Comparative cardiovascular safety of traditional nonsteroidal anti-inflammatory drugs

A network-based study reveals multimorbidity patterns in people with type 2 diabetes

Patients with type 2 diabetes mellitus (T2DM) are at a heightened risk of living with multiple comorbidities. However, the comprehension of the multimorbidity characteristics of T2DM is still scarce. This study aims to illuminate T2DM's prevalent comorbidities and their interrelationships using network analysis. Using electronic medical records (EMRs) from 496,408 Chinese patients with T2DM, we constructed male and female global multimorbidity networks and age- and sex-specific networks. Employing diverse network metrics, we assessed the structural properties of these networks. Furthermore, we identified hub, root, and burst diseases within these networks while scrutinizing their temporal trends. Our findings uncover interconnected T2DM comorbidities manifesting as emergence in clusters or age-specific outbreaks and core diseases in each sex that necessitate timely detection and intervention. This data-driven methodology offers a comprehensive comprehension of T2DM's multimorbidity, providing hypotheses for clinical considerations in the prevention and therapeutic strategies.

Type 2 diabetes mellitus and osteoarthritis

OBJECTIVES

Type 2 diabetes mellitus (T2DM) and osteoarthritis (OA) are common diseases that frequently co-exist, along with overweight/obesity. While the mechanical impact of excess body weight on joints may explain lower limb OA, we sought to explore whether T2DM is linked to OA outside of excess weight and whether T2DM may play a role in OA pathophysiology. The consequence of T2DM on OA outcomes is a question of research interest.

METHODS

We conducted a critical review of the literature to explore the association between T2DM and OA, whether any association is site-specific for OA, and whether the presence of T2DM impacts on OA outcomes. We also reviewed the literature to assess the safety of anti-OA treatments in patients with T2DM.

RESULTS

T2DM has a pathogenic effect on OA through 2 major pathways involving oxidative stress and low-grade chronic inflammation resulting from chronic hyperglycemia and insulin resistance. T2DM is a risk factor for OA progression and has a negative impact on arthroplasty outcomes. Evidence is mounting for safety concerns with some of the most frequently prescribed anti-OA medications, including paracetamol, non-steroidal anti-inflammatory drugs, and corticosteroid injections, while other anti-OA medications may be safely prescribed in OA patients with T2DM, such as glucosamine and intra-articular hyaluronic acid.

CONCLUSIONS

Future research is needed to better understand whether diabetes control and prevention can modulate OA occurrence and progression. The selection of therapy to treat OA symptoms in patients with T2DM may require careful consideration of the evidence based to avoid untoward safety issues.

Safety of nonsteroidal anti-inflammatory drugs in patients with cardiovascular risk

The review presents current information on the role of NSAIDs in the development of cardiovascular disasters. The development of non-desirable cardiovascular effects and an increase in cardiovascular risk with the administration of NSAIDs, most experts assess in terms of the antagonistic effect on the platelet-vascular homeostasis of metabolites of COX-thromboxane A2 and prostaglandin I2 (prostacyclin). All the presented reviews confirming an increase in the risk of MI complications in the administration of NSAIDs, indicate the class-specificity of this undesirable effect, not homogeneous for different representatives of the group. Important clinical aspects of prescribing NSAIDs for patients with low and moderate cardiovascular risk are the clinical features of the patient and the individual set of risk factors for CVD. Such pharmacokinetic characteristics of NSAIDs as a short half-life, a high degree of binding to blood plasma albumins are indicative of greater safety of NSAIDs, but the final decision must be made based on the accumulated data of clinical trials and meta-analyzes. Keywords: nonsteroidal anti-inflammatory drugs, cardiovascular diseases, cardiovascular risk, lornoxicam, diclofenac sodium, thrombo-elastogram, myocardial infarction, stroke.

QSAR of 2-(4-methylsulphonylphenyl)pyrimidine derivatives as cyclooxygenase-2 inhibitors: simple structural fragments as potential modulators of activity

The cyclooxygenase-2 (COX-2) inhibitory activity of 2-(4-methylsulphonylphenyl)pyrimidine derivatives has been quantitatively analyzed in terms of Dragon descriptors. The derived QSAR models have provided rationales to explain the activity of titled derivatives. The descriptors (Me, Mp, GATS1p and GATS5p) identified in CP-MLR analysis have highlighted the role of atomic properties, such as Sanderson electronegativity and polarizability, to explain the inhibitory activity. Additionally, prevalence of aromatic ether functionality (descriptor nRORPh) and certain structural fragments (number of Me groups, C-001; number of H attached to heteroatom, H-050 and number of H attached to α-C, H-051) in a molecular structure are helpful to rationalize the COX-2 inhibitory activity of pyrimidine derivatives. The partial least square (PLS) analysis has also confirmed the dominance of information content of CP-MLR-identified descriptors for modelling the activity.

Headache and medication overuse: are clinical case series appropriate to reveal differential risks of different medications?

IMPORTANCE OF THE FIELD

The question of whether different migraine and headache medications show a differential risk of medication overuse headache (MOH) induction has been discussed extensively but has not been definitively answered to date.

AREAS COVERED IN THIS REVIEW

Clinical case series of interest that include statements on a differential risk of MOH development due to the use of different headache medications are identified by systematic literature research and analyzed.

WHAT THE READER WILL GAIN

In the present work, an expert evaluation is made of the existing evidence for different risks of different headache and migraine medications with regard to MOH occurrence, as has been claimed in various publications.

TAKE HOME MESSAGE

Despite several different attempts to obtain direct or indirect answers from clinical case series, the fact is that due to the intrinsic selection bias, confounding and other limitations inherent to clinical case series, they are not suitable to answer this question reliably. Thus, the repeated claims of a differential risk of different drugs and drug groups are simply not scientifically sound.

Are NSAIDs useful to treat Alzheimer's disease or mild cognitive impairment?

Several epidemiological studies suggest that long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) may protect subjects carrying one or more ε4 allele of the apolipoprotein E (APOE ε4) against the onset of Alzheimer's disease (AD). The biological mechanism of this protection is not completely understood and may involve the anti-inflammatory properties of NSAIDs or their ability of interfering with the β-amyloid (Aβ) cascade. Unfortunately, long-term, placebo-controlled clinical trials with both non-selective and cyclooxygenase-2 (COX-2) selective inhibitors in mild-to-moderate AD patients produced negative results. A secondary prevention study with rofecoxib, a COX-2 selective inhibitor, in patients with mild cognitive impairment was also negative. A primary prevention study (ADAPT trial) of naproxen (a non-selective COX inhibitor) and celecoxib (a COX-2 selective inhibitor) in cognitively normal elderly subjects with a family history of AD was prematurely interrupted for safety reasons after a median period of treatment of 2 years. Although both drugs did not reduce the incidence of dementia after 2 years of treatment, a 4-year follow-up assessment surprisingly revealed that subjects previously exposed to naproxen were protected from the onset of AD by 67% compared to placebo. Thus, it could be hypothesized that the chronic use of NSAIDs may be beneficial only in the very early stages of the AD process in coincidence of initial Aβ deposition, microglia activation and consequent release of pro-inflammatory mediators. When the Aβ deposition process is already started, NSAIDs are no longer effective and may even be detrimental because of their inhibitory activity on chronically activated microglia that on long-term may mediate Aβ clearance. The research community should conduct long-term trials with NSAIDs in cognitively normal APOE ε4 carriers.

The effects of lumiracoxib 100 mg once daily vs. ibuprofen 600 mg three times daily on the blood pressure profiles of hypertensive osteoarthritis patients taking different classes of antihypertensive agents

AIMS

To examine whether the blood pressure (BP) profiles of lumiracoxib and high-dose ibuprofen differed in patients treated with different classes of antihypertensive medications.

METHODS

A 4-week, multicentre, randomised, double-blind study has compared the effects of lumiracoxib 100 mg once daily (od) (n = 394) and ibuprofen 600 mg three times daily (tid) (n = 393) on ambulatory BP in osteoarthritis (OA) patients with controlled hypertension. Here, we present subgroup analyses for patients receiving different antihypertensive classes. The primary outcome was a comparison of the change in 24-h mean systolic ambulatory BP (MSABP) from baseline to week 4. Patients receiving angiotensin receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACEIs) represented the largest subgroups receiving antihypertensive monotherapy.

RESULTS

For patients receiving an ARB monotherapy, the least squares mean (LSM) 24-h MSABP at week 4 fell with lumiracoxib 100 mg od and increased with ibuprofen 600 mg tid, creating an estimated treatment difference of 8.1 mmHg in favour of lumiracoxib (p < 0.001). For patients receiving an ACEI and a beta-blocker monotherapy, the estimated treatment difference was 8.2 mmHg (p < 0.001) and 5.8 mmHg (p = 0.002) in favour of lumiracoxib respectively. These treatment differences were greater than observed in the overall population (5.0 mmHg in favour of lumiracoxib). In patients receiving diuretics or calcium channel blockers, treatment differences in MSABP were smaller and not statistically significant, although they remained in favour of lumiracoxib.

CONCLUSION

Lumiracoxib 100 mg od resulted in less destabilisation of BP than high-dose ibuprofen 600 mg tid, and this effect was the greatest in subgroups treated with drugs blocking the renin-angiotensin system.

An update on the efficacy of non-steroidal anti-inflammatory drugs in Alzheimer's disease

Several epidemiological studies suggest that long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) may protect against Alzheimer's disease (AD), especially for patients carrying one or more epsilon4 allele of the apolipoprotein E. The biological mechanism of this protection is not completely understood and may involve inhibition of COX activity, inhibition of beta-amyloid(1-42) (Abeta42) production and aggregation, inhibition of beta-secretase activity, activation of PPAR-gamma or stimulation of neurotrophin synthesis. Unfortunately, long-term, placebo-controlled clinical trials with both non-selective and COX-2 selective NSAIDs in AD patients produced negative results. A secondary prevention study with rofecoxib in patients with mild cognitive impairment and a primary prevention study with naproxen and celecoxib in elderly subjects with a family history of AD were also negative. All these failures have diminished the hope that NSAIDs could be beneficial in the treatment of AD. It is hypothesized that the chronic use of NSAIDs may be beneficial only in the normal brain by inhibiting the production of Abeta42. Once the Abeta deposition process has started, NSAIDs are no longer effective and may even be detrimental because of their inhibiting activity on activated microglia of the AD brain, which mediates Abeta clearance and activates compensatory hippocampal neurogenesis.

A comparison of the blood pressure changes of lumiracoxib with those of ibuprofen and naproxen

The 52-week Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET) investigated the gastrointestinal and cardiovascular safety profile of lumiracoxib 400 mg once daily compared with 2 traditional nonsteroidal anti-inflammatory drugs (NSAIDs): ibuprofen 800 mg 3 times daily and naproxen 500 mg twice daily. Data from TARGET were analyzed to examine the effect of lumiracoxib compared with ibuprofen and naproxen on blood pressure (BP), incidence of de novo and aggravated hypertension, prespecified edema events, and congestive heart failure. Lumiracoxib resulted in smaller changes in BP as early as week 4. Least-squares mean change from baseline at week 4 for systolic BP was +0.57 mm Hg with lumiracoxib compared with +3.14 mm Hg with ibuprofen (P<.0001) and +0.43 with lumiracoxib compared with +1.80 mm Hg with naproxen (P<.0001). In conclusion, the use of lumiracoxib and traditional NSAIDs results in differing BP changes; these might be of clinical relevance.

4 years after withdrawal of rofecoxib: where do we stand today?

On the 24th of October 2006, the European Medicines Agency (EMEA) stated that "it cannot be excluded that non-selective non-steroidal anti-inflammatory drugs (nsNSAIDs) may be associated with a small increase in the absolute risk for thrombotic events". Reviewing the most recent literature including meta-analyses of randomized clinical studies and pharmacoepidemiological studies show that this statement contrasts with the 2005 EMEA evaluation of cyclooxygenase-2 inhibitors, which contained a number of regulations including several contraindications for coxibs. Recent clinical data indicate that the entire substance group of NSAIDs may have cardiovascular side effects but to different degrees. Results of basic research support these observations showing that the increase for cardiovascular risk not only depends on the ratio of inhibition of thromboxan and prostacyclin but also on other mechanisms including blood pressure elevation and cyclooxygenase independent actions. In clinical practice, many patients require anti-inflammatory therapy with NSAIDs but are at high cardiovascular and gastrointestinal risk. The combination of nsNSAIDs with proton pump inhibitors shows comparable safety to coxibs in averting upper gastrointestinal events, but evidence is increasing coxibs have advantages regarding lower gastrointestinal side effects. Concomitant therapy with aspirin is another issue. There is a negative effect on gastrointestinal safety, as well as the influence of nsNSAIDs on the cardioprotective effect of aspirin. As the contraindications for coxibs announced by the EMEA may prevent some patients from receiving optimal treatment, a warning for the entire substance group, as issued by the American Food and Drug Administration, with no contraindictions, would certainly be more reasonable.

Ventricular diastolic function of ankylosing spondylitis patients by using conventional pulsed wave Doppler, myocardial performance index and tissue Doppler imaging

OBJECTIVE

The aim of this study was to evaluate ventricular functions by using standard Doppler echocardiography (SDE), myocardial performance index (MPI), and pulsed wave tissue Doppler imaging (PW-TDI) in patients with ankylosing spondylitis (AS) and healthy controls.

METHODS

Forty-nine AS patients (38 +/- 11 years, 25 M/24 F) and 33 controls (36 +/- 9 years, 17 M/16 F) were studied. Two-dimensional, M-Mode, SDE, PW-TDI echocardiography examinations were performed. Spinal mobility was assessed by the Bath ankylosing spondylitis metrology index (BASMI) measurement. Patients were also evaluated using the Bath ankylosing spondylitis functional index (BASFI) and the Bath ankylosing spondylitis disease activity index (BASDAI).

RESULTS

Four control subjects and six AS patients met the left ventricular (LV) diastolic dysfunction (DD) criteria by using conventional Doppler echocardiography (p > 0.05). However, using PW-TDI method 22 patients in the AS group and six subjects in the control group were diagnosed to have LV DD (Em/Am < 1). Pseudonormalized pattern was present in 16 AS patients and two control subjects. Correlation analysis revealed significant moderate negative correlations between Em/Am and BASMI, age and body mass index (p < 0.05; r =-0.3, -0.6, and -0.4, respectively). No correlation was observed between Em/Am and disease duration, BASFI, BASDAI, CRP, and ESR. We could not detect any right ventricular function involvement either by conventional or by recently introduced echocardiography methods. The risk of developing LV DD was found to be 3.7 times higher in AS patients.

CONCLUSION

When sensitive echocardiographic Doppler techniques such as MPI, TDI-derived MPI, and PW-TDI are utilized, DD can be detected in a significant proportion of patients with AS without cardiovascular (CV) disease which may contribute CV mortality in these patients.

Novel 2-(4-methylsulfonylphenyl)pyrimidine derivatives as highly potent and specific COX-2 inhibitors

New series of 2-(4-methylsulfonylphenyl) and 2-(4-sulfamoylphenyl)pyrimidines were synthesized and evaluated for their ability to inhibit cyclooxygenase-2 (COX-2). COX-1 and COX-2 inhibitory activity of these compounds was determined using purified enzyme (PE) and human whole blood (HWB) assays. Extensive structure-activity relationship (SAR) work was carried out within these series, and a wide number of potent and specific COX-2 inhibitors were identified (HWB COX-2 IC(50)=2.4-0.3nM and 80- to 780-fold more selective than rofecoxib).

Risk of myocardial infarction associated with selective COX-2 inhibitors: meta-analysis of randomised controlled trials

PURPOSE

To evaluate the risk of myocardial infarction (MI) associated with the use of selective cyclooxygenase-2 (COX-2) inhibitors (coxibs).

METHODS

Systematic review and meta-analysis of randomised controlled trials (RCTs) using a fixed-effect model to estimate the odds ratios (ORs) for risk of MI associated with coxibs compared against placebo, non-steroidal anti-inflammatory drugs (NSAIDs) and other coxibs.

RESULTS

Fifty-five trials (99 087 patients) were included in the meta-analysis. The overall pooled OR for MI risk for any coxib compared against placebo was 1.46 (95%CI: 1.02, 2.09). We found celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib were associated with higher MI risks compared against placebo. The pooled OR for any coxib compared against other NSAIDs was 1.45 (95%CI: 1.09, 1.93). Rofecoxib had a significantly higher risk of MI than naproxen (OR: 5.39; 95%: 2.08, 14.02) and valdecoxib had lower MI risk than diclofenac (OR: 0.14, 95%CI: 0.03, 0.73). There were no significant differences identified in the risk of MI from the available head-to-head comparisons of coxibs.

CONCLUSIONS

Coxibs were associated with increased risks of MI when compared against placebo or non-selective NSAIDs. Differences in MI risk were also apparent between comparisons of individual NSAIDs. Future work should consider using individual patient data (IPD) meta-analysis to explore differences in MI risk between different subgroups of patients.

Cyclooxygenase-2 (COX-2)-independent anticarcinogenic effects of selective COX-2 inhibitors

Nonsteroidal antiinflammatory drugs (NSAIDs) appear to reduce the risk of developing cancer. One mechanism through which NSAIDs act to reduce carcinogenesis is to inhibit the activity of cyclooxygenase-2 (COX-2), an enzyme that is overexpressed in various cancer tissues. Overexpression of COX-2 increases cell proliferation and inhibits apoptosis. However, selective COX-2 inhibitors can also act through COX-independent mechanisms. In this review, we describe the COX-2-independent molecular targets of these COX-2 inhibitors and discuss how these targets may be involved in the anticarcinogenic activities of these selective COX-2 inhibitors. We also compare the concentrations of these inhibitors used in in vitro and in vivo experiments and discuss the implications of the in vitro studies for clinical management of cancer with these drugs.