Cyclooxygenase-2 inhibitor-associated acute renal failure: case report with rofecoxib and review of the literature

Chronic Pain Management in the Elderly

Chronic pain is extremely prevalent in older adults and is associated with significant morbidity, including limited mobility, social isolation, and depressed mood. Pain is defined by a biopsychosocial model highlighting the importance of a multidisciplinary approach to treatment, including multimodal medications, selected interventions, physical therapy and rehabilitation, and psychological treatments. In this narrative review, the authors highlight the use of these approaches in older adults with specific attention paid to considerations unique to aging, including alterations in drug metabolism, avoidance of polypharmacy, and physiologic changes predisposing to painful conditions.

The epidemiology of drug-induced disorders: the kidney

The epidemiology of drug-induced renal disorders is a complex topic. Drug-associated nephrotoxicity accounts for 18 - 27% of all acute kidney injury cases in US hospitals. Medications can affect all aspects of the kidney, and drugs that are associated with renal dysfunction are used commonly in clinical practice. The article reviews six major mechanisms of drug-induced renal dysfunction as well as lists the major medications involved. NSAIDs, aminoglycosides, amphotericin B and calcineurin inhibitors are just some examples of drugs that contribute to renal dysfunction. The medical community must be aware of patient risk factors for nephrotoxicity, as well as the drug's inherent nephrotoxic potential, when prescribing and administering medications.

Drug-Associated Renal Dysfunction

Acute renal failure (ARF) in patients in the ICU is associated with a high mortality. Drug-induced renal dysfunction is an important, yet often overlooked, cause of ARF in this patient population. A drug use evaluation at the authors' institution, to assess the prescribing patterns of potential nephrotoxins in the adult and pediatric ICUs, found that antibiotics (aminoglycosides, amphotericin B, penicillins, cephalosporins, acyclovir), nonsteroidal anti-inflammatory drugs, contrast dye, and various other nephrotoxic medications are used widely in all of the ICUs. By focusing on several commonly prescribed classes of nephrotoxic medications in the ICU, this article reviews the general mechanisms of drug-associated renal dysfunction.

Tacrolimus and nonsteroidal anti-inflammatory drugs: an association to be avoided

BACKGROUND

Tacrolimus (FK) and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause acute nephrotoxicity. The expanding use of tacrolimus and the intense consumption of NSAIDS increase the chances of their simultaneous use.

METHODS

Rats receiving a nonselective COX inhibitor (diclofenac, D) and FK or a selective COX-2 inhibitor (rofecoxib, RO) and FK were treated with FK (2 mg/kg/day), D (10 mg/kg/day), RO (3 mg/kg/day), FK+D, FK+RO and vehicle for 7 days on low-salt diet.

RESULTS

Both associations significantly impaired glomerular filtration rate (GFR; 0.63 +/- 0.06 ml/min/100 g in FK+D, 0.83 +/- 0.06 ml/min/100 g in FK+RO) which did not occur with single drug therapy (0.98 +/- 0.03 ml/min/100 g in D, 1.06 +/- 0.04 ml/min/100 g in RO, 0.99 +/- 0.05 ml/min/ 100 g in FK) or vehicle (1.10 +/- 0.05 ml/min/100 g). GFR decrease was significantly higher with FK+D. GFR impairment occurred without RBF or RVR major changes. Mild tubular vacuolization and dilatation and acute degenerative changes were observed in tubular cells. FK+D animals showed a marked weight loss, not observed in the other groups. FK+NSAIDs association decreased FK blood levels (1.73 +/- 0.3 ng/ml in FK+D, 1.8 +/- 0.3 ng/ml in FK+RO, 3.2 +/- 0.4 ng/ml in FK, p < 0.05).

CONCLUSIONS

The association of FK and nonselective or COX-2 selective NSAIDs in salt-depleted animals caused a significant GFR impairment and decreased FK blood levels.

Drug dosing in chronic kidney disease

Patients with chronic kidney disease (CKD) are at high risk for adverse drug reactions and drug-drug interactions. Drug dosing in these patients often proves to be a difficult task. Renal dysfunction-induced changes in human pathophysiology regularly results may alter medication pharmacodynamics and handling. Several pharmacokinetic parameters are adversely affected by CKD, secondary to a reduced oral absorption and glomerular filtration; altered tubular secretion; and reabsorption and changes in intestinal, hepatic, and renal metabolism. In general, drug dosing can be accomplished by multiple methods; however, the most common recommendations are often to reduce the dose or expand the dosing interval, or use both methods simultaneously. Some medications need to be avoided all together in CKD either because of lack of efficacy or increased risk of toxicity. Nevertheless, specific recommendations are available for dosing of certain medications and are an important resource, because most are based on clinical or pharmacokinetic trials.

Selektive Zyklooxygenase-2-Inhibitoren zur postoperativen Schmerztherapie

Systemic administration of analgesics is still the most widely used method for postoperative pain therapy. In the concept of balanced or multimodal analgesia non-steroidal anti-inflammatory drugs (NSAIDs) play an important role besides opioids. Their analgesic effect is based on a diminished prostaglandin synthesis by inhibition of the cyclooxygenase (COX) enzyme in the arachidonic acid metabolism. The discovery of at least two COX isoenzymes led to the development of selective COX-2 inhibitors that were hypothesized to have an improved risk-benefit-ratio compared with conventional NSAIDs. In this context the analgesic efficacy and adverse effects of selective COX-2 inhibitors for postoperative pain therapy were evaluated by reviewing the pertinent literature.