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Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH, Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69:617-629. [PMID: 31937550 DOI: 10.1136/gutjnl-2019-319300] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong
| | - Kentaro Sugano
- Jichi Medical University, Shimotsuke, Tochigi, Japan.,Asian Pacific Association of Gastroenterology (APAGE), Tochigi, Japan
| | - Ji-Guang Wang
- Shanghai Institute of Hypertension, Shanghai, Shanghai, China.,Asia Pacific Society of Hypertension (APSH), Shanghai, China
| | - Kazuma Fujimoto
- Saga University, Saga, Japan.,Asia-Pacific Society for Digestive Endoscopy (APSDE), Saga, Japan
| | - Samuel Whittle
- The University of Adelaide, Adelaide, South Australia, Australia.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Gopesh K Modi
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Chen-Huen Chen
- National Yang-Ming University, Taipei, Taiwan.,Pulse of Asia (PoA), Taipei, Taiwan
| | - Jeong-Bae Park
- Pulse of Asia (PoA), Taipei, Taiwan.,JB Lab and Clinic and Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Kriengsak Vareesangthip
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Mahidol University, Nakorn Pathom, Thailand
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Varrassi G, Pergolizzi JV, Dowling P, Paladini A. Ibuprofen Safety at the Golden Anniversary: Are all NSAIDs the Same? A Narrative Review. Adv Ther 2020; 37:61-82. [PMID: 31705437 DOI: 10.1007/s12325-019-01144-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Indexed: 02/06/2023]
Abstract
Ibuprofen first came to market about 50 years ago and rapidly moved to over-the-counter (OTC) sales. In April 2019, the National Agency for the Safety of Medicines and Health Products (ANSM) of France issued a warning for NSAID uses by patients with infectious diseases based on an analysis of 20 years of real-world safety data on ibuprofen and ketoprofen. Nevertheless, ibuprofen remains a mainstay in the analgesic armamentarium and with numerous randomized clinical trials, head-to-head studies, and decades of clinical experience. The authors offer a review of the safety of ibuprofen and how it may differ from other NSAIDs. Ibuprofen is associated with certain well-known gastrointestinal adverse effects that are related to dose and patient population. Among nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen has a comparatively low risk of cardiovascular adverse effects. It has been associated with renal and hepatic adverse effects, which appear to depend on dose, concomitant medications, and patient population. The association of ibuprofen with infections is more complex in that it confers risk in some situations but benefits in others, the latter in cystic fibrosis. Emerging interest in the literature is providing evidence of the role of ibuprofen as a possible endocrine disrupter as well as its potential antiproliferative effects for cancer cells. Taken altogether, ibuprofen has a favorable safety profile and is an effective analgesic for many acute and chronic pain conditions, although it-like other NSAIDs-is not without risk. After 50 years, evidence is still emerging about ibuprofen and its unique safety profile among NSAIDs. FUNDING: The Rapid Service Fee was funded by Abbott Established Pharmaceuticals Division (EPD).
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Affiliation(s)
- Giustino Varrassi
- Paolo Procacci Foundation, Via Tacito 7, 00193, Rome, Italy.
- World Institute of Pain, Winston-Salem, USA.
| | | | - Pascal Dowling
- Abbott Product Operations AG, Allschwil, EPD Headquarters, Hegenheimermattweg 127, 4123, Allschwil, Switzerland
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Rogoveanu OC, Streba CT, Vere CC, Petrescu L, Trăistaru R. Superior digestive tract side effects after prolonged treatment with NSAIDs in patients with osteoarthritis. J Med Life 2015; 8:458-61. [PMID: 26664470 PMCID: PMC4656952 DOI: pmid/26664470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Anti-inflammatory drugs (NSAIDs) represent one of the classes of drugs commonly recommended for patients with osteoarthritis. These drugs have side effects that sometimes affect the digestive tract. PATIENTS AND METHODS 30 patients with either axial or peripheral osteoarthritis, hospitalized between January 2013 and January 2015 in the Rehabilitation Clinic of the Clinical Emergency County Hospital of Craiova, were followed. All the patients included had upper gastrointestinal endoscopy performed, excluding patients who had a history of gastritis, endoscopically demonstrated ulcer or those with a history of gastrointestinal dyspeptic phenomena. RESULTS The endoscopic examination found acute erosive gastritis in eight cases, gastric ulcer (four cases) and duodenal ulcer (six cases). No serious complications were encountered. Four patients had no clinical manifestations with endoscopic expression. Lesions were mainly mild esophagitis (Grade I) and only in three cases, esophagitis grade II or III was found. Twelve patients (40%) had Helicobacter pylori infection and had endoscopic changes (gastric ulcer, duodenal ulcer, or gastric lesions). CONCLUSIONS The adverse effects of NSAIDs in patients with osteoarthritis vary in severity. Patient age significantly influences the severity of injuries. We have not found significant differences in the incidence of COX2 selective and non-selective NSAID-induced lesions. Pathogenic interaction between the NSAID and Helicobacter Pylori infection is most often a synergistic effect in the development of gastritis or gastroduodenal ulcer.
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Affiliation(s)
- O C Rogoveanu
- Department of Medical Sciences II, Medical Rehabilitation, University of Medicine and Pharmacy of Craiova, Romania
| | - C T Streba
- Research Center for Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Bucharest
| | - C C Vere
- Research Center for Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Bucharest ; Department of Medical Sciences I, Gastroenterology, University of Medicine and Pharmacy of Craiova, Bucharest
| | - L Petrescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - R Trăistaru
- Department of Medical Sciences II, Medical Rehabilitation, University of Medicine and Pharmacy of Craiova, Romania
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Sanka K, Pragada RR, Veerareddy PR. A pH-triggered delayed-release chronotherapeutic drug delivery system of aceclofenac for effective management of early morning symptoms of rheumatoid arthritis. J Microencapsul 2015; 32:794-803. [PMID: 26362349 DOI: 10.3109/02652048.2015.1081417] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Rheumatoid arthritis (RA) is differentiated as an early morning exacerbation of the core arthritis condition associated with increase in pain and stiffness in joints and necessitate for medication. OBJECTIVE The aim of the present work was to develop and optimise a pH-triggered delayed-release colon-specific aceclofenac microspheres and to accomplish chronotherapy of RA. METHODS A 3-factor, 3-level Box-Behnken design (BBD) was used to optimise selected variables. Developed formulation was evaluated for in vivo delayed response and anti-arthritis activity in rats. RESULTS The particle size and encapsulation efficacy of these microspheres were 117.36 ± 10.54 µm and 85.06 ± 5.85%, respectively. Optimised formulation was analysed by SEM, DSC, X-RPD and FTIR. The in vivo evaluation revealed delayed anti-inflammatory activity in carrageenan-induced rats and anti-arthritic activity in freund's adjuvant-induced arthritis rats. CONCLUSION The optimised aceclofenac microspheres formulation is potential for the chronotherapy of early morning symptoms of RA.
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Affiliation(s)
- Krishna Sanka
- a Department of Pharmaceutics , School of Pharmacy , AGI , Hyderabad , Telangana , India .,b School of Pharmaceutical Sciences and Technologies, JNTUK , Kakinada, Andhra Pradesh , India
| | - Rajeswara Rao Pragada
- c College of Pharmaceutical Sciences, Andhra University , Visakhapatnam, Andhra Pradesh , India , and
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Banihani SA. Histamine-2 Receptor Antagonists and Semen Quality. Basic Clin Pharmacol Toxicol 2015; 118:9-13. [DOI: 10.1111/bcpt.12446] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/06/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Saleem A. Banihani
- Department of Medical Laboratory Sciences; Jordan University of Science and Technology; Irbid Jordan
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Bello AE, Kent JD, Holt RJ. Gastroprotective efficacy and safety of single-tablet ibuprofen/famotidine vs ibuprofen in older persons. PHYSICIAN SPORTSMED 2015; 43:193-9. [PMID: 26165391 DOI: 10.1080/00913847.2015.1066229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES A combination tablet of ibuprofen 800 mg and famotidine 26.6 mg given three times daily is effective for the treatment of rheumatoid arthritis and osteoarthritis and decreases the risk of developing upper gastrointestinal (GI) ulcers. This analysis evaluated the gastroprotective efficacy and safety of the single-tablet combination of ibuprofen/famotidine compared with ibuprofen alone on the basis of age and the presence of one or more risk factors for development of upper GI ulcer. METHODS Pooled data from the 24-week, randomized, double-blind, parallel-group REDUCE-1 and REDUCE-2 trials were used. Endoscopies were performed in patients aged 40-80 years. The proportion of patients who developed ≥ 1 upper GI ulcer during treatment with ibuprofen/famotidine versus ibuprofen alone stratified on the basis of age (< 60 or ≥ 60 years) was evaluated. Further, analyses were performed on additional risk factors for ulcer development. RESULTS Gastroprotective efficacy of the combination was not affected by age. Pooled results demonstrated statistically significantly fewer upper GI (10.0 vs 19.5%, p < 0.0001), gastric (8.9 vs 16.8%, p = 0.0004), and duodenal ulcers (1.1 vs 5.4%, p < 0.0001) in patients < 60 years treated with ibuprofen/famotidine versus ibuprofen alone compared with 12.9 vs 26.6% (p = 0.0002), 11.9 vs 23.4% (p = 0.0011), and 1.0 vs 4.5% (p = 0.0096), respectively, in patients ≥ 60 years. The ibuprofen/famotidine combination provided nearly 51 and 59% reduction in the risk of developing a GI ulcer in patients <60 years and ≥ 60 of age, respectively. Efficacy was maintained in the presence of additional risk factors, as well. CONCLUSIONS These results indicate that the fixed-combination of ibuprofen/famotidine provides gastroprotection in those of older age, with or without additional risk factors for the development of upper GI ulcers, as compared with ibuprofen alone. US National Institutes of Health registry, http://www.clinicaltrials.gov, NCT00450658 and NCT00450216.
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Bello AE, Kent JD, Grahn AY, Ball J, Holt RJ. One-year open-label safety evaluation of the fixed combination of ibuprofen and famotidine with a prospective analysis of dyspepsia. Curr Med Res Opin 2015; 31:397-405. [PMID: 25495134 DOI: 10.1185/03007995.2014.999152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the long-term safety of the single-tablet combination of ibuprofen 800 mg and famotidine 26.6 mg. RESEARCH DESIGN AND METHODS A phase 3b open-label study (NCT00984815) was conducted in 86 adults requiring daily non-steroidal anti-inflammatory drug (NSAID) administration for ≥12 months. The combination tablet of ibuprofen/famotidine was self-administered orally three times daily for up to 54 consecutive weeks. Adverse events (AEs) were collected beginning at the first dose and continued through completion (54 weeks). The Severity of Dyspepsia Assessment (SODA) questionnaire was completed by patients to assess tolerability. RESULTS Most patients (65%) finished the trial, with 76% contributing data at 6 months, and 21% withdrew due to adverse effects. Overall and gastrointestinal AE discontinuation rates (21% and 13%, respectively) were lower than that previously reported with ibuprofen 2400 mg given alone. Each of the SODA subscale scores demonstrated improvement by week 6 and improved statistically significantly at week 24 and week 54. Of the cardiovascular AEs, hypertension was reported most frequently (9/86, 9.3%), with 3.5% determined to be drug related. Twelve serious AEs were reported by 9 of 86 (10%) patients; two were considered possibly related to the study medication (unstable angina and gastric ulcer). There were no reports of serious gastrointestinal or CV complications. Most AEs were mild or moderate in severity and not considered drug related. CONCLUSIONS These data, together with previously reported findings of a significant decrease in upper gastrointestinal endoscopic ulcer rate at 6 months, support the overall safety, compliance, and tolerability of this single-tablet formulation.
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Affiliation(s)
- Alfonso E Bello
- University of Illinois-Chicago, College of Medicine, and Illinois Bone and Joint Institute, LLC , Glenview, IL , USA
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Bello AE, Grahn AY, Ball J, Kent JD, Holt RJ. One-year safety of ibuprofen/famotidine fixed combination versus ibuprofen alone: pooled analyses of two 24-week randomized, double-blind trials and a follow-on extension. Curr Med Res Opin 2015; 31:407-20. [PMID: 25516006 DOI: 10.1185/03007995.2014.1000086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the safety of the fixed combination of ibuprofen and famotidine compared with ibuprofen alone from two 24-week, multicenter, double-blind trials designed to evaluate the comparative incidence of endoscopically documented upper gastrointestinal ulcers and a 28-week double-blind extension study. RESEARCH DESIGN AND METHODS Safety was analyzed by pooling data from the two double-blind trials and the follow-on study. Safety was assessed by monitoring the incidence, causality, and severity of adverse events (AEs). RESULTS In the pivotal efficacy and safety trials, discontinuation rates due to any cause and dyspepsia were significantly lower for the ibuprofen/famotidine combination versus ibuprofen alone. Other than dyspepsia, gastrointestinal and cardiovascular AEs of special interest were similar. Events judged to be treatment related were significantly lower with the ibuprofen/famotidine combination (20.6% vs. 25%). In the safety extension population, there were no differences in the discontinuation rates and the reporting of AEs or serious AEs (SAEs) between the two groups. Gastrointestinal-related events were similar between the groups. Incidence of cardiovascular-related AEs of special interest were 11% (ibuprofen/famotidine) and 2% (ibuprofen) (p=0.06), possibly due to a higher number of rheumatoid arthritis patients in the combination group. Of these, 80% were reports of hypertension (8% ibuprofen/famotidine vs. 2% ibuprofen). Three cases of hypertension in the ibuprofen/famotidine group were considered treatment related. The probability of a cardiovascular event decreased during days 112-167 of treatment and remained low with continued treatment. CONCLUSIONS One-year safety data from two pivotal trials and a long-term extension study indicate that the ibuprofen/famotidine combination demonstrates a favorable gastrointestinal safety profile and more patients continued on therapy compared to ibuprofen alone. No new safety signals have been identified. These data offer additional evidence supporting a new therapeutic option to improve gastrointestinal safety and adherence for patients who require long-term ibuprofen.
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Affiliation(s)
- Alfonso E Bello
- University of Illinois-Chicago, College of Medicine, and Illinois Bone and Joint Institute LLC , Glenview, IL , USA
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