms and KEGG pathways were extracted.

RESULTS

Some important GO terms and KEGG pathways were uncovered, which were concluded to be significant for determining chemical toxicity effects.

CONCLUSIONS

Several GO terms and KEGG pathways are highly related to all investigated toxicity effects, while some are specific to a certain toxicity effect.

GENERAL SIGNIFICANCE

The findings in this study have the potential to further our understanding of different chemical toxicity mechanisms and to assist scientists in developing new chemical toxicity prediction algorithms. This article is part of a Special Issue entitled "System Genetics" Guest Editor: Dr. Yudong Cai and Dr. Tao Huang.

Latent association between low urine pH and low body weight in an apparently healthy population

Low urine pH, a plausible predictor for chronic kidney disease and metabolic disorders, is often observed in obese individuals. However, the association between low urine pH and low body weight is equivocal. We examined clinical parameters including urine pH and body mass index (BMI) in a cross-sectional study of 3629 apparently healthy Japanese adults aged 25-80 years who underwent a health-screening check-up. Urine pH was lower and the prevalence of proteinuria was significantly higher in subjects with BMI of ≥ 27.0 kg/m(2) compared with those with BMI of 21.0-22.9 kg/m(2). By contrast, hematuria was more prevalent in subjects with BMI of ≤ 20.9 kg/m(2). Logistic regression analysis showed that BMI of ≥ 27.0 kg/m(2) was significantly associated with low urine pH (≤ 5.5), which remained significant after adjustment for relevant confounders including age, sex, proteinuria, estimated glomerular filtration rate, urine density, hematuria, smoking status, and daily alcohol drinking. However, the association disappeared after further adjustment for serum uric acid. In contrast, the association between low urine pH and BMI of ≤ 19.0 kg/m(2) was significant after adjustment for age and sex and rather strengthened by the further adjustment for serum uric acid. In conclusion, low urine pH may be independently associated with low BMI. However, the underlying mechanisms of low urine pH in low body weight may differ from those in high body weight.

NOSH-aspirin (NBS-1120), a dual nitric oxide and hydrogen sulfide-releasing hybrid, reduces inflammatory pain

The development of nitric oxide (NO)- and hydrogen sulfide (H₂S)-releasing nonsteroidal anti-inflammatory drugs (NSAIDs) has generated more potent anti-inflammatory drugs with increased safety profiles. A new hybrid molecule incorporating both NO and H₂S donors into aspirin (NOSH-aspirin) was recently developed. In the present study, the antinociceptive activity of this novel molecule was compared with aspirin in different models of inflammatory pain. It was found that NOSH-aspirin inhibits acetic acid-induced writhing response and carrageenan (Cg)-induced inflammatory hyperalgesia in a dose-dependent (5–150 μmol/kg, v.o.) manner, which was superior to the effect of the same doses of aspirin. NOSH-aspirin’s antinociceptive effect was also greater and longer compared to aspirin upon complete Freund’s adjuvant (CFA)-induced inflammatory hyperalgesia. Mechanistically, NOSH-aspirin, but not aspirin, was able to reduce the production/release of interleukin-1 beta (IL-1β) during Cg-induced paw inflammation. Furthermore, NOSH-aspirin, but not aspirin, reduced prostaglandin E₂-induced hyperalgesia, which was prevented by treatment with a ATP-sensitive potassium channel (K_ATP) blocker (glibenclamide; glib.). Noteworthy, the antinociceptive effect of NOSH-aspirin was not associated with motor impairment. The present results indicate that NOSH-aspirin seems to present greater potency than aspirin to reduce inflammatory pain in several models. The enhanced effects of NOSH-aspirin seems to be due to its ability to reduce the production of pronociceptive cytokines such as IL-1 β and directly block hyperalgesia caused by a directly acting hyperalgesic mediator in a mechanism dependent on modulation of K_ATP channels. In conclusion, we would like to suggest that NOSH-aspirin represents a prototype of a new class of analgesic drugs with more potent effects than the traditional NSAID, aspirin.

Aspirin and nonsteroidal anti-inflammatory drug use and the risk of Barrett's esophagus

BACKGROUND

The use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) may decrease the risk of esophageal adenocarcinoma; however, it is unknown where these agents may act in the proposed pathway from normal mucosa to Barrett's esophagus to esophageal adenocarcinoma.

AIM

The aim of the study was to evaluate the association between aspirin and NSAID use and Barrett's esophagus in a case-control study within a large community-based population.

METHODS

We conducted a case-control study of aspirin/NSAID use and Barrett's esophagus within the Kaiser Permanente Northern California population. Cases had a new diagnosis of Barrett's esophagus between October 2002 and September 2005; controls were members without a diagnosis of Barrett's esophagus.

RESULTS

Persons with Barrett's esophagus were less likely to use aspirin than population controls [odds ratio (OR) 0.59, 95 % confidence interval (CI) 0.39-0.87]; a stronger association was found among cases and controls with reflux symptoms (OR 0.49, 95 % CI 0.32-0.75; p value interaction = 0.004). Similar associations were found with the use of either aspirin and/or non-aspirin NSAIDs (OR 0.53, 95 % CI 0.35-0.81), although NSAID use alone was not significantly associated with Barrett's esophagus (OR 0.74, 95 % CI 0.47-1.16). The strength of the association was highest among persons with at least moderate-to-high total medication intake.

CONCLUSIONS

Regular use of aspirin or NSAIDs was associated with a decreased risk of Barrett's esophagus, particularly among persons with gastroesophageal reflux disease symptoms. These findings have implications for chemoprevention, as some of the previously described protective association between aspirin/NSAIDs and esophageal adenocarcinoma may be explained by events that occur prior to the development of Barrett's esophagus.