Drug-induced liver injury (DILI) ascribed to non-steroidal anti-inflammatory drugs (NSAIDs) in the USA-Update with genetic correlations

OBJECTIVE

To describe patients with NSAID-DILI, including genetic factors associated with idiosyncratic DILI.

METHODS

In DILIN, subjects with presumed DILI are enrolled and followed for at least 6 months. Causality is adjudicated by a Delphic approach. HLA sequencing of multiethnic NSAID-DILI patients and HLA allele imputation of matching population controls were performed following overall, class and drug-based association analysis. Significant results were tested in a non-Hispanic White (NHW) case-control replication cohort.

RESULTS

Between September 2004 and March 2022, causality was adjudicated in 2498, and 55 (41 [75%] women) were assessed as likely due to NSAIDs. Median age at onset was 55 y (range 22-83 y). Diclofenac was the causative drug in 29, celecoxib in 7, ibuprofen in 5, etodolac and meloxicam each in 4. Except for meloxicam and oxaprozin (n = 2), the liver injury was hepatocellular with median R 15-25. HLA-DRB1*04:03 and HLA-B*35:03 were significantly more frequent in NSAID-DILI patients than in non-NSAID DILI controls. Interestingly, 85% of the HLA-DRB1*04:03 carriers developed DILI due to the use of acetic acid derivative NSAIDs, supporting the hypothesis that HLA-DRB1*04:03 could be a drug and/or class risk factor. HLA-B*35:03 but not HLA-DRB1*04:03 association was confirmed in the independent NHW replication cohort, which was largely driven by diclofenac.

CONCLUSIONS

Despite prevalent use, NSAID-DILI is infrequent in the United States. Diclofenac is the most commonly implicated, and adherence to warnings of risk and close observation are recommended. The increased frequency of HLA-B*35:03 and DRB1*04:03, driven by diclofenac, suggests the importance of immune-mediated responses.

Adsorption Capacity of Carbon-Silica Composites Towards Diclofenac in Poly(acrylic acid) Containing Systems: A Crucial Study on Common Wastewater Contaminants

Diclofenac is one of the most popular over-the-counter non-steroidal anti-inflammatory drug and poly(acrylic acid) is a frequently used as thickener, filler or stabilizer. For these reasons, they are common organic contaminants in raw wastewater. The purpose of the presented studies was to compare the adsorption capacity of three carbon-silica composites - metal-free C/SiO2, iron-enriched C/Fe/SiO2 and manganese-enriched C/Mn/SiO2 towards diclofenac. The studies were carried out in single, and mixed systems in the presence of poly(acrylic acid) polymer. Adsorption, desorption and kinetics of the adsorption process were investigated. The concentration of diclofenac in the supernatants was determined using high-performance liquid chromatography. The solids were also characterized with an ASAP apparatus using low-temperature nitrogen desorption adsorption isotherms at liquid nitrogen temperature. In addition, potentiometric titrations and electrophoretic mobility measurements, as well as stability tests of the studied suspensions were carried out. The most efficient composite among investigated ones proved to be C/Fe/SiO2 removing diclofenac at the level of 46.68 mg/g for its initial concentration of 90 ppm. The results obtained clearly demonstrated that the carbon-silica composites are effective in separation of drugs from aqueous solutions and can be successfully used in the future for the removal of organic pollutants from water environment.

Topical Diclofenac to Manage Opioid-Refractory Pain in a Rare Pancreatic Fibrosarcoma

Pancreatic cancer is often diagnosed at an advanced stage and is frequently associated with severe pain. Traditional pain management in this condition may be improved with the use of topical diclofenac. A 39-year-old man with advanced pancreatic fibrosarcoma metastatic to the thoracic spine presented to the hospital with severe abdominal pain refractory to escalating doses of opioids. A celiac plexus block produced significant, yet inadequate, pain reduction. Satisfactory pain control and opioid de-escalation were ultimately achieved with the application of topical diclofenac gel to an area of bony metastasis. This case illustrates the potential for pain control using topical diclofenac in patients with pancreatic soft tissue tumors and vertebral metastases. Topical diclofenac may exert antitumoral effects and targeted application may improve absorption, leading to improved pain control. The use of topical diclofenac for pain management in metastatic pancreatic cancer presents an interesting tool that should be considered in similar cases.

The Protective Effects of Vitamin B Complex on Diclofenac Sodium-Induced Nephrotoxicity: The Role of NOX4/RhoA/ROCK

Diclofenac sodium (DIC) is a widely used non-steroidal anti-inflammatory drug. Unfortunately, its prolonged use is associated with nephrotoxicity due to oxidative stress, inflammation, and fibrosis. We aimed to investigate the nephroprotective effects of vitamin B complex (B1, B6, B12) against DIC-induced nephrotoxicity and its impact on NOX4/RhoA/ROCK, a pathway that plays a vital role in renal pathophysiology. Thirty-two Wistar rats were divided into four groups: (1) normal control; (2) vitamin B complex (16 mg/kg B1, 16 mg/kg B6, 0.16 mg/kg B12, intraperitoneal); (3) DIC (10 mg/kg, intramuscular); and (4) DIC plus vitamin B complex group. After 14 days, the following were assayed: serum renal biomarkers (creatinine, blood urea nitrogen, kidney injury molecule-1), oxidative stress, inflammatory (tumor necrosis factor-α, interleukin-6), and fibrotic (transforming growth factor-β) markers as well as the protein levels of NOX4, RhoA, and ROCK. Structural changes, inflammatory cell infiltration, and fibrosis were detected using hematoxylin and eosin and Masson trichrome stains. Compared to DIC, vitamin B complex significantly decreased the renal function biomarkers, markers of oxidative stress and inflammation, and fibrotic cytokines. Glomerular and tubular damage, inflammatory infiltration, and excessive collagen accumulation were also reduced. Protein levels of NOX4, RhoA, and ROCK were significantly elevated by DIC, and this elevation was ameliorated by vitamin B complex. In conclusion, vitamin B complex administration could be a renoprotective approach during treatment with DIC via, at least in part, suppressing the NOX4/RhoA/ROCK pathway.

New Insights into the Role of Humic Acid in Permanganate Oxidation of Diclofenac: A Novel Electron Transfer Mechanism

Humic acid (HA) ubiquitously existing in aquatic environments has been reported to significantly impact permanganate (KMnO4) decontamination processes. However, the underlying mechanism of the KMnO4/HA system remained elusive. In this study, an enhancing effect of HA on the KMnO4 oxidation of diclofenac (DCF) was observed over a wide solution pH range of 5-9. Surprisingly, the mechanism of HA-induced enhancement varied with solution pH. Quenching and chemical probing experiments revealed that manganese intermediates (Mn(III)-HA and MnO2) were responsible for the enhancement under acidic conditions but not under neutral and alkaline conditions. By combining KMnO4 decomposition, galvanic oxidation process experiments, electrochemical tests, and FTIR and XPS analysis, it was interestingly found that HA could effectively mediate the electron transfer from DCF to KMnO4 in neutral and alkaline solutions, which was reported for the first time. The formation of an organic-catalyst complex (i.e., HA-DCF) with lower reduction potential than the parent DCF was proposed to be responsible for the accelerated electron transfer from DCF to KMnO4. This electron transfer likely occurred within the complex molecule formed through the interaction between HA-DCF and KMnO4 (i.e., HA-DCF-KMnO4). These results will help us gain a more comprehensive understanding of the role of HA in the KMnO4 oxidation processes.

Exploring monocarboxylate transporter inhibition for cancer treatment

Cells are separated from the environment by a lipid bilayer membrane that is relatively impermeable to solutes. The transport of ions and small molecules across this membrane is an essential process in cell biology and metabolism. Monocarboxylate transporters (MCTs) belong to a vast family of solute carriers (SLCs) that facilitate the transport of certain hydrophylic small compounds through the bilipid cell membrane. The existence of 446 genes that code for SLCs is the best evidence of their importance. In-depth research on MCTs is quite recent and probably promoted by their role in cancer development and progression. Importantly, it has recently been realized that these transporters represent an interesting target for cancer treatment. The search for clinically useful monocarboxylate inhibitors is an even more recent field. There is limited pre-clinical and clinical experience with new inhibitors and their precise mechanism of action is still under investigation. What is common to all of them is the inhibition of lactate transport. This review discusses the structure and function of MCTs, their participation in cancer, and old and newly developed inhibitors. Some suggestions on how to improve their anticancer effects are also discussed.

Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department

BACKGROUND

The optimal pain relief method for acute renal colic in the emergency department remains controversial.

OBJECTIVE

We compared the safety and efficacy of intradermal sterile water injection (ISWI) to treatment with intramuscular (IM) diclofenac, intravenous (IV) opioids, and IV paracetamol in patients with acute renal colic.

METHODS

This randomized, single-blind study included 320 patients with renal colic to one of four treatment groups. The first group received ISWI at four different points around the most painful flank area. Patients in the DI, PARA, and TRAM groups received 75 mg IM diclofenac, 1 g IV paracetamol, and 100 mg IV tramadol, respectively. Pain intensity was measured using a visual analog scale (VAS) before treatment and 15, 30, and 60 min after treatment.

RESULTS

VAS scores 15 and 30 min after treatment were significantly lower in group ISWI than in groups DI, PARA, and TRAM. However, there were no significant differences in the decrease in the pain score at baseline and at 60 min after treatment. In addition, fewer patients required rescue analgesia in group ISWI than in group TRAM. However, no significant differences were observed between group ISWI and group DI or PARA in terms of the need for rescue analgesia. Finally, there were significantly fewer adverse events in group ISWI than in groups DI and TRAM.

CONCLUSIONS

ISWI had similar efficacy, faster pain relief, and lower need for rescue analgesia compared with diclofenac, paracetamol, and tramadol for the management of acute renal colic. In addition, ISWI was well-tolerated and had no adverse effects.

Topical Treatment Is Effective and Safe for Acute Ankle Sprains: The Multi-Center Double-Blind Randomized Placebo-Controlled TRAUMED Trial

BACKGROUND

Topical NSAIDs are widely used to treat ankle sprains. Traumed (Tr14) gel is a multicomponent formulation, demonstrating inflammation-resolution properties.

METHODS

This multicenter, double-blind trial investigated the efficacy and safety of Tr14 gel versus placebo gel and non-inferiority versus 1% diclofenac gel, applied 3×/day for 7 days after acute lateral ankle sprain (EudraCT Number: 2016-004792-50). The primary outcome was AUC for pain on passive movement, assessed by VAS from baseline to Days 4 and 7.

RESULTS

The trial population included 625 patients aged 18 to 78 years. The AUC scores were 187.88 and 200.75 on Day 4 (p = 0.02) and 294.14 and 353.42 on Day 7 (p < 0.001) for Tr14 and placebo, respectively. For Tr14 compared to diclofenac, the AUC scores were 187.50 and 197.19 on Day 4 (p = 0.3804) and 293.85 and 327.93 on Day 7 (p = 0.0017), respectively. On the FAAM-ADL subscale, Tr14 was superior to placebo and non-inferior to diclofenac at all time points. Time to 50% pain improvement was lowest for Tr14 (6.0 days), compared to placebo (7.1 days) and diclofenac (7.0 days). Adverse events were uncommon and minor.

CONCLUSIONS

Tr14 gel is effective and safe in acute ankle sprains, compared to placebo gel and diclofenac gel, and has faster pain resolution.

TRIAL REGISTRATION

The trial was registered in clinicaltrialsregister.eu, EudraCT number 2016-004792-50 on 07.06.2017.

Oxadiazole Derivatives of Diclofenac as an Anti-proliferative Agent for B-cell Non-Hodgkin Lymphoma: An In vitro and In Silico Studies

BACKGROUND

Non-Hodgkin lymphoma of B cell origin is the common type of lymphoma- related malignancy with poor response rate with conventional front-line therapies.

AIM

The aim of the present study was to investigate the potential of new anti-inflammatory oxadiazole derivatives of Diclofenac as an anti-lymphoma agent through in vitro and in silico approaches.

METHOD

The compound (II) showed anti-lymphoma activity against both follicular and Burkitt's lymphoma cells, whereas compound (V) inhibited follicular lymphoma cells only. The diclofenac (I) and derivatives (III, IV and VI) exhibited no anti-proliferative effects. The (II) significantly inhibited the expression of BCL-2, p-38 MAPK and TGF-β in both follicular and Burkitt's lymphoma cells and was non-toxic against normal human fibroblast cells (BJ).

RESULT

The in silico studies against BCL-2 revealed that the unsubstituted Sulphur group in compound (II) is involved in the crucial interactions with the binding site residue.

CONCLUSION

The compound (II) can be a potential therapeutic candidate for B-cell non-Hodgkin lymphoma and deserves further development as a novel anti-lymphoma agent.

Switching Topical Diclofenac from Higher to Lower Strength: Financial and Clinical Evaluation

Background

In February 2020, the Fraser Health Authority in British Columbia introduced an automatic therapeutic interchange policy, whereby orders for any strength of topical diclofenac would be automatically interchanged to the commercially available diclofenac 2.32% gel for twice-daily administration. The new policy was intended mainly as a cost-saving measure but had the potential for clinical impacts that needed to be considered.

Objectives

To evaluate the financial and clinical impact of the automatic therapeutic interchange policy for topical diclofenac.

Methods

A financial evaluation and a clinical evaluation were conducted. Expenditures for topical diclofenac before and after implementation of the automatic therapeutic interchange policy were compared. To obtain information about the clinical impact of the interchange, a retrospective chart review was conducted at long-term care sites. The primary outcome was a composite of 7 components that could indicate worsening of pain in 3 prespecified scenarios.

Results

The financial evaluation showed that the interchange could potentially save the health authority more than $200 000 over 12 months. The clinical evaluation showed that 25%-48% of patients met the primary outcome of worsening pain (analyzed according to 3 different scenarios) after the switch to lower-strength diclofenac, with increases in use of as-needed topical diclofenac and other analgesics being the main indicators of worsening pain.

Conclusions

An automatic therapeutic interchange policy that switched orders for higher strengths of diclofenac to the 2.32% concentration resulted in large financial savings and, in most cases (52%-75% of patients), did not appear to affect pain control. Prospective studies comparing the clinical impact of higher- and lower-strength topical diclofenac products are warranted.

The effect of tyrosol on diclofenac sodium-induced acute nephrotoxicity in rats

Although diclofenac (DCF) is a nonsteroidal anti-inflammatory drug that is considered safe, its chronic use and overdose may show some toxic effects. The protective effect of tyrosol (Tyr) pretreatment against DCF-induced renal damage was investigated in this study. The 32 rats used in the study were randomly divided into four groups of eight rats each. According to the data obtained, it was determined that creatinine, urea, and blood urea nitrogen (BUN) levels increased in serum samples of the DCF group. Besides, the levels of reduced glutathione (GSH) and glutathione peroxidase (GPx) activity decreased and the malondialdehyde (MDA) level increased in the kidney tissue. However, no change was observed in catalase (CAT) activity. Cyclooxygenase-2 (COX-2), nuclear factor kappa B (NF-κB), and tumor necrosis factor-alpha (Tnf-α) levels increased and nuclear factor erythroid 2-related factor 2 (Nrf-2) levels decreased. No change was detected in the level of interleukin 1 beta (IL-1β). When the DCF+Tyr group and the DCF group were compared, it was assessed that Tyr had a curative effect on all biochemical parameters. Also, kidney damages, such as degeneration and necrosis of tubular epithelium and congestion of veins, were obviated by treatment with tyrosol in histopathological examinations. It was determined that Tyr pretreatment provided a protective effect against nephrotoxicity induced by DCF with its anti-inflammatory and antioxidant properties.

Evaluation of the protective role of selenium

BACKGROUND AND PURPOSE

Organisms, including humans, are subjected to the simultaneous action of a wide variety of pollutants, the effects of which should not be considered in isolation, as many synergies and antagonisms have been found between many of them. Therefore, this work proposes an in vivo study to evaluate the effect of certain metal contaminants on the bioavailability and metabolism of pharmacologically active compounds. Because the most frequent entry vector is through ingestion, the influence of the gut microbiota and the possible protective effects of selenium has been additionally evaluated.

EXPERIMENTAL APPROACH

A controlled exposure experiment in mammals (Mus musculus) to a "chemical cocktail" consisting of metals and pharmaceuticals (diclofenac and flumequine). The presence of selenium has also been evaluated as an antagonist. Mouse plasma samples were measured by UPLC-QTOF. A targeted search of 48 metabolites was also performed.

KEY RESULTS

Metals significantly affected the FMQ plasma levels when the gut microbiota was depleted. Hydroxy FMQ decreased if metals were present. Selenium minimized this decrease. The 3-hydroxy DCF metabolite was not found in any case. Changes in some metabolic pathways are discussed.

CONCLUSIONS AND IMPLICATIONS

The presence of metals in the mouse diet as well as the prior treatment of mice with an antibiotic mixture (Abxs), which deplete the gut microbiota, has a decisive effect on the bioavailability and metabolism of the tested pharmaceuticals and dietary selenium minimize some of their effects.

Removal of Diclofenac and Heavy Metal Ions from Aqueous Media Using Composite Sorbents in Dynamic Conditions

Pharmaceuticals and heavy metals pose significant risks to human health and aquatic ecosystems, necessitating their removal from water and wastewater. A promising alternative for this purpose involves their removal by adsorption on composite sorbents prepared using a conventional layer-by-layer (LbL) method or an innovative coacervate direct deposition approach. In this study, four novel composite materials based on a silica core (IS) and a polyelectrolyte coacervate shell were used for the investigation of dynamic adsorption of three heavy metals (lead, nickel and cadmium) and an organic drug model (diclofenac sodium salt, DCF-Na). The four types of composite sorbents were tested for the first time in dynamic conditions (columns with continuous flow), and the column conditions were similar to those used in wastewater treatment plants. The influence of the polyanion nature (poly(acrylic acid) (PAA) vs. poly(sodium methacrylate) (PMAA)), maintaining a constant poly(ethyleneimine) (PEI), and the cross-linking degree (r = 0.1 and r = 1.0) of PEI chains on the immobilization of these pollutants (inorganic vs. organic) on the same type of composite was also studied. The experiments involved both single- and multi-component aqueous solutions. The kinetics of the dynamic adsorption process were examined using two non-linear models: the Thomas and Yoon-Nelson models. The tested sorbents demonstrated good adsorption capacities with affinities for the metal ions in the following order: Pb2+ > Cd2+ > Ni2+. An increase in the initial diclofenac sodium concentration led to an enhanced adsorption capacity of the IS/(PEI-PAA)c-r1 sorbent. The calculated sorption capacities were in good agreement with the adsorption capacity predicted by the Thomas and Yoon-Nelson models. The substantial affinity observed between DCF-Na and a column containing composite microparticles saturated with heavy metal ions was explained.

Mitochondrial H2O2 Is a Central Mediator of Diclofenac-Induced Hepatocellular Injury

Nonsteroidal anti-inflammatory drug (NSAID) use is associated with adverse consequences, including hepatic injury. The detrimental hepatotoxicity of diclofenac, a widely used NSAID, is primarily connected to oxidative damage in mitochondria, which are the primary source of reactive oxygen species (ROS). The primary ROS responsible for inducing diclofenac-related hepatocellular toxicity and the principal antioxidant that mitigates these ROS remain unknown. Peroxiredoxin III (PrxIII) is the most abundant and potent H2O2-eliminating enzyme in the mitochondria of mammalian cells. Here, we investigated the role of mitochondrial H2O2 and the protective function of PrxIII in diclofenac-induced mitochondrial dysfunction and apoptosis in hepatocytes. Mitochondrial H2O2 levels were differentiated from other types of ROS using a fluorescent H2O2 indicator. Upon diclofenac treatment, PrxIII-knockdown HepG2 human hepatoma cells showed higher levels of mitochondrial H2O2 than PrxIII-expressing controls. PrxIII-depleted cells exhibited higher mitochondrial dysfunction as measured by a lower oxygen consumption rate, loss of mitochondrial membrane potential, cardiolipin oxidation, and caspase activation, and were more sensitive to apoptosis. Ectopic expression of mitochondrially targeted catalase in PrxIII-knockdown HepG2 cells or in primary hepatocytes derived from PrxIII-knockout mice suppressed the diclofenac-induced accumulation of mitochondrial H2O2 and decreased apoptosis. Thus, we demonstrated that mitochondrial H2O2 is a key mediator of diclofenac-induced hepatocellular damage driven by mitochondrial dysfunction and apoptosis. We showed that PrxIII loss results in the critical accumulation of mitochondrial H2O2 and increases the harmful effects of diclofenac. PrxIII or other antioxidants targeting mitochondrial H2O2 could be explored as potential therapeutic agents to protect against the hepatotoxicity associated with NSAID use.

Cellular mechanisms of taste disturbance induced by the non-steroidal anti-inflammatory drug, diclofenac, in mice

Drug-induced taste disorders are a serious problem in an aging society. This study investigated the mechanisms underlying taste disturbances induced by diclofenac, a non-steroidal anti-inflammatory drug that reduces pain and inflammation by inhibiting the synthesis of prostaglandins by cyclooxygenase enzymes (COX-1 and COX-2). RT-PCR analyses demonstrated the expression of genes encoding arachidonic acid pathway components such as COX-1, COX-2 and prostaglandin synthases in a subset of mouse taste bud cells. Double-staining immunohistochemistry revealed that COX-1 and cytosolic prostaglandin E synthase (cPGES) were co-expressed with taste receptor type-1 member-3 (T1R3), a sweet/umami receptor component, or gustducin, a bitter/sweet/umami-related G protein, in a subset of taste bud cells. Long-term administration of diclofenac reduced the expression of genes encoding COX-1, gustducin and cPGES in mouse taste buds and suppressed both the behavioral and taste nerve responses to sweet and umami taste stimuli but not to other tastants. Furthermore, diclofenac also suppressed the responses of both mouse and human sweet taste receptors (T1R2/T1R3, expressed in HEK293 cells) to sweet taste stimuli. These results suggest that diclofenac may suppress the activation of sweet and umami taste cells acutely via a direct action on T1R2/T1R3 and chronically via inhibition of the COX/prostaglandin synthase pathway inducing down-regulated expression of sweet/umami responsive components. This dual inhibition mechanism may underlie diclofenac-induced taste alterations in humans.

Possible Participation of Adenine Nucleotide Translocase ANT1 in the Cytotoxic Action of Progestins, Glucocorticoids, and Diclofenac on Tumor Cells

A comparative analysis of the cytostatic effects of progestins (gestobutanoyl, megestrol acetate, amol, dienogest, and medroxyprogesterone acetate), glucocorticoids (hydrocortisone, dexamethasone), and diclofenac on tumor cells was carried out in order to confirm their in silico predicted probabilities experimentally. The results showed the different sensitivity of HeLa, MCF-7, Hep-2, K-562, and Wi-38 cell lines to progestins, glucocorticoids, and diclofenac. The minimum IC50 was found for progestin gestobutanoyl (GB) as 18 µM for HeLa cells, and varied from 31 to 38 µM for MCF-7, Hep-2, and K-562. Glucocorticoids and diclofenac were much less cytotoxic in the HeLa, MCF-7, and Hep-2 cell lines than progestins, with IC50 values in the range of 150-3000 μM. Myelogenous leukemia K-562 cells were the least sensitive to the action of progestins and glucocorticoids but the most sensitive to diclofenac, which showed a pronounced cytotoxic effect with an IC50 of 31 μM. As we have shown earlier, progestins can uniquely modulate MPTP opening via the binding of adenine nucleotide translocase. On this basis, we evaluated the expression of adenylate nucleotide translocase ANT1 (SLC25 A4) as a possible participant in cytotoxic action in these cell lines after 48 h incubation with drugs. The results showed that progestins differently regulated ANT1 expression in different cell lines. Gestobutanoyl had the opposite effect on ANT1 expression in the HeLa, K562, and Wi-38 cells compared with the other progestins. It increased the ANT1 expression more than twofold in the HeLa and K562 cells but had no influence on the Wi-38 cells. Glucocorticoids and diclofenac increased ANT1 expression in the Wi-38 cells and decreased it in the K562, MCF-7, and Hep-2 cells. The modulation of ANT1 expression discovered in our study can be a new explanation of the cytotoxic and cytoprotective effects of hormones, which can vary depending on the cell type. ANT isoforms in normal and cancerous cells could be a new target for steroid hormone and anti-inflammatory drug action.

Sb-Doped Cerium Molybdate: An Emerging Material as Dielectric and Photocatalyst for the Removal of Diclofenac Potassium from Aqueous Media

This work reports the influence of antimony substitution in a cerium molybdate lattice for improved dielectric and photocatalytic properties. For this purpose, a series of Ce2-xSbx(MoO4)3 (x = 0.00, 0.01, 0.03, 0.05, 0.07, and 0.09) were synthesized through a co-precipitation route. The as-synthesized materials were characterized for their optical properties, functional groups, chemical oxidation states, structural phases, surface properties, and dielectric characteristics using UV-Vis spectroscopy (UV-Vis), Fourier transform infrared (FTIR) and Raman spectroscopies, X-ray photoelectron spectroscopy (XPS), X-ray diffraction (XRD), Brunauer-Emmett-Teller (BET) analysis, and impedance spectroscopy, respectively. UV-Vis study showed a prominent red shift of absorption maxima and a continuous decrease in band gap (3.35 eV to 2.79 eV) by increasing the dopant concentration. The presence of Ce-O and Mo-O-Mo bonds, detected via FTIR and Raman spectroscopies, are confirmed, indicating the successful synthesis of the desired material. The monoclinic phase was dominant in all materials, and the crystallite size was decreased from 40.29 nm to 29.09 nm by increasing the Sb content. A significant increase in the dielectric constant (ε' = 2.856 × 108, 20 Hz) and a decrease in the loss tan (tanδ = 1.647, 20 Hz) were exhibited as functions of the increasing Sb concentration. Furthermore, the photocatalytic efficiency of pristine cerium molybdate was also increased by 1.24 times against diclofenac potassium by incorporating Sb (x = 0.09) in the cerium molybdate. The photocatalytic efficiency of 85.8% was achieved within 180 min of UV light exposure at optimized conditions. The photocatalytic reaction followed pseudo-first-order kinetics with an apparent rate constant of 0.0105 min-1, and the photocatalyst was recyclable with good photocatalytic activity even after five successive runs. Overall, the as-synthesized Sb-doped cerium molybdate material has proven to be a promising candidate for charge storage devices and a sustainable photocatalyst for wastewater treatment.

Phenotypic and metabolic adaptations of Rhodococcus cerastii strain IEGM 1243 to separate and combined effects of diclofenac and ibuprofen

Introduction

The increasing use of non-steroidal anti-inflammatory drugs (NSAIDs) has raised concerns regarding their environmental impact. To address this, understanding the effects of NSAIDs on bacteria is crucial for bioremediation efforts in pharmaceutical-contaminated environments. The primary challenge in breaking down persistent compounds lies not in the biochemical pathways but in capacity of bacteria to surmount stressors.

Methods

In this study, we examined the biodegradative activity, morphological and physiological changes, and ultrastructural adaptations of Rhodococcus cerastii strain IEGM 1243 when exposed to ibuprofen, diclofenac, and their mixture.

Results and Discussion

Our findings revealed that R. cerastii IEGM 1243 exhibited moderate biodegradative activity towards the tested NSAIDs. Cellular respiration assay showed higher metabolic activity in the presence of NSAIDs, indicating their influence on bacterial metabolism. Furthermore, catalase activity in R. cerastii IEGM 1243 exposed to NSAIDs showed an initial decrease followed by fluctuations, with the most significant changes observed in the presence of DCF and the NSAID mixture, likely influenced by bacterial growth phases, active NSAID degradation, and the formation of multicellular aggregates, suggesting potential intercellular synergy and task distribution within the bacterial community. Morphometric analysis demonstrated alterations in size, shape, and surface roughness of cells exposed to NSAIDs, with a decrease in surface area and volume, and an increase in surface area-to-volume ratio (SA/V). Moreover, for the first time, transmission electron microscopy confirmed the presence of lipid inclusions, polyphosphates, and intracellular membrane-like structures in the ibuprofen-treated cells.

Conclusion

These results provide valuable insights into the adaptive responses of R. cerastii IEGM 1243 to NSAIDs, shedding light on the possible interaction between bacteria and pharmaceutical compounds in the environment.

Time-Dependent Differences in the Effects of Oleic Acid and Oleyl Alcohol on the Human Skin Barrier

Oleic acid and oleyl alcohol are commonly used permeation and penetration enhancers to facilitate topical drug delivery. Here, we aimed to better understand the mechanism of their enhancing effects in terms of their interactions with the human skin barrier using diclofenac diethylamine (DIC-DEA), a nonsteroidal anti-inflammatory drug for topical pain management. Oleic acid promoted DIC-DEA permeation through ex vivo human skin more rapidly than oleyl alcohol (both applied at 0.75%) due to fluidization of stratum corneum lipids as revealed by infrared spectroscopy. After 12 h, the effect of these enhancers on DIC-DEA permeation leveled off, fluidization was no longer evident, and skin permeabilization was mainly due to the formation of fluid enhancer-rich domains. Contrary to oleyl alcohol, oleic acid adversely affected two indicators of the skin barrier integrity, transepidermal water loss and skin electrical impedance. The content of oleyl alcohol in the stratum corneum was lower than that of oleic acid (even 12 h after the enhancers were removed from the skin surface), but it caused higher DIC-DEA retention in both epidermis and dermis compared to oleic acid. The effects of oleyl alcohol and oleic acid on DIC-DEA permeation and retention in the skin were similar after a single and repeated application (4 doses every 12 h). Thus, oleyl alcohol offers several advantages over oleic acid for topical drug delivery.

Efficacy of mixed diclofenac solutions against root canal biofilms

The objective of this research was to evaluate the efficacy of diclofenac sodium solutions, with or without cetrimide (CTR) added, against polymicrobial root canal biofilms grown in dentin specimens. The study groups were: (1) 5% diclofenac sodium (DCS); (2) 2.5% DCS; (3) 2.5% DCS + 0. 2% CTR; (4) 2.5% DCS + 0.4% CTR and (5) 0.9% saline solution (SS) as the control. After 5 min of solution contact with the biofilms, the antimicrobial activity was evaluated by means of the adenosine triphosphate (ATP) assay as well as confocal laser scanning microscopy (CLSM). Microbial quantification was indicated as the percentage reduction of relative light units (RLUs) for the ATP assay, the Log10 total biovolume and the viability percentage (green cells) for CLSM. Solutions of 2.5% DCS + 0.4% CTR and 5% DCS showed the highest antimicrobial efficacy. Cetrimide increased the antibiofilm activity of diclofenac sodium against endodontic biofilms.

Dentists' attitudes and prescription practices for analgesics and antibiotics in Kirkuk Governorate, Iraq

The inappropriate use of analgesics and antibiotics is a widespread issue among dentists globally, leading to the risk of over-prescription that could negatively affect patient health and quality of life. This study aimed to assess the prescribing patterns of analgesics and antibiotics by dentists in Kirkuk City, Iraq, focusing on their attitudes, knowledge levels, and practices regarding these medications. A cross-sectional survey was conducted among 280 dentists in Kirkuk City. The dentists were contacted via their work email addresses, and they responded to a survey. Descriptive statistics, including frequency analysis, were employed to evaluate the appropriateness of analgesic and antibiotic prescriptions for different dental conditions. The first-choice analgesic for 44.6% of dentists was mefenamic acid, followed by paracetamol (31.1%). Regarding antibiotic use, 56.8% of dentists in Kirkuk City reported using antibiotics for empirical and direct therapy. Other dentists (43.2%) revealed that they did not have enough information regarding antibiotic group preference in empirical therapy. 106 of the participants (37.85%) recommended the use of broad-spectrum antibiotics in the treatment of bacterial infections. However, most (45%) were unfamiliar with the group preferences in empirical therapy. Dentists in Kirkuk City showed variations in knowledge and awareness regarding using analgesics and antibiotics. This requires further education and training on proper analgesics and antibiotic stewardship guidelines.

Antifungal Biofilm Inhibitory Effects of Combinations of Diclofenac and Essential Oils

Systemic fungal infections have risen in recent decades and most of them are caused by Candida species, which are becoming increasingly resistant to conventional antifungal drugs. Biofilm production has been considered the most common growth form of Candida cells and is associated with a high level of antifungal resistance. At present, international research reports on the antifungal activity of non-traditional antimicrobial drugs and their potential use against life-threatening resistant fungal infections. Indeed, drug repurposing has led to the consideration of well-known compounds as a last-line therapy. The goal of this work is to evaluate the potential synergistic antifungal biofilm activity of new combinations between diclofenac sodium salt (DSS), a widely used non-steroidal anti-inflammatory drug (NSAID), with the essential oils (EOs) of Mentha piperita, Pelargonium graveolens, and Melaleuca alternifolia, whose antifungal activity has been well documented over the years. The in vitro antifungal activity of DSS and EOs was determined on different Candida strains. Susceptibility testing and the synergism of DSS and EOs versus biofilm cells was performed by using the broth microdilution assay and checkerboard methods. Minimum inhibitory concentrations (sMIC50) of DSS alone ranged from 1.25 to 2.05 mg/mL for all the strains considered. These values significantly decreased when the drug was used in combination with the EOs. The fractional inhibitory concentration index (FICI) was lower than 0.5 for almost all the associations, thus indicating a significant synergism, particularly for the DSS-Pelargonium graveolens combination towards the Candida strains examined. These preliminary results show that the combination of the EOs with DSS improves the antifungal activity on all the tested Candida strains, significantly lowering the concentrations of the components used and thus allowing any toxic effects to be overcome.

Non-steroidal intravitreal injection for noninfectious uveitic cystoid macular edema: Systematic review and meta-analysis

PURPOSE

To systematically review the published manuscripts on the non-steroidal intravitreal injection for treatment of noninfectious uveitic cystoid macular edema (CME).

METHODS

The PubMed, Scopus, and Web of Science, Science Direct, ProQuest, Cochrane Library, ProQuest, Embase, Clinical Key, and Springer were searched for relevant articles published until May 2022. The random-effects models were used to estimate the mean difference (MD) and 95% confidence interval (CI) for postoperative central macular thickness (CMT) and visual acuity (VA) changes. VA was transformed into the logarithm of the minimum angle of resolution (LogMAR). Meta-regression was conducted for adjusting the effects of potential confounders.

RESULTS

A total of 17 relevant studies (258 eyes) were included in this meta-analysis. A significant improvement was observed in CMT in the last follow up (350.89 ± 108.43) compared to the baseline (452.3 ± 112.67) (Log MD = 1.82, 95% CI = 1.62, 2.02; I2 = 57.7%; P = 0.002). Additionally, VA also significantly improved in the last follow up (0.56 ± 0.29) compared to the baseline (0.75 ± 0.3) (Exponential MD = 0.82, 95% CI = 0.69, 0.95; I2 = 0.0%; P = 0.98). The subgroups analyzed included ten studies on anti-vascular endothelial growth factors (VEGF), three studies on infliximab, two studies on methotrexate (MTX), and two studies on diclofenac. All subgroups showed a significant improvement in both CMT and VA at the last follow-up (P < 0.05).

CONCLUSION

Non-steroidal intravitreal injection including bevacizumab, ranibizumab, infliximab, MTX and diclofenac appears to be an effective treatment option for noninfectious uveitic CME.

Retrospective evaluation of the incidence of gastrointestinal bleeding in dogs receiving ophthalmic nonsteroidal anti-inflammatory drugs

OBJECTIVES

To report the incidence of gastrointestinal (GI) bleeding and associated risk factors in a population of dogs receiving ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs).

ANIMAL STUDIED

Medical records of dogs prescribed ophthalmic NSAIDs (cases), dogs receiving systemic NSAIDs alone and dogs receiving systemic prednisone alone (controls).

PROCEDURES

Data were collected retrospectively from the medical records of 204 dogs prescribed ophthalmic NSAIDs (diclofenac, ketorolac, or flurbiprofen), which were subdivided based on if they received any concurrent systemic NSAIDs or glucocorticoids, 136 dogs receiving a systemic NSAID (carprofen or meloxicam) alone, and 151 dogs receiving a systemic glucocorticoid (prednisone) alone at a referral hospital from 2015 to 2019.

RESULTS

Gastrointestinal bleeds developed in 8/79 (10.1%) of topical NSAID-only cases, 10/136 (7.4%) of systemic NSAID controls, and 14/151 (9.3%) of systemic glucocorticoid controls, with no significant difference between the three groups (p = .6103). There were no significant differences in GI bleed rates between cases treated with ketorolac, diclofenac, or flurbiprofen (p = .160), although severe GI bleeding was only seen in ketorolac-treated dogs. Presence of a known concurrent risk factor for GI bleeding was significantly associated with the development of GI bleed in dogs on ophthalmic NSAIDs (p = .032).

CONCLUSIONS

Dogs treated with ophthalmic NSAIDs developed GI bleeding at a frequency comparable to dogs receiving systemic NSAIDs or systemic glucocorticoids alone, suggesting that dogs receiving ophthalmic NSAIDs may be at increased risk of GI bleeding.

Tubuloside A, a phenylethanoid glycoside, alleviates diclofenac induced hepato-nephro oxidative injury via Nrf2/HO-1

The most prominent adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (DF) are hepato-renal damage. Natural antioxidants can be preferred as an alternative and/or combination to improve this damage. This present study was conducted to evaluate the protective effect of Tubuloside A (TA) against diclofenac (DF)-induced hepato-renal damage. TA (1 mg/kg, ip) was administered to male Sprague-Dawley rats for 5 days, and DF (50 mg/kg, ip) was administered on Days 4 and 5. Plasma aspartate amino transferase, alanine amino transferase, alkaline phosphatase, blood urea nitrogen and creatinine were measured to evaluate liver and kidney functions. Additionally, oxidative stress parameters (malondialdehyde, glutathione, superoxide dismutase, catalase, and 8-oxo-7,8-dihydro-2'-deoxyguanosine) in blood, liver, and kidney tissues, changes in mRNA expression of genes involved in the Nrf2/HO-1 signalling pathway (Nrf2, HO-1, NQO-1, IL-6, iNOS, Cox-2, TNF-α, IL1-β and NFκB) and apoptotic process (Bcl-2, Cas-3 and Bax) in liver and kidney tissues were determined. Additionally, tissue sections were evaluated histopathologically. Biochemical, histopathological, and molecular results demonstrated the hepato-renal toxic effects of DF, and TA treatment protected the liver and kidney from DF-induced damage. This provides an explanation for the hepato-nephro damage caused by DF and offers new ideas and drug targets together with TA for the prevention and treatment of DF injury.

Topical Delivery Systems Effectively Transport Analgesics to Areas of Localized Pain via Direct Diffusion

Topical delivery systems (TDSs) enable the direct transport of analgesics into areas of localized pain and thus minimize the side effects of administration routes that rely on systemic drug distribution. For musculoskeletal pain, clinicians frequently prescribe topical products containing lidocaine or diclofenac. This study assessed whether drug delivery from a TDS into muscle tissue occurs mainly via direct diffusion or systemic transport. An investigational TDS containing 108 mg lidocaine (SP-103, 5.4% lidocaine), a commercially available TDS containing 36 mg lidocaine (ZTlido®, 1.8% lidocaine), and a topical pain relief gel (Pennsaid®, 2% diclofenac) were tested. Using open flow microperfusion (OFM), interstitial fluid from the dermis, subcutaneous adipose tissue (SAT), and muscle was continuously sampled to assess drug penetration in all tissue layers. Ex vivo and in vivo experiments showed a higher diffusive transport of lidocaine compared to diclofenac. The data showed a clear contribution of diffusive transport to lidocaine concentration, with SP-103 5.4% resulting in a significantly higher lidocaine concentration in muscle tissue than commercially available ZTlido® (p = 0.008). These results indicate that SP-103 5.4% is highly effective in delivering lidocaine into muscle tissue in areas of localized pain for the treatment of musculoskeletal pain disorders (e.g., lower back pain).

Emerging Mesoporous Polyacrylamide/Gelatin-Iron Lanthanum Oxide Nanohybrids towards the Antibiotic Drugs Removal from the Wastewater

The polyacrylamide/gelatin-iron lanthanum oxide (P-G-ILO nanohybrid) was fabricated by the free radical grafting co-polymerization technique in the presence of N,N-methylenebisacrylamide (MBA) as cross linker and ammonium persulfate (APS) as initiator. The P-G-ILO nanohybrid was characterized by the various spectroscopic and microscopic techniques that provided the information regarding the crystalline behavior, surface area, and pore size. The response surface methodology was utilized for the statistical observation of diclofenac (DF) adsorption from the wastewater. The adsorption capacity (qe, mg/g) of P-G-ILO nanohybrid was higher (254, 256, and 258 mg/g) than the ILO nanoparticle (239, 234, and 233 mg/g). The Freundlich isotherm model was the best fitted, as it gives the higher values of correlation coefficient (R2 = 0.982, 0.991 and 0.981) and lower value of standard error of estimate (SEE = 6.30, 4.42 and 6.52), which suggested the multilayered adsorption of DF over the designed P-G-ILO nanohybrid and followed the pseudo second order kinetic model (PSO kinetic model) adsorption. The thermodynamic study reveals that adsorption was spontaneous and endothermic in nature and randomness onto the P-G-ILO nanohybrids surface increases after the DF adsorption. The mechanism of adsorption of DF demonstrated that the adsorption was mainly due to the electrostatic interaction, hydrogen bonding, and dipole interaction. P-G-ILO nanohybrid was reusable for up to five adsorption/desorption cycles.

Comparison of Pain Levels With Postoperative Intramuscular Administration of Single-Dose Ketoprofen Versus Diclofenac Sodium in Patients Undergoing Lower Third Molar Surgery

Background Third molar surgeries are commonly performed in oral and maxillofacial surgery practice. Pain associated with this procedure is usually a frequent reason for patient apprehension and discomfort. Oral analgesics, though effective, do not provide sufficient pain relief in the immediate postoperative period.  Aim To assess the postoperative effect on pain levels of single-dose administration of ketoprofen and diclofenac sodium as an injection in patients undergoing third molar removal surgeries.  Methods This study was conducted among 30 patients divided into two groups (n=15). Patients in Group K received injection ketoprofen 100 mg and Group D included patients receiving injection diclofenac sodium 75 mg, both intramuscularly postoperatively. The intensity of pain was assessed at 30 minutes, two, six, and eight hours post-surgical removal of the impacted tooth using the visual analogue scale (VAS). The statistical data was analyzed using SPSS for Windows version 23.0 (IBM Corp., Armonk, NY, USA). The comparative statistical test adopted to compare pain scores between the two groups was the Independent samples t-test. A p-value of <0.05 was considered to be statistically significant. Results Our study results revealed that Group K patient's VAS scores after two hours, six hours, and eight hours were 3.9 ± 2.7, 4.5 ± 3.23, 2.93 ± 2.27 respectively. In Group D patient's VAS scores after two hours, six hours, and eight hours were 4.83 ± 2.82, 5.03 ± 2.9, 3.73 ± 2.91 respectively. Patients who were administered ketoprofen had lower pain levels when compared to patients who were given diclofenac but the difference was not statistically significant at any time point (p=0.172 after eight hours). Our results depicted that the pain levels uniformly reached their maximal levels six hours after the procedure and thereafter steadily declined in both groups.  Conclusion It can be concluded from the study that both the drugs ketoprofen and diclofenac sodium analyzed in this study can be used interchangeably for the reduction of pain following lower third molar surgery.

Ultrasonication-assisted synthesis of CN-TiO2 and its photocatalytic degradation of diclofenac under visible light irradiation

In this study, CN codoped TiO2 nanoparticles (CN-TiO2) were fabricated by solvothermal and low temperature calcination methods with the aid of ultrasonication. According to the number of ultrasonic treatments used in the preparation process, the samples were named NN, YN, NY and YY. The characteristics of transmission electron microscopy (TEM), X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), X-ray photoelectron spectroscopy (XPS) and ultraviolet-visible spectroscopy (UV-vis) were employed to analyse the effect of the ultrasonic treatment step in the synthetic process. The results showed that ultrasonication can increase the CN content in TiO2, reduce the band gap energy, and improve the catalytic performance of the CN-TiO2, and the effect of secondary ultrasound is particularly obvious. The YY obtained by two-step ultrasonication with the lowest band gap energy of 3.07 eV. The photocatalytic activity of the CN-TiO2 was evaluated using the degradation of diclofenac (DCF) under visible light irradiation (white LED strips with an emission wavelength of 450 nm). It was observed that the YY exhibited significantly superior DCF degradation activity. When using 0.4 g L-1 of YY, an excellent DCF degradation of 97% could be reached, which is 1.4 times that of NN (without ultrasonication). Moreover, YY had good visible light photocatalytic activity, and the degradation efficiency of YY for DCF under visible light was comparable to that of a xenon lamp. Therefore, ultrasonication played a critical role in the enhancement of photocatalytic activity during the synthesis of CN-TiO2.

Degradation of Diclofenac by Loaded Solid Superbase-Activated Persulfate

Alkali-activated persulfate (PS) is widely used in situ in chemical oxidation processes; however, studies on the innovation of the alkali activation process are very limited. Two supported solid superbases, namely KNO3/γ-Al2O3 (KAl) and KNO3/SBA-15/MgO (KSM), respectively, were prepared and used to activate persulfate to degrade DCF in this work. The results showed that the superbases elevated the solution pH once added and thus could catalyze persulfate to degrade diclofenac efficiently above pH 10.5. The catalytic efficiency of KAl was close to that of sodium hydroxide, and that of KSM was the highest. The mechanism might be that, in addition to raising the solution pH, some potassium existed as K2O2, which had a strong oxidizing effect and was conducive to DCF removal. Hydroxyl, sulfate and superoxide radicals were all found in the reaction system, among which hydroxyl might play the most important role. The material composition ratio, common anion and humic acid all had some influences on the catalytic efficiency. A total of five intermediates were found in the KSM/PS oxidation system, and six oxidation pathways, which were hydroxylation, dehydrogen, dechlorination, dehydration, decarboxylation, and C-N bond breakage, might be involved in the reaction process. Several highly toxic oxidation products that should be paid attention to were also proposed.

Nanosuspension-Based Dissolvable Microneedle Arrays to Enhance Diclofenac Skin Delivery

Applying a formulation on the skin represents a patient-acceptable and therapeutically effective way to administer drugs locally and systemically. However, the stratum corneum stands as an impermeable barrier that only allows a very limited number of drugs to be distributed in the underlying tissues, limiting the feasibility of this administration route. Microneedle arrays are minimally invasive platforms that allow the delivery of drugs within/across the skin through the temporary mechanical disruption of the stratum corneum. In this work, microneedle arrays were combined with nanosuspensions, a technology for solubility enhancement of water insoluble molecules, for the skin delivery of diclofenac. Nanosuspensions were prepared using a top-down method and loaded in the tips of 500 µm or 800 µm high microneedles. The quality of the combined platform was assessed using electron microscopy and spectroscopic and calorimetry techniques, demonstrating the ability to load high amounts of the hydrophobic drug and the compatibility between excipients. Lastly, the application of nanosuspension-loaded microneedles on the skin in vitro allowed the delivery of diclofenac within and across the stratum corneum, proving the potential of this combination to enhance skin delivery of scarcely soluble drugs.

The Importance of Humic Substances in Transporting "Chemicals of Emerging Concern" in Water and Sewage Environments

In this study, we examined the sorption of selected "chemicals of emerging concern" (CEC) on humic substances commonly found in water and municipal wastewater. These were ibuprofen, diclofenac, caffeine, carbamazepine, estrone, triclosan, bisphenol A, and isoproturon. The humic substances (HSs) were synthetic and not contaminated by the tested organic substances. The elemental composition and content of mineral micropollutants, gravimetric curves, and the IR spectrum of HSs were determined. We determined a relationship between the process efficiency and the characteristics of a sorbent and sorbate using the properties of organic substances sorbed on HSs. This relationship was confirmed by sorption tests on the HS complex, i.e., the HS-organic micropollutant. It has been shown that the given complexes have a greater affinity for hydrophobic surfaces than hydrophilic surfaces. To confirm the nature of the sorbent surfaces, we determined their zeta potential dependence on the pH of the solution. Studies have shown that HSs are carriers of both mineral substances and CEC in water and sewage environments.

Simultaneous Multifocal Intracranial Haemorrhages Associated with Staphylococcus Aureus Endocarditis: A Plausible Role for Diclofenac Administration

Introduction

Intracranial haemorrhage may complicate infective endocarditis, caused by ruptured mycotic aneurysms or haemorrhagic transformation of brain septic emboli. The risk of intracranial bleeding may increase with the use of non-steroidal anti-inflammatory agent (NSAIDs).

Case description

We report on a 53-year-old male patient with a past history of intravenous drug abuse, who was treated with diclofenac (75 mg IM) for a few hours of preceding fever and arthralgia. Seven hours later he was hospitalised with impaired consciousness and hemiparesis. Evaluation revealed multiple intracranial haemorrhages, at least one originating from a mycotic aneurysm. Repeated blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA), and echocardiography revealed a vegetation on the mitral valve, establishing the diagnosis of bacterial endocarditis.

Conclusion

The abrupt simultaneous multifocal intracranial bleeds shortly following the administration of NSAIDs for a few hours of febrile disease, one clearly originating from a mycotic aneurism, are exceptional. This raises a possibility of a role for diclofenac the intracranial bleeding diathesis in this unique clinical presentation. Intracranial haemorrhage in the set-up of undiagnosed infective endocarditis (IE) might be added to the long list of potential adverse outcomes of NSAID administration, and the possibility of IE should be considered before their administration for febrile disease of undetermined cause.

LEARNING POINTS

Intracranial haemorrhage in the set-up of undiagnosed infective endocarditis might be added to the long list of potential adverse outcomes of NSAID administration.The possibility of infective endocarditis should be considered before the administration of NSAIDs for febrile disease of an undetermined cause.

on diclofenac-induced toxicity in rats

Background and Aim

Tessaria integrifolia Ruiz and Pav. (also known as "Pájaro bobo") is known for its medicinal properties, including antiulcer, antiasthmatic, leishmanicidal, antipyretic, antispasmodic, diuretic, anti-inflammatory, analgesic, and hepatoprotective effects. Therefore, we aimed to evaluate its hepatoprotective and nephroprotective effects using a rat model of diclofenac-induced toxicity.

Materials and Methods

We administered three different doses of the methanolic extract of T. integrifolia (100, 200, and 400 mg/kg/day orally) and compared them with the commercial medicine silymarin (100 mg/kg orally). The rats received the T. integrifolia extracts for 5 days, and on days 3 and 4, 1 h after receiving the extracts, diclofenac was administered intraperitoneally at a dose of 50 mg/kg. The animals were euthanized 48 h after the last diclofenac injection, and blood samples were obtained to measure biochemical parameters related to liver and kidney function, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, cholesterol, triglycerides, creatinine, and urea. Kidney and liver tissues were preserved in 10% formaldehyde and sent for histopathological analysis.

Results

The results show that T. integrifolia has hepatoprotective and nephroprotective effects. These effects are verified by the lower blood levels of ALT, AST, urea, and creatinine compared to the diclofenac group, which exhibited elevated biochemical parameters. In addition, histopathological analysis showed that the groups that received T. integrifolia did not display necrosis or infiltration, which were observed in the diclofenac group.

Conclusion

The methanolic extract of T. integrifolia has hepatoprotective and nephroprotective effects, with the highest protective activity observed at a dose of 400 mg/kg/day.

Polypyrrole- and Polyaniline-Coated Cotton Fabrics as Efficient Adsorbents for the Pharmaceutical Water Contaminants Diclofenac and Salicylic Acid

The emerging pharmaceutical contaminants diclofenac (DCF) and salicylic acid (SA) pose potential hazards to humans and living organisms due to their persistence in water environments. In this work, the conductive polymers polypyrrole (PPY) and polyaniline (PANI) were successfully coated on cotton fabrics, as confirmed by FTIR and SEM measurements. The coated fabrics efficiently removed DCF at pH 5.3 and SA at pH 4, with removal efficiencies that exceeded 90% and 70%, respectively. Adsorption was rapid for most of the tested contaminant-fabric systems and reached equilibrium within 20-30 min. The best adsorption performance for both contaminants was shown on the PPY-coated fabrics, which yielded adsorption capacities of about 65 and 21 mg/g for DCF and SA, respectively. This could be explained by molecular modeling simulations, which mostly estimated higher total cohesive energy densities for adsorption on the PPY-coated fabrics than on the PANI-coated ones. The adsorption mechanism involved both coulombic electrostatic attractions and non-coulombic van der Waals and π-π stacking. The fabrics could be reused for three adsorption-desorption cycles. Immobilization of the conductive polymers on cotton fabrics provides a facile method for their handling and collection during adsorption and regeneration cycles while maintaining their multi-functionality in adsorbing different contaminants.

Long-Term Outcomes of Breast Cancer Patients Receiving Levobupivacaine Wound Infiltration or Diclofenac for Postoperative Pain Relief

Breast cancer is the most common malignant disease in women. Preclinical studies have confirmed that the local anesthetic levobupivacaine has a cytotoxic effect on breast cancer cells. We examined whether postoperative wound infiltration with levobupivacaine influences survival in 120 patients who were operated on for breast cancer and underwent quadrantectomy or mastectomy with axillary lymph node dissection. Groups with continuous levobupivacaine wound infiltration, bolus wound infiltration, and diclofenac analgesia were compared. Long-term outcomes examined were quality of life, shoulder disability, and hand grip strength (HGS) after one year and survival after 5 and 10 years. Groups that had infiltration analgesia had better shoulder function compared to diclofenac after one year. The levobupivacaine PCA group had the best-preserved HGS after 1 year (P = 0.022). The most significant predictor of the 5-year outcome was HGS (P = 0.03). Survival at 10 years was 85%, 92%, and 77% in the diclofenac, levobupivacaine bolus, and levobupivacaine PCA groups (ns. P = 0.36). The extent of the disease at the time of surgery is the most important predictor of long-term survival (P = 0.03). A larger prospective clinical study could better confirm the effect of levobupivacaine wound infiltration on outcomes after breast cancer surgery observed in this pilot study-trial number NCT05829707.

Non-steroidal Anti-inflammatory Drugs and Osteopathic Manipulative Treatment for Pain Management in Patients With Osteoarthritis: A Literature Review

The pathophysiology of osteoarthritis (OA) involves the destruction of articular cartilage and the overgrowth of bone with lipping and spur formation. Nerve endings in the joint capsule and adjacent tissues play a major role in the pain mechanisms of osteoarthritis. This often requires patients to seek pain control measures beyond over-the-counter drugs, such as local anesthetics. Osteopathic manipulation treatment (OMT) is a conservative, non-pharmacological treatment that can be used to help treat chronic pain associated with OA. Other non-pharmacologic therapies include weight loss, exercise, physical therapy (PT), and assistive devices. However, pharmacologic management may be added synergistically to control flares and maintain baseline activities of daily living. While oral non-steroidal anti-inflammatory drugs (NSAIDs) have been the mainstay of treatment for pain and inflammation associated with OA, they have a non-selective inhibitory action that often results in negative side effects when used chronically. The possibility of minimizing these complications through alternate treatments such as topical NSAIDs provides an opportunity for patients to receive adequate pain relief from OA without suffering unnecessary consequences. This literature review seeks to assess the state of research regarding topical NSAIDs and OMT as alternatives to the current gold-standard treatment of OA. The significant inclusion criteria consisted of articles that described the effects of OMT on OA or the use of topical NSAIDs such as Voltaren on OA. Due to the limited articles found, a qualitative analysis was performed, and the salient conclusions are outlined. Alternative pharmacological and non-pharmacological treatments, such as topical diclofenac gel and OMT, have shown promising results in the treatment of pain in OA. It is seen that a majority of patients achieve pain management using NSAIDs, acetaminophen, or topical analgesics. Both diclofenac sodium and OMT have individually been shown to be effective treatments of OA when compared to the use of oral NSAIDs. A holistic treatment approach that utilizes both topical diclofenac sodium and OMT may provide OA patients with an effective option to reduce their moderate to severe chronic pain with limited side effects. Further, high-quality randomized controlled trials are needed to identify whether synergistic effects occur when combining diclofenac sodium gel and OMT for pain relief in patients with OA.

Protective impacts of Withania somnifera leaf extract from Taif area against diclofenac induced hepato-renal toxicity: role of antioxidants, inflammation, apoptosis, and anti-oxidative stress biomarkers

Current study examined the boosting impacts of Withania somnifera leaf extract from Taif area (high-altitude area) against hepatic and renal toxicity induced by diclofenac in experimental rats. Withania is highly grown on Taif area as environmental herb with multiple functions. Diclofenac is non-steroidal medication used for treatment of pain but over dose has severe side effects. Thirty-two adult Wistar rats of male type were subdivided into 4 groups. The control rats (group 1) received saline. Second group received diclofenac (50 mg/kg BW intraperitoneally) at days 4 and 5. Third group received W. somnifera leaf extract (250 mg /kg body weight) for 6 days. The fourth protective group, received W. somnifera leaf extract plus diclofenac for 6 days as shown in groups 2 and 3. Diclofenac significantly increased serum AST, ALT, and decreased albumin and total proteins levels. It also increased serum concentrations of uric acid and creatinine. In addition, it increased lipid peroxidation, and decreased reduced glutathione and superoxide dismutase levels. Diclofenac increased inflammatory cytokines secretion and up-regulated hepatic oxidative stress genes (HO-1; hemoxygenase-1 and Nrf2nuclear factor erythroid 2-related factor 2 (Nrf2) and renal inflammatory transcriptional markers (TGF-β1; transforming growth factor-beta1 and COX-2; cycloxygenas-2). In parallel, hepatic caspase-3 expression was up-regulated as an apoptotic marker, while Bcl2; (B-cell lymphoma 2) mRNA expression was down regulated as anti-apoptotic marker. W. somnifera pre-administration in the protective group ameliorated the altered parameters induced by diclofenac. In conclusion, W. somnifera leaf extract has the potential to antagonize side effects of diclofenac by regulating the pathways of oxidative stress, inflammation, and apoptosis/antiapoptosis.

Protective effects of diclofenac on liver graft preservation

This study aims to evaluate the effect of diclofenac addition to the preservation solution Celsior on liver graft preservation. Liver from Wistar rats were cold flushed in situ, harvested, and then stored in Celsior solution (24 h, 4 °C) supplemented or not with 50 mg/L of diclofenac sodium salt. Reperfusion was performed (120 min, 37 °C) using the isolated perfusion rat liver model. Perfusate samples were collected to evaluate transaminases' activities after cold storage and by the end of reperfusion. To evaluate liver function, bile flow, hepatic clearance of bromosulfophthalein, and vascular resistance were assessed. Diclofenac scavenging property (DPPH assay) as well as oxidative stress parameters (SOD and MPO activities and the concentration of glutathione, conjugated dienes, MDA, and carbonylated proteins) were measured. Transcription factors (PPAR-γ and NF-κB), inflammation (COX-2, IL-6, HMGB-1, and TLR-4), as well as apoptosis markers (Bcl-2 and Bax) were determined by quantitative RT-PCR. Enriching the preservation solution Celsior with diclofenac sodium salt attenuated liver injuries and improved graft function. Oxidative stress, inflammation, and apoptosis were significantly reduced in Celsior + Diclo solution. Also, diclofenac activated PPAR-γ and inhibited NF-κB transcription factors. To decrease graft damage and improve transplant recovery, diclofenac sodium salt may be a promising additive to preservation solution.

Impacts of Organic Emerging Contaminants (Erythromycin, Ibuprofen, and Diclofenac) on the Performance of a Membrane Bioreactor Treating Urban Wastewater: A Heterotrophic Kinetic Investigation

The occurrence of emerging organic contaminants, such as pharmaceuticals, is a growing global concern. In this research, for a membrane bioreactor (MBR) laboratory plant operating at a hydraulic retention time (HRT) of 24 h, fed with real urban wastewater, the heterotrophic biomass behaviour was analysed for two concentrations of erythromycin, ibuprofen, and diclofenac. The concentrations studied for the first phase were erythromycin 0.576 mg L-1, ibuprofen 0.056 mg L-1, and diclofenac 0.948 mg L-1. For Phase 2, the concentrations were increased to erythromycin 1.440 mg L-1, ibuprofen 0.140 mg L-1, and diclofenac 2.370 mg L-1. Heterotrophic biomass was affected and inhibited by the presence of pharmaceutical compounds in both phases. The system response to low concentrations of pharmaceutical compounds occurred in the initial phase of plant doping. Under these operating conditions, there was a gradual decrease in the concentration of mixed liquor suspended solids and the removal of chemical oxygen demand of the system, as it was not able to absorb the effect produced by the pharmaceutical compounds added in both phases.

Effect of Aging on Physicochemical Properties and Size Distribution of PET Microplastic: Influence on Adsorption of Diclofenac and Toxicity Assessment

Microplastics (MPs) are detected in the water, sediments, as well as biota, mainly as a consequence of the degradation of plastic products/waste under environmental conditions. Due to their potentially harmful effects on ecosystems and organisms, MPs are regarded as emerging pollutants. The highly problematic aspect of MPs is their interaction with organic and inorganic pollutants; MPs can act as vectors for their further transport in the environment. The objective of this study was to investigate the effects of ageing on the changes in physicochemical properties and size distribution of polyethylene terephthalate (PET), as well as to investigate the adsorption capacity of pristine and aged PET MPs, using pharmaceutical diclofenac (DCF) as a model organic pollutant. An ecotoxicity assessment of such samples was performed. Characterization of the PET samples (bottles and films) was carried out to detect the thermooxidative aging effects. The influence of the temperature and MP dosage on the extent of adsorption of DCF was elucidated by employing an empirical modeling approach using the response surface methodology (RSM). Aquatic toxicity was investigated by examining the green microalgae Pseudokirchneriella subcapitata. It was found that the thermooxidative ageing process resulted in mild surface changes in PET MPs, which were reflected in changes in hydrophobicity, the amount of amorphous phase, and the particle size distribution. The fractions of the particle size distribution in the range 100-500 μm for aged PET are higher due to the increase in amorphous phase. The proposed mechanisms of interactions between DCF and PET MPs are hydrophobic and π-π interactions as well as hydrogen bonding. RSM revealed that the adsorption favors low temperatures and low dosages of MP. The combination of MPs and DCF exhibited higher toxicity than the individual components.

Mesoporous Silicas Obtained by Time-Controlled Co-Condensation: A Strategy for Tuning Structure and Sorption Properties

Mesoporous silicas synthesized by the co-condensation of two and three different silica monomers were synthesized by varying the time intervals between the addition of individual monomers, while the total time interval was kept constant. This resulted in different structural properties of the final silicas, particularly in their porosity and local ordering. One of the obtained samples exhibited an unusual isotherm with two hysteresis loops and its total pore volume was as high as 2.2 cm³/g. In addition, to be thoroughly characterized by a wide range of instrumental techniques, the obtained materials were also employed as the adsorbents and release platforms of a diclofenac sodium (DICL; used here as a model drug). In the case of DICL adsorption and release, differences between the samples were also revealed, which confirms the fact that time control of a monomer addition can be successfully used to fine-tune the properties of organo-silica materials.

The Anti-Arthritic Activity of Diclofenac Lipid-Core Nanocapsules: Stereological Analysis Showing More Protection of Deep Joint Components

Diclofenac is the most prescribed nonsteroidal anti-inflammatory drug worldwide and is used to relieve pain and inflammation in inflammatory arthritis. Diclofenac is associated with serious adverse effects, even in regular-dose regimens. Drug delivery systems can overcome this issue by reducing adverse effects and optimizing their efficacy. This study evaluated the activity of lipid-core nanocapsules loaded with diclofenac (DIC-LNCs) in an experimental model of adjuvant-induced arthritis. The diclofenac nanoformulation was obtained via self-assembly. A stereological analysis approach was applied for the morphological quantification of the volume, density, and cellular profile count of the metatarsophalangeal joints of rats. Proinflammatory cytokines and biochemical profiles were also obtained. Our results showed that the diclofenac nanocapsule DIC-LNCs were able to reduce arthritis compared with the control group and the DIC group. DIC-LNCs efficiently reduced proinflammatory cytokines, C-reactive protein, and xanthine oxidase levels. Additionally, DIC-LNCs reduced the loss of synoviocytes and chondrocytes compared with the DIC (p < 0.05) and control groups (p < 0.05). These data suggest that DIC-LNCs have anti-arthritic activity and preserve joint components, making them promising for clinical use.

Establishing a cell-based screening workflow for determining the efficiency of CYP2C9 metabolism: moving towards the use of breath volatiles in personalised medicine

The use of volatile biomarkers in exhaled breath as predictors to individual drug response would advance the field of personalized medicine by providing direct information on enzyme activity. This would result in enormous benefits, both for patients and the healthcare sector. Non-invasive breath tests would also gain a high acceptance by patients. Towards this goal, differences in metabolism resulting from extensive polymorphisms in a major group of drug-metabolizing enzymes, the cytochrome P450 (CYP) family, need to be determined and quantified. CYP2C9 is responsible for metabolising many crucial drugs (e.g., diclofenac) and food ingredients (e.g., limonene). In this paper, we provide a proof-of-concept study that illustrates the in vitro bioconversion of diclofenac in recombinant HEK293T cells overexpressing CYP2C9 to 4'-hydroxydiclofenac. This in vitro approach is a necessary and important first step in the development of breath tests to determine and monitor metabolic processes in the human body. By focusing on the metabolic conversion of diclofenac, we have established a workflow using a cell-based system for CYP2C9 activity. Using limonene, we illustrate how the bioconversion of diclofenac can be limited in the presence of another CYP2C9 metabolising substrate, with increasing limonene levels continuously reducing the formation of 4'-hydroxydiclofenac. Michaelis-Menten kinetics were performed for the diclofenac 4'-hydroxylation, with and without limonene, giving a kinetic constant of the reaction, KM, of 103 µM and 94.1 µM, respectively, and a maximum reaction rate, Vmax, of 46.8 pmol min-1 106 cells-1 and 56.0 pmol min-1 106 cells-1 with and without the inhibitor, respectively, suggesting a non-competitive or mixed inhibition type. The half maximal inhibitory concentration value (IC50) for the inhibition of the formation of 4'-hydroxydiclofenace by limonene is determined to be 1413 µM.

Reduced Staphylococcus Abundance Characterizes the Lesional Microbiome of Actinic Keratosis Patients after Field-Directed Therapies

Skin microbiome dysbiosis with a Staphylococcus overabundance is a feature of actinic keratosis (AK) and squamous skin carcinoma (SCC) patients. The impact of lesion-directed treatments for AK lesions such as diclofenac (DIC) and cold atmospheric plasma (CAP) on the lesional microbiome is not established. We studied 321 skin microbiome samples of 59 AK patients treated with DIC 3% gel versus CAP. Microbial DNA from skin swabs taken before start of treatment (week 0), at the end of the treatment period (week 24), and 3 months after end of treatment (week 36) was analyzed after sequencing the V3/V4 region of the 16S rRNA gene. The relative abundance of S. aureus was scrutinized by a tuf gene specific TaqMan PCR assay. The total bacterial load and both, relative and absolute abundance of Staphylococcus genus was reduced upon both therapies at week 24 and 36 compared to week 0. Notably, the lesional microbiome of patients responding to CAP therapy at week 24 was characterized by an increased relative abundance of Corynebacterium genus compared to nonresponders. A higher relative abundance of Staphylococcus aureus at week 36 was a feature of patients classified as nonresponders for both treatments 12 weeks after therapy completion. The reduction of the Staphylococcus abundance after treatment of AK lesions and alterations linked to treatment response encourage further studies for investigation of the role of the skin microbiome for both, the carcinogenesis of epithelial skin cancer and its function as predictive therapeutic biomarker in AK. IMPORTANCE The relevance of the skin microbiome for development of actinic keratosis (AK), its progression into squamous skin cancer, and for field-directed treatment response is unknown. An overabundance of staphylococci characterizes the skin microbiome of AK lesions. In this study, analyses of the lesional microbiome from 321 samples of 59 AK patients treated with diclophenac gel versus cold atmospheric plasma (CAP) revealed a reduced total bacterial load and reduced relative and absolute Staphylococcus genus abundance upon both treatments. A higher relative Corynebacterium abundance was a feature of patients classified as responders at the end of CAP-treatment period (week 24) compared with nonresponders and the Staphylococcus aureus abundance of patients classified as responders 3 months after treatment completion was significantly lower than in nonresponders. The alterations of the skin microbiome upon AK treatment encourage further investigations for establishing its role for carcinogenesis and its function as predictive biomarker in AK.

Ligninolytic enzyme activity and removal efficiency of pharmaceuticals in a water matrix by fungus Rhizopus sp. Isolated from cassava

Residual amounts of pharmaceutical compounds (PhCs) and by-products are continually released into surface water with effluents from conventional wastewater treatment plants (WWTPs). This study evaluated the ability of fungal isolate to remove selected PhCs [carbamazepine (CBZ), diclofenac (DCF) and ibuprofen (IBP)] from wastewater. The fungus used was Rhizopus sp. which was isolated from tuberous roots of cassava (Manihot esculenta). The isolate exhibited an important removal efficiency up to 100% and this was linked to ligninolytic enzymatic activity for lignin peroxidase (15.29 ± 2.69U/L) and manganese peroxidase (85.22 ± 4.26U/L), except laccase. This activity was optimum on day 9 of treatment. PhC metabolites were identified during the experiment revealing the existence of a biotransformation process catalysed by the isolated fungus. The disappearance of PhCs was attributed to their biosorption and biotransformation. However, it was not possible to establish a relationship between the ligninolytic enzymatic activity and the removal efficiency, which leads to the conclusion that there are other fungal metabolites which also play an important role in the biotransformation and biodegradation of the selected PhCs.

Complete Biodegradation of Diclofenac by New Bacterial Strains: Postulated Pathways and Degrading Enzymes

The accumulation of xenobiotic compounds in different environments interrupts the natural ecosystem and induces high toxicity in non-target organisms. Diclofenac is one of the commonly used pharmaceutical drugs that persist in the environment due to its low natural degradation rate and high toxicity. Therefore, this study aimed to isolate potential diclofenac-degrading bacteria, detect the intermediate metabolites formed, and determine the enzyme involved in the degradation process. Four bacterial isolates were selected based on their ability to utilize a high concentration of diclofenac (40 mg/L) as the sole carbon source. The growth conditions for diclofenac degradation were optimized, and bacteria were identified as Pseudomonas aeruginosa (S1), Alcaligenes aquatilis (S2), Achromobacter spanius (S11), and Achromobacter piechaudii (S18). The highest percentage of degradation was recorded (97.79 ± 0.84) after six days of incubation for A. spanius S11, as analyzed by HPLC. To detect and identify biodegradation metabolites, the GC-MS technique was conducted for the most efficient bacterial strains. In all tested isolates, the initial hydroxylation of diclofenac was detected. The cleavage step of the NH bridge between the aromatic rings and the subsequent cleavage of the ring adjacent to or in between the two hydroxyl groups of polyhydroxylated derivatives might be a key step that enables the complete biodegradation of diclofenac by A. piechaudii S18, as well as P. aeruginosa S1. Additionally, the laccase, peroxidase, and dioxygenase enzyme activities of the two Achromobacter strains, as well as P. aeruginosa S1, were tested in the presence and absence of diclofenac. The obtained results from this work are expected to be a useful reference for the development of effective detoxification bioprocesses utilizing bacterial cells as biocatalysts. The complete removal of pharmaceuticals from polluted water will stimulate water reuse, meeting the growing worldwide demand for clean and safe freshwater.

Carvacrol Exerts Anti-Inflammatory, Anti-Oxidative Stress and Hepatoprotective Effects Against Diclofenac-Induced Liver Injury in Male Rats

Background

Diclofenac (DIC) is an NSAID that can cause toxic effects in animals and humans and carvacrol (CAR) is a monoterpene compound that displays effective pharmacological and biological actions. The purpose of this work was to assess the influences of CAR on DIC-induced liver injury and oxidative stress in male rats.

Methods

The male Wistar rats were segregated into four groups. Group 1, the control group; Group 2 received DIC-only (10 mg/kg BW, p.o); Group 3, received CAR-only (10 mg/kg BW, p.o), and group 4 received DIC plus CAR. The serum levels as well as the activity of several liver-associated markers, and oxidative and anti-oxidant compounds were tested. The expression of pro-inflammatory mediators was also studied using the qRT-PCR analysis.

Results

Our results showed that DIC treatment was associated with the elevation in the serum levels of liver-related markers together with the increase in the serum and the hepatic levels of malondialdehyde (MDA) and protein carbonyl (PC). Moreover, DIC reduced the activity of the antioxidant system in the rats and increased lymphocyte infiltration into the hepatocytes. CAR; however, protected the hepatocytes from the toxic effects of DIC by enhancing the activity of antioxidant enzymes such as catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx), and Glutathione (GSH). By diminishing the expression of tumor necrosis factor (TNF)-α, CAR was also capable of preventing the inflammatory effects of DIC on liver cells.

Conclusions

The findings of this study indicated that the administration of CAR could alleviate the noxious effects of DIC on the antioxidant defense system and liver tissue.

Phytoremediation of diclofenac using the Green Liver System: Macrophyte screening to system optimization

Green Liver Systems employ the ability of macrophytes to take up, detoxify (biotransform), and bioaccumulate pollutants; however, these systems require optimization to target specific pollutants. In the present study, the aim was to test the applicability of the Green Liver System for diclofenac remediation considering the effects of selected variables. As a starting point, 42 macrophyte life forms were evaluated for diclofenac uptake. With the three best performing macrophytes, the system efficiency was evaluated at two diclofenac concentrations, one environmentally relevant and that other significantly higher (10µg/L and 150µg/L) and in two system sizes (60L and 1000L) as well as at three flow rates (3, 7, and 15L/min). The effect of single species and combinations on removal efficiency was also considered. The highest internalization percentage was recorded in Ceratophyllum spp., Myriophyllum spp., and Egeria densa. Phytoremediation efficiency with species combinations was far superior to utilizing only a single macrophyte type. Furthermore, the results indicate that the flow rate significantly affected the removal efficiency of the pharmaceutical tested, with the highest remediation efficiency obtained with the highest flow rate. System size did not significantly affect phytoremediation; however, increase diclofenac concentration reduced the systems performance significantly. When planning the setup of a Green Liver System for wastewater remediation, basic knowledge about the water, i.e., pollutant types and flow, must be utilized during planning to optimize remediation. Various macrophytes show diverse uptake efficiencies for different contaminants and should be selected based on the pollutant composition of the wastewater.