NSAID-associated adverse effects and acid control aids to prevent them: a review of current treatment options

Experimental and Machine-Learning-Assisted Design of Pharmaceutically Acceptable Deep Eutectic Solvents for the Solubility Improvement of Non-Selective COX Inhibitors Ibuprofen and Ketoprofen

Deep eutectic solvents (DESs) are commonly used in pharmaceutical applications as excellent solubilizers of active substances. This study investigated the tuning of ibuprofen and ketoprofen solubility utilizing DESs containing choline chloride or betaine as hydrogen bond acceptors and various polyols (ethylene glycol, diethylene glycol, triethylene glycol, glycerol, 1,2-propanediol, 1,3-butanediol) as hydrogen bond donors. Experimental solubility data were collected for all DES systems. A machine learning model was developed using COSMO-RS molecular descriptors to predict solubility. All studied DESs exhibited a cosolvency effect, increasing drug solubility at modest concentrations of water. The model accurately predicted solubility for ibuprofen, ketoprofen, and related analogs (flurbiprofen, felbinac, phenylacetic acid, diphenylacetic acid). A machine learning approach utilizing COSMO-RS descriptors enables the rational design and solubility prediction of DES formulations for improved pharmaceutical applications.

Molecular hybridization: a powerful tool for multitarget drug discovery

INTRODUCTION

The current drug discovery paradigm of 'one drug, multiple targets' has gained attention from both the academic medicinal chemistry community and the pharmaceutical industry. This is in response to the urgent need for effective agents to treat multifactorial chronic diseases. The molecular hybridization strategy is a useful tool that has been widely explored, particularly in the last two decades, for the design of multi-target drugs.

AREAS COVERED

This review examines the current state of molecular hybridization in guiding the discovery of multitarget small molecules. The article discusses the design strategies and target selection for a multitarget polypharmacology approach to treat various diseases, including cancer, Alzheimer's disease, cardiac arrhythmia, endometriosis, and inflammatory diseases.

EXPERT OPINION

Although the examples discussed highlight the importance of molecular hybridization for the discovery of multitarget bioactive compounds, it is notorious that the literature has focused on specific classes of targets. This may be due to a deep understanding of the pharmacophore features required for target binding, making targets such as histone deacetylases and cholinesterases frequent starting points. However, it is important to encourage the scientific community to explore diverse combinations of targets using the molecular hybridization strategy.

Conquering rheumatic diseases: are parasitic worms the answer?

Despite the introduction of novel treatment strategies, management of rheumatic disorders remains associated with substantial unmet clinical need. Of interest therefore, it has recently become apparent that there is a global inverse relationship between the incidence of such conditions and parasitic helminth infection, with striking examples involving rheumatoid arthritis (RA)/systemic lupus erythematosus (SLE) patients and filarial nematode worm infection in studies in India. Such findings reflect that helminths are master manipulators of the immune system, particularly in being able to modulate proinflammatory responses. The aim of this article is thus to consider findings to date on this exciting and intriguing research area to form an opinion on whether parasitic worms may be exploited to generate novel therapies for rheumatic diseases.

Comparative Evaluation of the Efficacy of Two Modes of Delivery of Diclofenac for the Management of Post-Endodontic Pain: A Randomized Controlled Clinical Trial

Background

This study aimed to compare the efficacy of two modes of delivery of diclofenac for the management of post-endodontic pain.

Materials and Methods

This study comprised 30 patients reporting to the department with pain in their teeth. Pain was assessed using the visual analog scale (VAS): group A (control group), group B (oral diclofenac), and group C (transdermal patch). A VAS was given to the patients in each group, and the severity of any pain was self-assessed by patients after 4 hrs, 8 hrs, 12 hrs, 24 hrs, and 48 hrs following the completion of treatment.

Results

A comparison between group oral and diclofenac transdermal patch was carried out. The pain frequency was measured at 4 hrs, 8 hrs, 12 hrs, 24 hrs, and 48 hrs postoperatively with P values of 0.744, 0.035, 0.570, 0.060, and 0.508 and was statistically insignificant.

Conclusion

Preoperative analgesics play an important role in reducing post-endodontic pain. Transdermal patches containing diclofenac show a promising analgesic modality in managing endodontic pain.

Analgesic Efficacy of Ketoprofen Transdermal Patch versus Ibuprofen Oral Tablet on Postendodontic Pain in Patients with Irreversible Pulpitis: A Randomized Clinical Trial

Materials and Methods

In this randomized clinical trial, 64 patients who had mandibular first and second molars with irreversible pulpitis were randomly divided into two groups (n = 32) by stratified permuted block randomization. The experimental group used 60 mg KTP every 6 hours, and the control group received 400 mg ibuprofen tablets every 6 hours for 1 day. The severity of pain experienced by patients was quantified before and at 2, 4, 8, 12, 24, and 48 hours after endodontic treatment, using the numerical rating scale (NRS). Data were analyzed by using the t-test, Mann-Whitney test, and generalized estimating equation (GEE) (alpha = 0.05).

Results

The pain score was not significantly different between the two groups at the baseline or any other postoperative time point (P > 0.05). The reduction in the pain score was significant in both groups from 2 to 10 hours and 10 to 48 hours, postoperatively (P < 0.001). The interaction effect of time and group was not significant on the postoperative pain score in the abovementioned time intervals, and the pattern of pain reduction was the same over time in both groups (P > 0.05).

Conclusion

Both KTP and ibuprofen effectively decreased postendodontic pain. Considering the comparable pattern of pain reduction, KTP can be used as an alternative to ibuprofen tablets for effective pain control after endodontic treatment of mandibular first and second molars with irreversible pulpitis.

Design, synthesis, modeling studies and biological evaluation of pyrazole derivatives linked to oxime and nitrate moieties as nitric oxide donor selective COX-2 and aromatase inhibitors with dual anti-inflammatory and anti-neoplastic activities

Two new series of pyrazole derivatives 10a-f and 11a-f with selective COX-2 inhibition pharmacophore and oxime/nitrate moieties as NO donor moiety were designed, synthesized and tested for anti-inflammatory, cytotoxic activities and NO release. Compounds 10c, 11a, 11e were more selective for COX-2 isozyme (S.I. = 25.95, 22.52 and 21.54 respectively) in comparison to celecoxib (S.I. = 21.41). Regarding anti-cancer activity, all synthesized compounds were screened by the National Cancer Institute (NCI), Bethesda, USA for anticancer activity against 60 human cancer cell lines representing the following cancer types: leukemia, non-small cell lung, colon, CNS, melanoma, ovarian, renal, prostate, and breast cancers. Compounds 10c, 11a, 11e were found to be the most potent inhibitors on breast, ovarian and melanoma cell lines (MCF-7, IGROV1 and SK-MEL-5), compound 11a causing 79 % inhibition in case of MCF-7, 78.80 % inhibition in case of SK-MEL-5 and unexpected cell growth -26.22 % inhibition in case of IGROV1 (IC₅₀ = 3.12, 4.28, 4.13 μM respectively). On the other hand, compounds 10c and 11e showed lower inhibition on the same cell lines with IC₅₀ = 3.58, 4.58, 4.28 μM respectively for 10c, IC₅₀ = 3.43, 4.73, 4.43 μM respectively for 11e. Furthermore, DNA-flow cytometric analysis showed that compound 11a induces cell cycle arrest at G2/M phase leading to cell proliferation inhibition and apoptosis. Additionally, these derivatives examined against F180 fibroblasts to investigate their selectivity indexes. The pyrazole derivative with internal oxime 11a was the most potent compound against most used cell lines especially MCF-7, IGROV1 and SK-MEL-5 (IC₅₀ = 3.12, 4.28, 4.13 μM respectively) with 4.82-fold selectivity towards MCF-7 than F180 fibroblasts. Moreover, oxime derivative 11a showed potent aromatase inhibitory activity (IC₅₀ 16.50 μM) when compared with reference compound letrozole (IC₅₀ 15.60 μM). All compounds 10a-f and 11a-f released NO in a slow rate (0.73-3.88 %) and the six derivatives 10c, 10e, 11a, 11b, 11c and 11e were the highest NO releasers (3.88, 2.15, 3.27, 2.27, 2.55 and 3.74 % respectively). Herein structure based and ligand based studies were implemented to under stand and evaluate the compounds activity for further in vivo and preclinical studies. Docking mode of final designed compounds with celecoxib (ID: 3LN1) represented that their triazole ring adopted as the core aryl in Y shaped structure. Regarding aromatase enzyme inhibition, docking was carried out with ID: 1 M17. The internal oxime series was more active as anticancer because of their ability to form extra HBs with receptor cleft.

Novel dual-target μ‑opioid and TRPV1 ligands as potential pharmacotherapeutics for pain management

Currently, the development of effective analgesic drugs with few side effects remains a great challenge. Studies have suggested that multi-target drug treatments show high efficacy and reduced side effects compared to single-target drug therapies. In this work, we designed and synthesized two series of novel MOR/TRPV1 dual active ligands in which the phenylpiperidine group or the N-phenyl-N-(piperidin-4-yl) propionamide group as the MOR pharmacophore was fused to the benzylpiperazinyl urea-based TRPV1 pharmacophore. In particular, compound 5a exhibited promising dual pharmacological activity for MOR (EC₅₀ = 53.7 nM) and TRPV1 (IC₅₀ = 32.9 nM) in vitro. In formalin tests, compound 5a showed potent, dose-dependent in vivo analgesic activity in both the 1st and 2nd phases. Gratifyingly, compound 5a did not cause the side effects of hyperthermia and analgesic tolerance. Consistent with its in vitro activity, compound 5a also simultaneously agonized MOR and antagonized TRPV1 in vivo. Further studies on compound 5a showed acceptable pharmacokinetic properties and brain permeability. Furthermore, molecular docking studies showed that compound 5a tightly bound to the active pockets of hMOR and hTRPV1, respectively. Overall, this work shows the promise in discovering new analgesic treatments through the strategy of simultaneously targeting MOR and TRPV1 with a single molecule.

Design and synthesis of ibuprofen-quinoline conjugates as potential anti-inflammatory and analgesic drug candidates

A new set of ibuprofen-quinoline conjugates comprising quinolinyl heterocycle and ibuprofen moieties linked by an alkyl chain were synthesized in good yields utilizing an optimized reaction procedure in a molecular hybridization approach to overcome the drawbacks of the current non-steroidal anti-inflammatory drugs. The synthesized conjugates were screened for their anti-inflammatory, and ulcerogenic properties. Several conjugates were found to have significant anti-inflammatory properties in the carrageenan-induced rat paw edema test without showing any ulcerogenic liability. In addition, most conjugates showed promising peripheral analgesic activity in the acetic acid-induced writhing test as well as central analgesic properties in the in vivo hot plate test. The most promising conjugates were the unsubstituted and 6-substituted fluoro- and chloro-derivatives of 2-(trifluoromethyl)quinoline linked to ibuprofen by a propyl chain. Their anti-inflammatory activity was evaluated against LPS-stimulated inflammatory reactions in RAW264.7 mouse macrophages. In this regard, it was found that most of the conjugates were able to significantly reduce the release and production of nitric oxide in the LPS-stimulated macrophages. The secretion and expression of the pro-inflammatory cytokines IL-6, TNF-α, and inducible nitric oxide synthase (iNOS) were also significantly suppressed.

The Effect of Effleurage Massage Therapy on Symptoms of Osteoarthritis in Elderly Women with Osteoarthritis: A Cross-Clinical Trial

BACKGROUND: Osteoarthritis is the main and most common cause of pain and disability in older people. It affects women 3.5 times more than men. AIM: Therefore, the present study aimed to determine the effect of effleurage massage therapy on symptoms of osteoarthritis in elderly women with osteoarthritis. MATERIALS AND METHODS: The present study was a cross-sectional clinical trial with a control group on 58 elderly women with mild to moderate osteoarthritis in 2018. At the first stage of the study, we give a massage on each knee every day for 15 min a week by the Effleurage method with standard treatment (100 mg diclofenac) and the control group only received standard treatment. At the second stage, the intervention was shifted in groups according to the study type after 3 weeks of washout. The research instrument was a native questionnaire (The Knee Injury and Osteoarthritis Outcome Score [KOOS]). We analyzed data using the SPSS20. RESULTS: The research results indicated that knee massage techniques could reduce the severity of symptoms at both stages of the study in the intervention group. At the first stage, the severity of symptoms in Group A (intervention group) significantly decreased after the intervention compared to the pre-intervention and also decreased after washout in Group B (intervention group) after the intervention compared to the pre-intervention (p < 0.0001). CONCLUSION: Given the effect of massage on reducing symptoms of knee osteoarthritis (morning dryness, stiffness, and swelling,) in elderly women with osteoarthritis, massage therapy is recommended as an effective intervention to reduce symptoms of knee osteoarthritis in these patients.

The efficacy of high- and low-dose curcumin in knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to critically appraise and evaluate effects of low- and high-dose curcuminoids on pain and functional improvement in patients with knee osteoarthritis (OA) and to compare adverse events (AEs) between curcuminoids and non-steroid anti-inflammatory drugs (NSAIDs).

METHODS

We systematically reviewed all randomized controlled trials (RCTs) on curcuminoids in knee osteoarthritis from the PubMed, Embase, Cochrane Library, AMED, Cinahl, ISI Web of Science, Chinese medical database, and Indian Scientific databases from inception to June 21, 2021.

RESULTS

We included eleven studies with a total of 1258 participants with primary knee OA. The meta-analysis results showed that curcuminoids were significantly more effective than comparators regarding visual analogue scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scores. However, no significant difference in pain relief or AEs between the high-dose (daily dose ≥1000 mg or total dose ≥42 gm) and low-dose (daily dose <1000 mg or total dose <42 gm) curcuminoid treatments was observed. When comparing curcumininoids versus NSAIDs, a significant difference in VAS pain was found. For AE analysis, three of our included studies used NSAIDs as comparators, with all reporting higher AE rates in the NSAID group, though significance was reached in only one study.

CONCLUSIONS

The results of our meta-analysis suggest that low- and high-dose curcuminoids have similar pain relief effects and AEs in knee OA. Curcuminoids are also associated with better pain relief than NSAIDs; therefore, using curcuminoids as an adjunctive treatment in knee OA is recommended.

The retinoid X receptor α modulator K-80003 suppresses inflammatory and catabolic responses in a rat model of osteoarthritis

Osteoarthritis (OA), a most common and highly prevalent joint disease, is closely associated with dysregulated expression and modification of RXRα. However, the role of RXRα in the pathophysiology of OA remains unknown. The present study aimed to investigate whether RXRα modulator, such as K-80003 can treat OA. Experimental OA was induced by intra-articular injection of monosodium iodoacetate (MIA) in the knee joint of rats. Articular cartilage degeneration was assessed using Safranin-O and fast green staining. Synovial inflammation was measured using hematoxylin and eosin (H&E) staining and enzyme-linked immunosorbent assay (ELISA). Expressions of MMP-13, ADAMTS-4 and ERα in joints were analyzed by immunofluorescence staining. Western blot, RT-PCR and co-Immunoprecipitation (co-IP) were used to assess the effects of K-80003 on RXRα-ERα interaction. Retinoid X receptor α (RXRα) modulator K-80003 prevented the degeneration of articular cartilage, reduced synovial inflammation, and alleviated osteoarthritic pain in rats. Furthermore, K-80003 markedly inhibited IL-1β-induced p65 nuclear translocation and IκBα degradation, and down-regulate the expression of HIF-2α, proteinases (MMP9, MMP13, ADAMTS-4) and pro-inflammatory factors (IL-6 and TNFα) in primary chondrocytes. Additionally, knockdown of ERα with siRNA blocked these effects of K-80003 in chondrocytes. In conclusion, RXRα modulators K-80003 suppresses inflammatory and catabolic responses in OA, suggesting that targeting RXRα-ERα interaction by RXRα modulators might be a novel therapeutic approach for OA treatment.

Effect of dry cupping versus soft and prolonged massage in the management of knee osteoarthritis - a randomized controlled clinical trial

OBJECTIVES

Osteoarthritis is one of the most common musculoskeletal diseases which leads to functional decline and loss of quality of life. Knee osteoarthritis is considered as highly burdensome disease as well as highest contributor to global disability. Ḥijāmah (Cupping Therapy) and Dalk (Massage) are claimed effective in the treatment of Waja'ul Mafāṣil (osteoarthritis). Present study was framed to compare the efficacy of Ḥijāmah bilā Sharṭ (Dry Cupping) and Dalk-i-Layyin Kathīr (soft and prolonged massage) with Roghan-i-Bābūna (chamomile oil) in the management of Waja' ur Rukbah (knee osteoarthritis).

METHODS

In present randomised controlled clinical trial, a total of 48 diagnosed patients of knee osteoarthritis were allocated randomly into group A (n=24) and group B (n=24). Group A was treated with soft and prolonged massage with Roghan-i-Bābūna while group B was managed with dry cupping on alternate day for 15 min. Visual Analog Scale (VAS) and Knee osteoarthritis outcome score (KOOS) were used for the assessment of efficacy. A total of 40 patients, group A (n=20) and group B (n=20), were completed the allocated duration of protocol therapy and were restricted to statistical analysis.

RESULTS

Statistically highly significant improvement was observed in objective parameters using both paired and unpaired t-tests. VAS and all KOOS subscales were found to be strongly significant at 20th day when compared with baseline (p<0.001). In intergroup comparison significant change (p>0.05) was not observed. Safety parameters were in their normal range after treatment.

CONCLUSIONS

Dalk-i-Layyin Kathīr with Roghan-i-Bābūna and Ḥijāmah bilā Sharṭ both were found safe and effective in the management of Waja'ur Rukbah. Hence, it may be concluded that both regimenal therapies are safe, effective and almost equal in their efficacy in the management of Knee Osteoarthritis.

Antiinflammatory Medicinal Plants from the Ugandan Greater Mpigi Region Act as Potent Inhibitors in the COX-2/PGH2 Pathway

Our study investigates 16 medicinal plants via assessment of inhibition of proinflammatory enzymes such as cyclooxygenases (COX). The plants are used by traditional healers in the Greater Mpigi region in Uganda to treat inflammation and related disorders. We present results of diverse in vitro experiments performed with 76 different plant extracts, namely, (1) selective COX-2 and COX-1 inhibitor screening; (2) 15-LOX inhibition screening; (3) antibacterial resazurin assay against multidrug-resistant Staphylococcus aureus, Listeria innocua, Listeria monocytogenes, and Escherichia coli K12; (4) DPPH assay for antioxidant activity; and (5) determination of the total phenolic content (TPC). Results showed a high correlation between traditional use and pharmacological activity, e.g., extracts of 15 out of the 16 plant species displayed significant selective COX-2 inhibition activity in the PGH₂ pathway. The most active COX-2 inhibitors (IC₅₀ < 20 µg/mL) were nine extracts from Leucas calostachys, Solanum aculeastrum, Sesamum calycinum subsp. angustifolium, Plectranthus hadiensis, Morella kandtiana, Zanthoxylum chalybeum, and Warburgia ugandensis. There was no counteractivity between COX-2 and 15-LOX inhibition in these nine extracts. The ethyl acetate extract of Leucas calostachys showed the lowest IC₅₀ value with 0.66 µg/mL (COX-2), as well as the most promising selectivity ratio with 0.1 (COX-2/COX-1). The TPCs and the EC₅₀ values for DPPH radical scavenging activity showed no correlation with COX-2 inhibitory activity. This led to the assumption that the mechanisms of action are most likely not based on scavenging of reactive oxygen species and antioxidant activities. The diethyl ether extract of Harungana madagascariensis stem bark displayed the highest growth inhibition activity against S. aureus (MIC value: 13 µg/mL), L. innocua (MIC value: 40 µg/mL), and L. monocytogenes (MIC value: 150 µg/mL). This study provides further evidence for the therapeutic use of the previously identified plants used medicinally in the Greater Mpigi region.

Development of multitarget inhibitors for the treatment of pain: Design, synthesis, biological evaluation and molecular modeling studies

Multitarget-directed ligands are a promising class of drugs for discovering innovative new therapies for difficult to treat diseases. In this study, we designed dual inhibitors targeting the human fatty acid amide hydrolase (FAAH) enzyme and human soluble epoxide hydrolase (sEH) enzyme. Targeting both of these enzymes concurrently with single target inhibitors synergistically reduces inflammatory and neuropathic pain; thus, dual FAAH/sEH inhibitors are likely to be powerful analgesics. Here, we identified the piperidinyl-sulfonamide moiety as a common pharmacophore and optimized several inhibitors to have excellent inhibition profiles on both targeted enzymes simultaneously. In addition, several inhibitors show good predicted pharmacokinetic properties. These results suggest that this series of inhibitors has the potential to be further developed as new lead candidates and therapeutics in pain management.

Managing Acute Dental Pain: Principles for Rational Prescribing and Alternatives to Opioid Therapy

Pharmacotherapy forms an integral part of acute dental pain management. In a majority of cases, safe and effective management of acute dental pain can be accomplished with a non-opioid medication regimen. Nonetheless, in certain circumstances use of opioid medications may be needed. Furthermore, there are various pain management regimens, such as pre-emptive analgesia, post-procedural cold compression, use of long acting anesthetic, and compound drug therapy that can improve the efficacy of analgesics to achieve a desired therapeutic response without compromising patient safety.

Gelatin nanoparticles for NSAID systemic administration: Quality by design and artificial neural networks implementation

The present study evaluates the preparation of systemic administrated NSAID gelatin nanoparticles with the aid of quality by design and artificial neural networks (ANNs). Specifically, two different preparation techniques (i.e. nanoprecipitation and two-step desolvation) were implemented for the formulation of diclofenac sodium (DLC) gelatin nanoparticles (GNs). Preliminary screening experiments showed that in the case of nanoprecipitation the best compromise (in terms of achieving both small particle size and high encapsulation efficiency) was the use of poloxamer 407 (as stabilizer) and acetone (as non-solvent), while in the case of two-step desolvation significant effect had the use of acetone, gelatin type and bloom number (type B with bloom 150 was selected for further evaluation). Implementation of a central composite experimental design (CCD), showed that in the case of nanoprecipitation the optimum formulation can be achieved at high poloxamer, high gelatin and moderate to high glutaraldehyde (GTA used for crosslinking) concentrations, while in the case of two-step desolvation high gelatin and GTA concentrations are needed. Artificial neural networks (ANN) implementation showed significantly improved prediction ability compared to MLR, while verification experiments showed good agreement between the ANN predicted and the experimentally obtained results. SEM analysis of the optimum suggested formulations showed nanoparticles with smooth surface, while powder X-ray diffraction (XRD) analysis showed the formation of amorphously dispersed systems, and Fourier transform infrared spectroscopy (FTIR) revealed the presence of molecular interactions irrespectively of the preparation method followed. A slightly faster release profile was observed in the case of nanoprecipitation based GNs, while all formulations followed biphasic release profile.

Conjugation of 4-aminosalicylate with thiazolinones afforded non-cytotoxic potent in vitro and in vivo anti-inflammatory hybrids

Eicosanoids like leukotrienes and prostaglandins that produced within the arachidonic acid cascade are involved in the pathogenesis of pain, acute and chronic inflammatory diseases. A promising approach for an effective anti-inflammatory therapy is the development of inhibitors targeting more than one enzyme of this cascade. Aiming to develop balanced COX/LOX inhibitors; 4-aminosalicylate based thiazolinones having different substituents at the 5th position of the 4-thiazolinone ring (2-22) were designed, synthesized, characterized and evaluated in vitro and in vivo for their anti-inflammatory activity. Most of the investigated compounds showed high COX-2 inhibitory potencies (IC₅₀ 39-200 nM) with selectivity indexes (30-84). Two compounds, 19 and 21, (IC₅₀ = 41 and 44 nM), are equipotent to celecoxib (IC₅₀ = 49 nM), while compound 22 (IC₅₀ = 39 nM) was the most potent. For 15-LOX, compounds 5, 11, 19, 21 and 22 revealed higher potency (IC₅₀ 1.5-2.2 µM) than zileuton (IC₅₀ 15 µM). Thus, compounds 5, 11, 19, 21 and 22 are potent dual inhibitors of COX-2 and 15-LOX. In vivo anti-inflammatory testing of these compounds revealed that, compounds 5 and 21 had an anti-inflammatory activity similar to indomethacin and celecoxib (% inhibition of oedema = 60 ± 9) and higher than diclofenac potassium (% inhibition = 52 ± 29), while compound 22 (% inhibition = 63 ± 5) was more active than the reference drugs. The results showed that the activity is controlled by the bulkiness and lipophilicity of the substituent at the 5th position. The cytotoxicity results revealed that all compounds are not cytotoxic, additionally, in an experimental model of ulcerogenic effect, the most active compounds 21 and 22 showed better safety profile than indomethacin. Further, at the active sites of the COX-1, COX-2 and 15-LOX co-crystal, 19, 21, and 22 showed high binding forces in free binding energy study, which is consistent with in vitro and in vivo results. In conclusion, these compounds are good candidates for further biological investigation as potential anti-inflammatory drugs with dual balanced inhibition of COX and 15-LOX and good safety profile.

Design and Development of Novel 2-(Morpholinyl)-N-substituted Phenylquinazolin-4-amines as Selective COX-II Inhibitor

Background:

A novel series of 2-(Morpholin-4-yl)-N-phenylquinazolin-4-amine derivatives were synthesized and confirmed with spectral and elemental techniques.

Methods:

The compounds were tested for analgesic and anti-inflammatory activity by various pain models in rodents whereas the selectivity towards COX-2 receptor is determined by in vitro assay.

Results:

Screening results of compounds exhibited comparable biological activity with that of standard compound Indomethacin used for study. Compound 5d was found to be significantly potent with respect to its anti-inflammatory and analgesic activity with substantial COX-II selectivity.

Conclusion:

In silico analysis by molecular docking and 3D-QSAR studies justifies activity profile of compound 5d, suggesting that it may have potential for further evaluation and development as lead molecule for therapy in pain management.

Pain Control by Novel Route of Gifted Choice Against Peroral Route

Introduction

Pain after surgical extraction of third molars has been a nemesis for oral surgeons with clinicians, thus striving for an analgesic modality. NSAIDs are among the most widely used therapeutic classes of analgesics. Transbuccal diclofenac sodium patches have been developed as an innovative drug delivery system using buccal mucosa as a gifted choice, hence overcoming first pass metabolism and offering the advantage of sustained drug delivery with reduced incidence of systemic adverse effects.

Aim

A comparative study was conducted to evaluate the efficacy of diclofenac sodium for pain control, administered via the far-fetched and gifted novel route through the transbuccal patch and by ever popular per oral route and also to assess the adverse effects vis-à-vis for transbuccal diclofenac patch and oral diclofenac following extraction of bilaterally symmetrical impacted mandibular third molars under local anaesthesia.

Methodology

Thirty healthy subjects of both the sexes in the age of 12 to 50 years with asymptomatic bilaterally symmetrical mandibular third molars underwent extraction under LA. It is a split-mouth study, i.e. after the extraction of tooth on one side, diclofenac sodium (50 mg) via oral route was given and then in another visit, when the same patient is comfortable and asymptomatic, extraction on contralateral side was executed and transbuccal patched diclofenac sodium (20 mg) was applied. Pain was measured on visual analog scale and verbal rating scale by the patient for 3 days and adverse effects if any were noted.

Result

Statistical analysis showed that transbuccal diclofenac sodium was significantly efficacious when compared to the drug administered orally. Also, statistically significant results were obtained in percentage reduction in pain from 1st to 3rd postoperative day in transbuccal group. No significant difference is seen for adverse reactions.

Conclusion

Transbuccal diclofenac sodium patch is more efficacious and can be used for pain control.

Efficacy and Safety of Massage for Osteoarthritis of the Knee: a Randomized Clinical Trial

BACKGROUND

Current treatment options for knee osteoarthritis have limited effectiveness and potentially adverse side effects. Massage may offer a safe and effective complement to the management of knee osteoarthritis.

OBJECTIVE

Examine effects of whole-body massage on knee osteoarthritis, compared to active control (light-touch) and usual care.

DESIGN

Multisite RCT assessing the efficacy of massage compared to light-touch and usual care in adults with knee osteoarthritis, with assessments at baseline and weeks 8, 16, 24, 36, and 52. Subjects in massage or light-touch groups received eight weekly treatments, then were randomized to biweekly intervention or usual care to week 52. The original usual care group continued to week 24. Analysis was performed on an intention-to-treat basis.

PARTICIPANTS

Five hundred fifty-one screened for eligibility, 222 adults with knee osteoarthritis enrolled, 200 completed 8-week assessments, and 175 completed 52-week assessments.

INTERVENTION

Sixty minutes of protocolized full-body massage or light-touch.

MAIN MEASURES

Primary: Western Ontario and McMaster Universities Arthritis Index. Secondary: visual analog pain scale, PROMIS Pain Interference, knee range of motion, and timed 50-ft walk.

KEY RESULTS

At 8 weeks, massage significantly improved WOMAC Global scores compared to light-touch (- 8.16, 95% CI = - 13.50 to - 2.81) and usual care (- 9.55, 95% CI = - 14.66 to - 4.45). Additionally, massage improved pain, stiffness, and physical function WOMAC subscale scores compared to light-touch (p < 0.001; p = 0.04; p = 0.02, respectively) and usual care (p < 0.001; p = 0.002; p = 0.002; respectively). At 52 weeks, the omnibus test of any group difference in the change in WOMAC Global from baseline to 52 weeks was not significant (p = 0.707, df = 3), indicating no significant difference in change across groups. Adverse events were minimal.

CONCLUSIONS

Efficacy of symptom relief and safety of weekly massage make it an attractive short-term treatment option for knee osteoarthritis. Longer-term biweekly dose maintained improvement, but did not provide additional benefit beyond usual care post 8-week treatment.

TRIAL REGISTRATION

clinicaltrials.gov NCT01537484.

Synthesis, biological evaluation and docking study of a new series of di-substituted benzoxazole derivatives as selective COX-2 inhibitors and anti-inflammatory agents

A new series of substituted-N-(3,4-dimethoxyphenyl)-benzoxazole derivatives 13a-13p was synthesized and evaluated in vitro for their COX (I and II) inhibitory activity, in vivo anti-inflammatory and ulcerogenic potential. Compounds 13d, 13h, 13k, 13l and 13n exhibited significant COX-2 inhibitory activity and selectivity towards COX-2 over COX-1. These selected compounds were screened for their in vivo anti-inflammatory activity by carrageenan induced rat paw edema method. Among these compounds, 13d was the most promising analogs of the series with percent inhibition of 84.09 and IC₅₀ value of 0.04 µM and 1.02 µM (COX-2 and COX-1) respectively. Furthermore, ulcerogenic study was performed and tested compounds (13d, 13h, 13k, 13l) demonstrated a significant gastric tolerance than ibuprofen. Molecular docking study was also performed with resolved crystal structure of COX-2 to understand the binding mechanisms of newly synthesized inhibitors in the active site of COX-2 enzyme and the results were found to be concordant with the biological evaluation studies of the compounds. These newly synthesized inhibitors also showed acceptable pharmacokinetic profile in the in silico ADME/T analyses.

Increased expression of tight junction protein occludin is associated with the protective effect of mosapride against aspirin-induced gastric injury

Mosapride is known to affect gastric motility, however whether mosapride has anti-ulcergenic effects in gastric mucosal injury is unclear. The aim of the present study was to investigate the effects of mosapride on aspirin-induced gastric injuries. GES-1 cells were cultured and divided into 5 groups: Control group, aspirin injury group (treated with 18.2 mmol/l aspirin) and mosapride pretreatment groups (treated with 0.4, 0.5, or 0.6 µmol/l mosapride). Cell proliferation was evaluated via MTT assay and cell apoptosis was investigated via flow cytometry. The expression of occludin was determined by western blot analysis. A total of 40 male Sprague-Dawley rats were randomized into five groups: Control group, aspirin injury group (150 mg/kg) and mosapride pretreatment groups (0.25, 0.50 or 0.75 mg/kg). Gastric mucosal lesions were induced by administering 200 mg/kg aspirin daily for 4 days. Rats in the mosapride groups were pretreated with mosapride 1 h prior to aspirin administration. Histological changes were evaluated under a light microscope and gastric epithelial TJs were observed via transmission electron microscopy. The results revealed that cell apoptosis was significantly increased in the aspirin injury group compared with the control (P<0.05), whereas apoptosis was significantly decreased in the mosapride pretreatment groups compared with the aspirin group (P<0.05). Cell viability was significantly increased in the mosapride pretreatment groups compared with the aspirin injury group (P<0.05), and that of the aspirin injury group was significantly decreased compared with the control group (P<0.05). Compared with the aspirin injury group, occludin expression was significantly increased in the three mosapride pre-treatment groups (all P<0.05). It was also demonstrated that gastric damage was significantly attenuated in the mosapride pretreatment groups compared with the aspirin injury group (P<0.05). Impaired TJ integrity was observed in aspirin injury group, whereas TJs in the mosapride groups were almost intact. In conclusion, the results of the present study suggest that mosapride exerts a gastroprotective action on aspirin-induced gastric mucosal injury at least in part via attenuating cell apoptosis and increasing occludin expression.

Redox Imbalance in the Development of Colorectal Cancer

Redox imbalance is resulted from the destruction of balance between oxidants and antioxidants. The dominant oxidants are reactive oxygen species (ROS), which are involved in multiple cellular processes by physiologically transporting signal as a second messenger or pathologically oxidizing DNA, lipids, and proteins. Generally speaking, low concentration of ROS is indispensable for cell survival and proliferation. However, high concentration of ROS is cytotoxic. Additionally, ROS are now known to induce the oxidative modification of macromolecules especially proteins. The redox modification of proteins is involved in numerous biological processes related to diseases including CRC. Herein, we attempt to afford an overview that highlights the crosstalk between redox imbalance and CRC.

Diclofenac Transdermal Patch: A Potential Ingress to Maxillofacial Surgery

PURPOSE

To evaluate the analgesic efficacy of a diclofenac transdermal patch with diclofenac intra muscular injection in the immediate postoperative period in patients undergoing major oral surgical procedures.

MATERIALS AND METHODS

Subjects who underwent bijaw surgeries for surgical correction of various dentofacial deformities were included. Sixty such patients who belonged to the above entity were randomly categorized into two groups from Jan 2012-Aug 2015. Group A (study group) received a single dose of 100 mg transdermal diclofenac patch, Group B (control group) received 75 mg intramuscular diclofenac and tramadol HCl 2 mg/kg body wt was used as rescue analgesic in the immediate post operative phase. The analgesic efficacy of the drugs are evaluated on periodic patient's perception of pain in the immediate postoperative phase of 2nd, 6th, 12th, 24th and 48 hours.

RESULTS

The mean VAS score in Group A was 2, mean duration of analgesia was 16 h 9 min, and in Group B the mean VAS score was 4, duration of analgesia was 8 h and 4 min. Tramadol HCl was given as rescue analgesia in 22 % (6) of patients belonging to Group A. None of the patients from both the groups reported local complications.

CONCLUSION

A noninvasive application of a single dose of 100 mg transdermal diclofenac patch is more effective than intramuscular diclofenac (75 mg) in the immediate post operative phase, without any significant side-effects is a novel ingress into the field of oral and maxillofacial surgery for post operative pain management.

The Molecular Basis for Dual Fatty Acid Amide Hydrolase (FAAH)/Cyclooxygenase (COX) Inhibition

The design of multitarget‐directed ligands is a promising strategy for discovering innovative drugs. Here, we report a mechanistic study that clarifies key aspects of the dual inhibition of the fatty acid amide hydrolase (FAAH) and the cyclooxygenase (COX) enzymes by a new multitarget‐directed ligand named ARN2508 (2‐[3‐fluoro‐4‐[3‐(hexylcarbamoyloxy)phenyl]phenyl]propanoic acid). This potent dual inhibitor combines, in a single scaffold, the pharmacophoric elements often needed to block FAAH and COX, that is, a carbamate moiety and the 2‐arylpropionic acid functionality, respectively. Molecular modeling and molecular dynamics simulations suggest that ARN2508 uses a noncovalent mechanism of inhibition to block COXs, while inhibiting FAAH via the acetylation of the catalytic Ser241, in line with previous experimental evidence for covalent FAAH inhibition. This study proposes the molecular basis for the dual FAAH/COX inhibition by this novel hybrid scaffold, stimulating further experimental studies and offering new insights for the rational design of novel anti‐inflammatory agents that simultaneously act on FAAH and COX.

Anti-inflammatory effects of Polygonum minus (Huds) extract (Lineminus™) in in-vitro enzyme assays and carrageenan induced paw edema

Background

The study was aimed to evaluate the anti-inflammatory activity of ethanolic and aqueous extracts of Polygonum minus (Huds) using in vitro and in vivo approaches.

Methods

The in vitro tests used to evaluate ethanolic extract are cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), lipooxygenase (5-LOX), secretory phospholipase-A2 (sPLA2) inhibition assay whilst the in-vivo effect was measured by the ability of aqueous extracts to reduce paw edema induced by λ-carrageenan, in rats.

Results

The ethanolic extract inhibited the activities of 5-LOX and COX-1(p < 0.05) whilst the inhibitory effect on COX-2 was only moderate. A marked inhibition of 5-LOX was observed at 30 μg/ ml. The extract did not inhibit the activity of sPLA2. The ability of the ethanolic extracts of Polygonum minus to inhibit both 5-LOX and COX, prompted a study to evaluate the effects of using an aqueous extract of Polygonum minus(Lineminus^TM); as this would be more suitable for future clinical testing. The anti-inhibitory activity of the aqueous extract from this plant was evaluated using a rat model where inflammation was induced in the paws by injection of λ-carrageenan. The aqueous extracts from Polygonum minus administered at doses of 100 and 300 mg/kg body weight (b.w.), significantly (p < 0.01) reduced paw edema induced by λ-carrageenan in the experimental model, at 4 h compared to the vehicle control. Furthermore, administration of 100 mg/kg b.w. or 300 mg/kg b.w. completely reduced inflammation of the paw 4 h after injection.

Conclusion

These findings suggest that aqueous extract of Polygonum minus possesses potent anti-inflammatory activities.

A randomized saline-controlled trial of NASHA hyaluronic acid for knee osteoarthritis

OBJECTIVE

NASHA hyaluronic acid is administered as a single intra-articular injection to treat the symptoms of osteoarthritis (OA). In a previous trial, post-hoc analysis indicated that NASHA provides significantly greater pain relief than saline in patients with OA confined to the study knee. We aimed to evaluate the safety and efficacy of NASHA in patients with unilateral knee OA.

RESEARCH DESIGN AND METHODS

This was a randomized, double-blind, saline-controlled trial. All patients had knee OA confirmed by American College of Rheumatology criteria and a WOMAC pain score of 7-17 in the study knee, but no pain in the previous 3 months in the non-study knee. Treatment comprised a single intra-articular injection of NASHA or saline control. The follow-up period was 6 weeks.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT01806207.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was the responder rate, defined as the percentage of patients with ≥40% improvement from baseline in WOMAC pain score and an absolute improvement of ≥5 points.

RESULTS

A total of 218 patients received study treatment (NASHA: 108, saline: 110). In the main intention-to-treat (ITT) analysis, no statistically significant difference in responder rate was found between the two groups at 6 weeks (NASHA: 30.6%; saline: 26.4%). A post-hoc subgroup analysis of patients without clinical effusion in the study knee at baseline showed a significantly higher 6 week responder rate with NASHA than with saline: 40.6% versus 19.7% (p = 0.0084). A total of 68 adverse events were reported among 44 patients in the NASHA group, compared with 69 adverse events among 44 patients in the saline group. The main weakness of the study was the short, 6 week follow-up duration. In addition, image guidance was not used to ensure injection as intended into the intra-articular space.

CONCLUSIONS

Single-injection NASHA was well tolerated and, although there was no significant benefit versus saline control in the primary analysis, post-hoc analysis showed a statistically significant improvement in pain relief at 6 weeks among patients without clinical effusion at baseline.

NASHA hyaluronic acid vs. methylprednisolone for knee osteoarthritis: a prospective, multi-centre, randomized, non-inferiority trial

OBJECTIVE

To compare NASHA hyaluronic acid gel as single-injection intra-articular (IA) treatment for knee osteoarthritis (OA) against methylprednisolone acetate (MPA).

DESIGN

This was a prospective, multi-centre, randomized, active-controlled, double-blind, non-inferiority clinical trial. A unique, open-label extension phase (OLE) was undertaken to answer further important clinical questions. Subjects with painful unilateral knee OA were treated and followed for 26 weeks (blinded phase). All patients attending the clinic at 26 weeks were offered NASHA treatment, with a subsequent 26-week follow-up period (extension phase). The primary objective was to show non-inferiority of NASHA vs MPA in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain responder rate (percentage of patients with ≥40% improvement from baseline in WOMAC pain score and an absolute improvement of ≥5 points) at 12 weeks.

RESULTS

In total, 442 participants were enrolled. The primary objective was met, with NASHA producing a non-inferior response rate vs MPA at 12 weeks (NASHA: 44.6%; MPA: 46.2%; difference [95% CI]: 1.6% [-11.2%; +7.9%]). Effect size for WOMAC pain, physical function and stiffness scores favoured NASHA over MPA from 12 to 26 weeks. In response to NASHA treatment at 26 weeks, sustained improvements were seen in WOMAC outcomes irrespective of initial treatment. No serious device-related adverse events (AEs) were reported.

CONCLUSIONS

This study shows that single-injection NASHA was well tolerated and non-inferior to MPA at 12 weeks. The benefit of NASHA was maintained to 26 weeks while that of MPA declined. An injection of NASHA at 26 weeks conferred long-term improvements without increased sensitivity or risk of complications. STUDY IDENTIFIER: NCT01209364 (www.clinicaltrials.gov).

Effects of captopril on factors affecting gastric mucosal integrity in aspirin-induced gastric lesions in Sprague-Dawley rats

INTRODUCTION

Captopril is an angiotensin-converting enzyme inhibitor, which is used as an antihypertensive agent and has shown antioxidant properties. This study aims at determining the effects of captopril on factors affecting gastric mucosal integrity in aspirin-induced gastric lesions.

MATERIAL AND METHODS

Eighteen male Sprague-Dawley (200-250 g) rats that were given aspirin (40 mg/100 g body weight) were divided into three groups: the control, captopril (1 mg/100 g body weight daily) and ranitidine (2.5 mg/100 g body weight twice daily) groups. Ranitidine and captopril were given orally for 28 days. Rats in all groups were sacrificed and the parameters measured.

RESULTS

Captopril reduced gastric acidity, and increased gastric glutathione (GSH) and prostaglandin E2 (PGE2) significantly in comparison to the control group. Captopril also reduced malondialdehyde (MDA) and gastric lesions insignificantly compared to the control group. Ranitidine healed the lesions significantly compared to the control group. There was no difference between ranitidine and captopril on the severity of lesions, gastric acidity, MDA and GSH. Captopril increased PGE2 compared to ranitidine (p < 0.05).

CONCLUSIONS

Captopril has desirable effects on the factors affecting gastric mucosal integrity (acidity, PGE2 and GSH) and is comparable to ranitidine in ulcer healing.

Training Self-Administered Acupressure Exercise among Postmenopausal Women with Osteoarthritic Knee Pain: A Feasibility Study and Lessons Learned

Background. Osteoarthritis (OA) is more prevalent in women, particularly after menopausal age. Women are more likely to seek complementary and alternative medicine (CAM) approaches. We examined the feasibility of training self-administered acupressure exercise and assessed its impact on OA symptoms among women with knee OA. Methods. Thirty-six eligible postmenopausal women were randomly assigned in the acupressure exercise group (n = 15) or the control group (n = 21) for 12 weeks. Feasibility outcomes (e.g., compliance and adverse effects) and clinical outcomes (e.g., pain, stiffness, and physical function) were assessed. Data were collected at baseline, 6 weeks and 12 weeks. Both per-protocol and intention-to-treat analysis were employed. Results. The training materials were well received. The feedback from participants suggests that self-administered acupressure exercise is easy to learn and safe to perform at home, although no statistically significant results of the clinical outcome were observed. Our findings didn't reveal superiority or inferiority of acupressure compared with usual care. Conclusion. Acupressure exercise is feasible to be trained among postmenopausal women with knee osteoarthritis. Due to the limitations of this study such as small sample size and high attrition rate, acupressure's efficacy needs to be further explored in larger scale studies with more rigorous design.

Identification and characterization of carprofen as a multitarget fatty acid amide hydrolase/cyclooxygenase inhibitor

Pain and inflammation are major therapeutic areas for drug discovery. Current drugs for these pathologies have limited efficacy, however, and often cause a number of unwanted side effects. In the present study, we identify the nonsteroidal anti-inflammatory drug carprofen as a multitarget-directed ligand that simultaneously inhibits cyclooxygenase-1 (COX-1), COX-2, and fatty acid amide hydrolase (FAAH). Additionally, we synthesized and tested several derivatives of carprofen, sharing this multitarget activity. This may result in improved analgesic efficacy and reduced side effects (Naidu et al. J. Pharmacol. Exp. Ther.2009, 329, 48-56; Fowler, C. J.; et al. J. Enzyme Inhib. Med. Chem.2012, in press; Sasso et al. Pharmacol. Res.2012, 65, 553). The new compounds are among the most potent multitarget FAAH/COX inhibitors reported so far in the literature and thus may represent promising starting points for the discovery of new analgesic and anti-inflammatory drugs.

Comparison of transdermal diclofenac patch with oral diclofenac as an analgesic modality following multiple premolar extractions in orthodontic patients: A cross over efficacy trial

Aims:

This study was performed to compare the degree of post operative analgesia, patient compliance, and frequency of adverse events with the use of oral diclofenac tablets and transdermal diclofenac patch following multiple premolar extractions in patients undergoing orthodontic treatment.

Materials and Methods:

Twenty young pre-orthodontic patients requiring bilateral maxillary and mandibular first premolar extractions were selected for the study. The right maxillary and mandibular first premolars were extracted first and 50 mg oral diclofenac sodium tablets were prescribed to be taken thrice a day for three days. In the next appointment, the contralateral first premolars were extracted and a 100 mg transdermal diclofenac patch was applied once a day for three days. Pain relief and pain intensity with both the diclofenac formulations was recorded for each of the three postoperative days using 5-point Verbal Pain Intensity and Pain Relief Score Charts.

Results and Conclusions:

Statistical analyses revealed that there was a gradual increase in pain relief scores and a gradual decrease in pain intensity scores with the use of oral diclofenac tablets as well as with the transdermal patch. However, subjects reported that they were more comfortable using the transdermal patch particularly due to the once-a-day application and lesser frequency of systemic adverse effects. Results of this study indicate that the transdermal diclofenac patch provides as potent analgesia as the oral diclofenac tablets with the added advantage of better patient compliance and may be used for routine post extraction analgesia.

H(2)S-releasing aspirin protects against aspirin-induced gastric injury via reducing oxidative stress

The aim of this study was to examine the effect of ACS14, a hydrogen sulfide (H(2)S)-releasing derivative of aspirin (Asp), on Asp-induced gastric injury. Gastric hemorrhagic lesions were induced by intragastric administration of Asp (200 mg/kg, suspended in 0.5% carboxymethyl cellulose solutions) in a volume of 1 ml/100 g body weight. ACS14 (1, 5 or 10 mg/kg) was given 30 min before the Asp administration. The total area of gastric erosions, H(2)S concentration and oxidative stress in gastric tissues were measured three hours after administration of Asp. Treatment with Asp (200 mg/kg), but not ACS14 (430 mg/kg, at equimolar doses to 200 mg/kg Asp), for 3 h significantly increased gastric mucosal injury. The damage caused by Asp was reversed by ACS14 at 1-10 mg/kg in a concentration-dependent manner. ACS14 abrogated Asp-induced upregulation of COX-2 expression, but had no effect on the reduced PGE(2) level. ACS14 reversed the decreased H(2)S concentrations and blood flow in the gastric tissue in Asp-treated rats. Moreover, ACS14 attenuated Asp-suppressed superoxide dismutase-1 (SOD-1) expression and GSH activity, suggesting that ACS14 may stimulate antioxidants in the gastric tissue. ACS14 also obviously inhibited Asp-induced upregulation of protein expression of oxidases including XOD, p47(phox) and p67(phox). In conclusion, ACS14 protects Asp induced gastric mucosal injury by inhibiting oxidative stress in the gastric tissue.

Non-steroidal anti-inflammatory drugs and gastroprotection with proton pump inhibitors: a focus on ketoprofen/omeprazole

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed agents for rheumatic disorders such as osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Despite the known association between NSAID use and gastropathy, however, only around one-third of patients at risk of NSAID-induced gastrointestinal toxicity receive adequate gastroprotection, and as many as 44% of these patients are non-adherent. We review the co-prescription of proton pump inhibitors (PPIs) for the prevention of NSAID-induced gastropathy, with a particular focus on the first fixed-dose NSAID/PPI formulation: ketoprofen/omeprazole modified-release capsules. The ketoprofen/omeprazole fixed-dose combination is available in doses of 100 mg/20 mg, 150 mg/20 mg or 200 mg/20 mg as a single capsule for once-daily administration. Ketoprofen monotherapy has been shown to be generally equivalent to other NSAIDs when used in the treatment of OA. In RA, ketoprofen has demonstrated equivalent efficacy to diclofenac, indometacin, piroxicam, aceclofenac, phenylbutazone, naproxen and flurbiprofen. Studies comparing ketoprofen with ibuprofen and sulindac in patients with RA have, in general, favoured ketoprofen. Studies in AS have generally reported similar efficacy between ketoprofen and phenylbutazone and pirprofen. Prophylaxis with omeprazole is effective for the prevention of gastroduodenal ulcers, maintenance of remission and alleviation of dyspeptic symptoms in NSAID recipients. Omeprazole is well tolerated, and adverse events are generally gastrointestinal in nature. The fixed-dose combination of ketoprofen and omeprazole has demonstrated bioequivalence to the respective monotherapies. The incidence of digestive symptoms and the need for dose reduction was reported to be lower with the combination than with its components. Ketoprofen/omeprazole modified-release capsules are the first fixed-dose NSAID/PPI formulation to be approved. This formulation ensures compliance with the gastroprotective prophylaxis, as whenever the NSAID is taken, the PPI is co-administered. Additionally, the once-daily formulation has the potential to improve adherence to anti-inflammatory therapy.