Side-effects of non-steroidal anti-inflammatory drugs

Repurposing of digoxin in pain and inflammation: An evidence-based study

In recent years, the drug repositioning strategy has gained considerable attention in the drug discovery process that involves establishing new therapeutic uses of already known drugs. In line with this, we have identified digoxin a cardiac glycoside, as a potent inhibitor of soluble epoxide hydrolase (sEH) enzyme employing in silico high throughput screening protocols and further confirmed using in vitro cell-free sEH inhibitory assay and in vivo preclinical studies in rodents for its repurposing in hyperalgesia, inflammation, and related disorders. Oral administration of digoxin at dose 0.2 mg/kg significantly reduced (p < .0001) the allodynia in mice induced by using hot plate (3.6 ± 1.9) and tail-flick test (7.58 ± 0.9). In addition, digoxin at a dose of 0.2 mg/kg showed marked reduction (94%, p < .0001) in acetic acid-induced abdominal contraction in rats. Further, digoxin also demonstrated antipyretic activity (37.04 ± 0.2, p < .0001) and showed notable reduction (0.60 ± 0.06) in carrageenan-induced paw edema in rats. Also, the histopathological evaluation revealed that digoxin treatment attenuated the edema, neutrophil infiltration, and alveolar septal thickening in lung tissue. These findings are novel and highlight the newer insights towards repurposing digoxin as a new lead in the treatment of hyperalgesia, inflammation, and related disorders.

Risk of Adverse Drug Events Related to Ibuprofen Use in a Community Sample

Objective:

To determine whether consumers are using nonprescription ibuprofen more predominantly to treat acute or chronic conditions, incidence of adverse effects, and whether a healthcare professional is providing patient information.

Design:

A questionnaire was developed and placed in 15 randomly selected community pharmacies in a major metropolitan area. Adult consumers who were purchasing an ibuprofen over-the-counter product or who had previously used an ibuprofen product were asked to complete a written questionnaire (n=190). The information collected included age, gender, prescription, and other over-the-counter drugs presently used, quantity, duration, present illnesses or conditions, both intended and past use of ibuprofen, and incidence of adverse reactions.

Results:

Most subjects who self-treated with ibuprofen were female (70.8 percent) with a mean age of 37 years. Consumers generally used ibuprofen for stress/tension headache (38.9 percent), menstrual cramps (34.2 percent), generalized pain (31.8 percent), or muscle strain/sprain (30.0 percent). Most (55.9 percent) took 400 mg when needed, and 42.2 percent used ibuprofen for a period of 24 hours. Counseling concerning ibuprofen use was provided by a physician (42.9 percent) or pharmacist (39.7 percent) in most cases. The label was read the majority of the time (75 percent), and everyone who read the label understood the printed information.

Conclusions:

The findings indicate that this community sample of consumers was using nonprescription ibuprofen appropriately for acute or as needed conditions over a short period of time. They experienced few adverse reactions to ibuprofen. Both pharmacists and physicians were providing patient information about ibuprofen. Counseling is needed regarding prescription and nonprescription drugs with a potential to interact with ibuprofen.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

Comparative tolerability of treatments for juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) includes several forms of chronic arthritis in children. Treatments are chosen according to the type and severity of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids remain the mainstays of therapy. Traditional slower acting anti-rheumatic drugs, such as gold therapy, penicillamine, sulfasalazine, tiopronin and hydroxychloroquine, are usually poorly active in children. In addition, adverse effects are common, including severe macrophage activation syndrome with gold therapy or sulfasalazine. Low dose, once weekly methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to the administration of an NSAID, especially in those with the extended oligoarticular subtype of the disease. Other immunosuppressive agents, such as cyclosporin, are sometimes combined with methotrexate. In recent years, novel treatments have been developed. Autologous hematopoietic stem cell transplantation is effective in a number of children with severe JIA, whose disease has been refractory to conventional therapy. However, only short term follow-up data are currently available for this novel therapy. In addition, severe infections complicated by macrophage activation syndrome and death have been reported. Finally, anti-tumour necrosis factor-alpha therapy has shown efficacy in more than two-thirds of children with JIA and polyarthritis, and other cytokine inhibitors may be soon available.

Studies on the in vitro release characteristics of ibuprofen-loaded polystyrene microparticles

Ibuprofen-loaded polystyrene microparticles were prepared by the emulsion-solvent evaporation process from an aqueous system. The effects of different parameters on the drug content and on the release of the drug from the microparticles were investigated. The drug content, in all the formulations, was less than the theoretical drug loading. The lower drug content was due to drug partitioning to the external aqueous phase during formulation. Statistical analysis revealed that the variation in the concentrations of the emulsion stabilizer and the organic disperse phase volume did not significantly alter the release of the drug. Although an increase in drug loading increased drug release from the microparticles, a biphasic linear relationship was observed between the time required for 50% drug release and the drug loading. The effect of size of the microparticles on drug release was more important for the low drug-loaded microparticles than that for the high drug-loaded microparticles. Such release behaviour from the microparticles was explained on the basis of the morphological structure of the microparticles.

Toward an understanding of NSAID-related adverse events: the contribution of longitudinal data

The ARAMIS (Arthritis, Rheumatism and Ageing Medical Information System) databanks have been used to objectify and quantify drug toxicity. The relative risk of a gastrointestinal (GI)-provoked hospitalization was more than five times greater in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) than in non-NSAID-treated patients, with an excess hospitalization rate of 1.3% per annum. Additionally, there was an excess GI-related death rate of around 3% in rheumatoid arthritis (RA) patients compared with the normal population. Age, previous NSAID-related GI events, prednisone use, higher doses and greater disability predicted high-risk patients. A toxicity index showed clear differences between NSAIDs, with aspirin, salsalate and ibuprofen emerging as the least toxic, and meclofenamate and indomethacin as the most toxic. Disease modifying anti-rheumatic drugs (DMARDs) were, surprisingly, found to have similar toxicity scores to the NSAIDs. This supports the contemporary practice of employing DMARDs earlier and more aggressively in the course of RA.

Development and use of a gastropathy index for ranking the safety of non-steroidal anti-inflammatory drugs in the elderly

This study, conducted at the Royal Devon & Exeter Hospital, Department of Geriatric Medicine, was carried out using 2987 sets of admission data. The number of patients taking non-steroidal anti-inflammatory drugs was identified together with a suite of clinical factors used to indicate the presence of gastrointestinal pathology. From this a gastropathy index was developed to establish a rank order for the individual drugs. Ketoprofen, piroxicam and fenbufen were all significantly associated with factors suggestive of gastropathy, whereas indomethacin, diclofenac and ibuprofen appeared relatively free of such association. Naproxen, azapropazone and mefenamic acid ranked in an intermediate category. This noninvasive analysis of routinely acquired data provides a potentially useful discriminator between individual non-steroidal anti-inflammatory drugs for this age group.

Comparative toxicity of non-steroidal anti-inflammatory agents

Comparative toxicity of non-steroidal anti-inflammatory drugs was assessed using the Stanford Toxicity Index consisting of weighted symptoms, laboratory abnormalities and hospitalizations in 2976 consecutively enrolled rheumatoid arthritis patients from eight data bank centers with 27,936 patient-years of observation. Scores ranged from 1.77 (SE 0.20) for aspirin to 5.94 (SE 0.92) for meclofenamate, with many differences between drugs being 2- to 3-fold and highly statistically significant. Results are consistent with our prior data, persist when assessed by several different scoring algorithms, are consistent across data bank centers and are consistent with data of others. There are major and reproducible differences in the overall toxicity of different non-steroidal anti-inflammatory drugs.

Comparison of naproxen and acetaminophen in a two-year study of treatment of osteoarthritis of the knee

OBJECTIVE

To compare the relative safety and efficacy of naproxen and acetaminophen in the treatment of osteoarthritis (OA) of the knee. The major outcome measures were radiographic progression and withdrawal from the trial due to lack of efficacy.

METHODS

One hundred seventy-eight patients with OA of the knee were enrolled in a 2-year prospective, controlled, double-blind multicenter trial and were randomly assigned to receive acetaminophen (ACT) or naproxen (NPX) treatment.

RESULTS

After 6 weeks of treatment, modest improvement in pain on motion and in physician's global assessment was seen in both the ACT and the NPX groups, and the NPX group also had modest improvement in pain at rest and in 50-foot walk time. Sixty-two patients completed the 2-year study. Among these patients, radiographic progression was similar in the 2 treatment groups. Withdrawal from the trial due to lack of drug efficacy was slightly more frequent among patients in the ACT group (22% versus 16%), but withdrawal due to adverse drug effects was slightly more common in the NPX group (23% versus 18%).

CONCLUSION

The efficacy of ACT treatment and NPX treatment was similar, although it was slightly better for NPX. The toxicity rate was slightly lower with ACT. However, the high rate of withdrawal in both treatment groups suggests that neither is satisfactory for the treatment of OA.

Gastric ulcer perforation associated with the use of injectable ketorolac

OBJECTIVE

To report a case of a perforated gastric ulcer associated with the use of injectable ketorolac tromethamine.

DATA SYNTHESIS

A 77-year-old woman with no previous history of peptic ulcer disease developed a perforated gastric ulcer after four days of treatment with ketorolac. To date, six other cases of gastrointestinal (GI) perforation associated with the use of ketorolac have been reported to the manufacturer.

CONCLUSIONS

Although ketorolac is an effective analgesic, it is a nonsteroidal antiinflammatory agent and thus has the propensity for causing GI ulceration. Caution should be used when administering this drug and patients should be monitored for GI adverse effects.