Efficacy of diclofenac/misoprostol vs diclofenac in the treatment of ankylosing spondylitis

Efficacy and tolerability of naproxen/esomeprazole magnesium tablets compared with non-specific NSAIDs and COX-2 inhibitors: a systematic review and network analyses

Non-steroidal anti-inflammatory drugs (NSAIDs), such as non-selective NSAIDs (nsNSAIDs) or selective cyclooxygenase-2 (COX-2) inhibitors, are commonly prescribed for arthritic pain relief in patients with osteoarthritis (OA), rheumatoid arthritis (RA), or ankylosing spondylitis (AS). Treatment guidelines for chronic NSAID therapy include the consideration for gastroprotection for those at risk of gastric ulcers (GUs) associated with the chronic NSAID therapy. The United States Food and Drug Administration has approved naproxen/esomeprazole magnesium tablets for the relief of signs and symptoms of OA, RA, and AS, and to decrease the risk of developing GUs in patients at risk of developing NSAID-associated GUs. The European Medical Association has approved this therapy for the symptomatic treatment of OA, RA, and AS in patients who are at risk of developing NSAID-associated GUs and/or duodenal ulcers, for whom treatment with lower doses of naproxen or other NSAIDs is not considered sufficient. Naproxen/esomeprazole magnesium tablets have been compared with naproxen and celecoxib for these indications in head-to-head trials. This systematic literature review and network meta-analyses of data from randomized controlled trials was performed to compare naproxen/esomeprazole magnesium tablets with a number of additional relevant comparators. For this study, an original review examined MEDLINE®, Embase®, and the Cochrane Controlled Trials Register from database start to April 14, 2009. Using the same methodology, a review update was conducted to December 21, 2009. The systematic review and network analyses showed naproxen/esomeprazole magnesium tablets have an improved upper gastrointestinal tolerability profile (dyspepsia and gastric or gastroduodenal ulcers) over several active comparators (naproxen, ibuprofen, diclofenac, ketoprofen, etoricoxib, and fixed-dose diclofenac sodium plus misoprostol), and are equally effective as all active comparators in treating arthritic symptoms in patients with OA, RA, and AS. Naproxen/esomeprazole magnesium tablets are therefore a valuable option for treating arthritic symptoms in eligible patients with OA, RA, and AS.

Different risks for NSAID-induced anaphylaxis

BACKGROUND

After drugs are marketed, spontaneous reporting systems can provide valuable information regarding the occurrence of suspected adverse drug reactions. The Netherlands Pharmacovigilance Foundation has received a substantial number of anaphylactic reaction reports related to the use of nonsteroidal antiinflammatory drugs (NSAIDs).

OBJECTIVE

To investigate whether the risk of anaphylactic reactions being reported during the use of various NSAIDs is greater than with other classes of drugs and if differences among NSAIDs exist.

METHODS

In a case/noncase design, reporting odds ratios (RORs) were calculated using logistic regression analysis. Cases were defined as reports in which anaphylactic or anaphylactoid reactions were reported; all other reports were considered as noncases. The index group consisted of reports in which NSAIDs were mentioned as the suspected medication; the reference group consisted of all other reports.

RESULTS

Between January 1985 and November 2000, the Netherlands Pharmacovigilance Foundation Lareb received 76 cases concerning anaphylactic reactions to NSAIDs. These drugs are strongly associated with anaphylactic reactions. The ROR adjusted for age, gender, and source of the reports was 9.4 (95% CI 6.9 to 12.7). Anaphylactic reactions associated with the use of naproxen, ibuprofen, and diclofenac were reported disproportionately with respect to other drugs. The corresponding RORs from logistic regression analysis adjusted for age, gender, and reporting source for diclofenac, naproxen, and ibuprofen were 17.2 (95% CI 12.1 to 24.5), 9.1 (95% CI 5.2 to 15.9), and 5.5 (95% CI 2.5 to 11.9), respectively.

CONCLUSIONS

The results of this study strengthen previous findings concerning the relative high risk of developing an anaphylactic reaction during the use of NSAIDs, particularly diclofenac, ibuprofen, and naproxen.

Diclofenac/misoprostol. A review of its pharmacology and therapeutic efficacy in painful inflammatory conditions

Diclofenac is a well established nonsteroidal anti-inflammatory drug (NSAID) used in the treatment of a variety of painful inflammatory conditions. Although generally well tolerated, diclofenac, like other NSAIDs, is associated with gastrointestinal adverse effects which infrequently can be serious and/or life-threatening. Misoprostol, a prostaglandin E1 analogue, reduces the incidence of NSAID related ulcers, both gastric and duodenal. The lack of conclusive pharmacoeconomic data for misoprostol and the widespread use of NSAIDs makes routine administration of misoprostol difficult to justify for all NSAID users. However, it appears to be an economically warranted approach in the elderly, who are at particularly high risk for NSAID-related gastrointestinal complications. The fixed combination of diclofenac 50mg and misoprostol 200 micrograms administered 2 to 3 times daily for 4 to 12 weeks has shown equivalent therapeutic efficacy to diclofenac (alone or combined with placebo), piroxicam and naproxen, and was slightly more effective than ibuprofen in clinical studies in patients with a variety of painful inflammatory conditions. No significant differences in therapeutic efficacy were noted between elderly (aged > or = 65 years) and younger patients in these studies. Gastrointestinal adverse events are common with diclofenac and misoprostol, administered alone or in combination. Diarrhoea (presumably attributable to the misoprostol component) appears to be more frequent in diclofenac/misoprostol recipients than in those receiving diclofenac alone or combined with placebo. However, diclofenac/misoprostol recipients had significantly fewer gastroduodenal ulcers at the end of treatment relative to patients receiving comparators in clinical trials. In addition, the types and incidences of adverse events are similar in elderly and younger patients. Routine ulcer prophylaxis with misoprostol in all NSAID users is not warranted from a pharmacoeconomic viewpoint. In common with other fixed combination products, dosage flexibility is somewhat compromised with diclofenac/misoprostol. However, once drug dosages are determined in the individual patient, the fixed combination of diclofenac and misoprostol offers the potential for increased patient convenience and possibly patient compliance, and lower drug acquisition costs than those of the individual drugs used together. Thus, it should be considered a useful treatment option in appropriately selected patients with a high risk for serious NSAID-related gastrointestinal complications who require NSAID therapy.