Comparison of gastrointestinal effects of aspirin and fenoprofen. A double blind crossover study

Visible small-intestinal mucosal injury in chronic NSAID users

BACKGROUND & AIMS

Patients who regularly take nonsteroidal anti-inflammatory drugs (NSAIDs) have an increased risk for small-intestinal mucosal ulceration and bleeding, which may present as anemia of undetermined gastrointestinal origin or protein loss. The prevalence and severity of small-intestinal lesions remains unclear. Our aim was to assess the frequency of NSAID-induced small-bowel injury among chronic NSAID users.

METHODS

Ambulatory patients with various types of arthritides who took NSAIDs daily (>3 mo duration) or took either acetaminophen alone or nothing were enrolled in the study. All patients fasted overnight and underwent wireless video capsule endoscopy. Two investigators, blind to therapy, reviewed each video beginning after the pylorus. Lesions were scored as normal, red spots, small erosions, large erosions, or ulcers. An ulcer was defined as a larger lesion with apparent depth and a definite rim.

RESULTS

Forty-one patients, 36 men and 5 women, ages ranging from 22 to 66 years (mean age, 49.8 y) were analyzed including 21 chronic NSAID users and 20 control patients. Small-bowel injury was seen in 71% of NSAID users compared with 10% of controls (P < .001). Injury was mild (few or no erosions, absence of large erosions/ulcers) in 10 NSAID users compared with 2 controls. Five NSAID users had major (>4 erosions or large ulcers/ulcers) damage compared with none in the control group. There were no complications or problems with the capsule endoscopy procedure.

CONCLUSIONS

Endoscopically evident small-intestinal mucosal injury is very common among chronic NSAID users. The role of endoscopically evident injury in unexplained iron-deficiency anemia and hypoalbuminemia among chronic NSAID users remains undetermined.

Complementary studies of the gastrointestinal safety of the cyclo-oxygenase-2-selective inhibitor etoricoxib

BACKGROUND

Cyclo-oxygenase-2-selective non-steroidal anti-inflammatory drugs are intended to preserve cyclo-oxygenase-1-mediated gastroprotection and platelet function, whilst inhibiting cyclo-oxygenase-2-mediated inflammation.

AIM

To assess the gastrointestinal safety of the cyclo-oxygenase-2-selective inhibitor etoricoxib vs. non-selective non-steroidal anti-inflammatory drugs.

METHODS

Two randomized, double-blind, placebo- and active-controlled studies were performed: (i) daily faecal red blood cell loss was measured in 62 subjects receiving etoricoxib (120 mg once daily), ibuprofen (800 mg t.d.s.) or placebo for 28 days; (ii) the incidence of endoscopically detectable gastric/duodenal ulcers was determined in 742 osteoarthritis or rheumatoid arthritis patients receiving etoricoxib (120 mg once daily), naproxen (500 mg b.d.) or placebo over 12 weeks.

RESULTS

In the first study, the between-treatment ratio of faecal blood loss for etoricoxib vs. placebo (1.06) was not significantly different from unity; however, the ratios for ibuprofen vs. placebo (3.26) and etoricoxib (3.08) were significantly greater than unity (P < 0.001). In the second study, the incidence of ulcers of > or = 3 mm with naproxen (25.3%) was significantly higher than that with etoricoxib (7.4%) or placebo (1.4%; P < 0.001); the results were similar for ulcers of > or = 5 mm.

CONCLUSIONS

The reduced toxicity of etoricoxib (less faecal blood loss and fewer endoscopically detectable lesions) suggests that use of this drug will may be associated with a reduced incidence of gastrointestinal perforations, ulcers and bleeds.

A randomized trial measuring fecal blood loss after treatment with rofecoxib, ibuprofen, or placebo in healthy subjects

PURPOSE

Gastrointestinal microbleeding, as assessed by the measurement of (51)chromium-labeled red blood cells, is a marker of the mucosal injury associated with the use of nonsteroidal anti-inflammatory drugs. This study tested the hypotheses that cyclooxygenase-2 specific inhibition with rofecoxib would cause less fecal blood loss than a therapeutic dose of ibuprofen and would be equivalent to placebo.

SUBJECTS AND METHODS

In this randomized, double-blind group study, gastrointestinal blood loss was assessed by measurement of fecal (51)chromium radioactivity during a 1-week placebo baseline period and during 4 weeks of treatment with rofecoxib (25 mg or 50 mg once daily), ibuprofen (800 mg three times daily), or placebo in 67 healthy subjects. Gastrointestinal blood loss during treatment weeks 2 to 4 (versus the baseline period) was expressed as the geometric mean ratio of fecal radioactivity in weeks 2 to 4 compared with baseline.

RESULTS

Ibuprofen caused significantly (P <0.001) greater gastrointestinal blood loss (geometric mean ratio of 5.2, 95% confidence interval [CI]: 4.2 to 6.3) than the 25-mg dose of rofecoxib (2.6, 95% CI: 2.2 to 3.1), the 50-mg dose of rofecoxib (2.6, 95% CI: 2.2 to 3.0), or placebo (2.1, 95% CI: 1.8 to 2.5). In contrast, gastrointestinal blood loss with both doses of rofecoxib were equivalent to placebo by a predetermined clinical similarity bound.

CONCLUSIONS

In healthy subjects, treatment with rofecoxib, at 2 to 4 times the doses that are currently recommended for the treatment of patients with osteoarthritis, produced significantly less fecal blood loss than a therapeutic dose of ibuprofen and was equivalent to placebo.

Gastrointestinal blood loss induced by bromfenac sodium, aspirin, and placebo

The effects of bromfenac sodium, aspirin, and placebo on gastrointestinal (GI) blood loss were compared. In a 22-day, randomized study, healthy men received treatment with either bromfenac sodium 300 mg/d, aspirin 3900 mg/d, or placebo for 10 days. On days 3 through 9 and days 20 through 22, all patients received placebo. Fecal blood was measured using the chromium 51-labeled red blood cell technique. Thirty-seven subjects entered the treatment period (13 in the aspirin group, 12 in the bromfenac sodium group, and 12 in the placebo group). The mean change in fecal blood loss during the treatment period compared with the baseline period was significantly greater in the aspirin group (8.00 +/- 4.17 mL/d) than in the bromfenac sodium group (1.63 +/- 1.01 mL/d). Blood loss in both the aspirin and bromfenac sodium groups was significantly greater than in the placebo group (-0.12 +/- 0.25 mL/d). It is concluded that bromfenac sodium 300 mg/d, a higher daily dose than the proposed daily dose, causes significantly less GI blood loss than aspirin 3900 mg/d.

Effects of nonsteroidal antiinflammatory drugs on platelet function and systemic hemostasis

Aspirin and nonaspirin nonsteroidal antiinflammatory drugs (NSAIDs) inhibit platelet cyclooxygenase, thereby blocking the formation of thromboxane A2. These drugs produce a systemic bleeding tendency by impairing thromboxane-dependent platelet aggregation and consequently prolonging the bleeding time. Aspirin exerts these effects by irreversibly blocking cyclooxygenase and, therefore, its actions persist for the circulating lifetime of the platelet. Nonaspirin NSAIDs inhibit cyclooxygenase reversibly and, therefore, the duration of their action depends on specific drug dose, serum level, and half-life. The clinical risks of bleeding with aspirin or nonaspirin NSAIDs are enhanced by the concomitant use of alcohol or anticoagulants and by associated conditions, including advanced age, liver disease, and other coexisting coagulopathies.

A comparison of severe gastric damage as a result of pirprofen and naproxen treatment in rheumatoid arthritis: a controlled endoscopic study

OBJECTIVE

The aim of this controlled endoscopic study was to compare the therapeutic efficacy and the gastric tolerance of two nonsteroidal anti-inflammatory drugs, pirprofen versus naproxen.

DESIGN

A randomized endoscopic double-blind double-dummy study.

SETTING

The gastrointestinal unit of a teaching hospital.

SUBJECTS

Forty patients suffering from rheumatoid arthritis were enrolled. After an initial upper gastrointestinal endoscopy to rule out the presence of gastric mucosal lesions, the patients were randomly allocated in a double-blind, double-dummy manner, to receive either pirprofen (400 mg t.i.d.) or naproxen (500 mg b.i.d.) for 4 weeks; endoscopic control followed this treatment period, or was anticipated in the event of painful dyspepsia.

INTERVENTIONS

Endoscopy at the beginning of the study and at 4 weeks, or anticipated in the event of painful dyspepsia.

MAIN OUTCOME MEASURES

Primary outcome measure of the study was the possibility that pirprofen was less toxic to the gastric mucosa than naproxen, and at least as effective.

RESULTS

Both drugs proved effective in relieving clinical symptoms, without a statistically significant difference. Gastric mucosa lesions were observed in 90% of pirprofen-treated patients and in 60% of those on naproxen (P = 0.03). The most severe lesions (grades 3 and 4) were found in 65% of subjects treated with pirprofen, as opposed to 15% of those treated with naproxen (P = 0.001).

CONCLUSIONS

This study shows that pirprofen is at least as active as naproxen in relieving rheumatic symptoms, but its administration results in a significantly severe degree of gastric damage.

Placebo-controlled comparison of piroxicam-beta-cyclodextrin, piroxicam, and indomethacin on gastric potential difference and mucosal injury in humans

The acute gastroduodenal mucosa injury and gastric potential difference (GPD) drops provoked by 14-day administration of 20 mg/day of a new piroxicam formulation (piroxicam-beta-cyclodextrin), 20 mg/day standard piroxicam and 100 mg/day indomethacin were evaluated and compared in a randomized, double-blind, placebo-controlled study carried out on 64 volunteers. Endoscopic examinations, performed after 14-day treatment, demonstrated that piroxicam-beta-cyclodextrin was less gastrolesive (mean endoscopic score +/- SE = 0.56 +/- 0.2) than either piroxicam (2.06 +/- 0.5) or indomethacin (2.25 +/- 0.5) (p < 0.01). The drop in GPD after a single dose of the assigned drug was considerably greater for piroxicam and indomethacin than for piroxicam-beta-cyclodextrin (p < 0.01), which registered similar values to placebo. Since GPD is an expression of the anatomo-functional integrity of the gastric barrier, the results indicate that piroxicam-beta-cyclodextrin exerts less direct acute damage on the gastric mucosa. Therefore, when administered short-term, piroxicam-beta-cyclodextrin appears to be less gastrolesive than either indomethacin or the standard piroxicam formulation.

Gastric protection by nocloprost against aspirin damage in humans. Possible role of epidermal growth factor

Ten healthy young male subjects took part in a double-blind, placebo-controlled crossover study to assess the effects of nocloprost on gastric microbleeding and endoscopic mucosal injury induced by the administration of aspirin (2.5 g). In addition, basal and pentagastrin-induced gastric acid and pepsin secretion and salivary and plasma contents of epidermal growth factor (EGF) were measured after placebo plus aspirin or nocloprost plus aspirin treatment in these subjects. Nocloprost (100 micrograms/dose) significantly reduced spontaneous gastric microbleeding and almost completely prevented gastric mucosal injury induced by aspirin. Nocloprost failed to affect basal and pentagastrin-stimulated gastric acid and pepsin secretion but increased significantly the salivary outputs and plasma concentrations of EGF. In conclusion, nocloprost is effective in preventing gastric injury by aspirin even at a non-antisecretory dose, and this protection may involve an excessive release of EGF.

Visual analogue scales for endoscopic evaluation of nonsteroidal anti-inflammatory drug-induced mucosal damage in the stomach and duodenum

The use of visual analogue scales in the evaluation of mucosal lesions may reduce sample size requirements in clinical trials, but they may be complex to use, and adding guide points may reduce their informative value. We found that two investigators with differing levels of endoscopic experience reached comparable conclusions in 4 clinical trials (738 scores), and their scores were highly correlated, with similar dispersion characteristics. With guide texts along the scales, thus avoiding points on the actual scales, no tendency towards accumulation was seen in 1449 scores. These results encourage the use of visual analogue scales in endoscopic studies.

Optimal assessment of gastrointestinal side effects induced by non-steroidal anti-inflammatory drugs. Endoscopic lesions, faecal blood loss, and symptoms not necessarily correlated, as observed after naproxen and oxindanac in healthy volunteers

Gastrointestinal side effects caused by naproxen and oxindanac (a developmental non-steroidal anti-inflammatory drug) were compared by combined endoscopy and determination of faecal blood loss in 16 healthy male volunteers in a randomized, double-blind, crossover study. Individual daily faecal blood loss was determined by means of 51Cr-labelled erythrocytes. Gastroduodenoscopy was performed before and after administration of naproxen, 750 mg/day, and oxindanac, 600 mg/day, for 1 week each. A washout period of at least 3 weeks was inserted between drug periods. Visual analogue scales (VAS) were used for endoscopic assessment of lesions and subjective complaints. Mean faecal blood loss increased from a base line 0.48 ml/24 h to 1.59 ml/24 h with naproxen (p less than 0.01) and from 0.56 ml/24 h to 1.31 ml/24 h with oxindanac (p less than 0.01). VAS scores for gastroduodenal lesions increased significantly with both drugs. Naproxen caused a significantly greater increase than oxindanac (p less than 0.05). There was no correlation between gastrointestinal blood loss and endoscopic findings. Subjective symptoms were correlated to faecal blood loss with naproxen, but not to endoscopic findings. No such correlations were observed for oxindanac. Naproxen caused a significant prolongation of bleeding time (p less than 0.01), whereas the increase caused by oxindanac was not significant (p = 0.09).

Etodolac, a new nonsteroidal anti-inflammatory drug: gastrointestinal microbleeding and endoscopic studies

A review of the literature is presented on the gastrointestinal effects of etodolac, a new nonsteroidal anti-inflammatory drug (NSAID), as evaluated in both microbleeding and endoscopic studies. In four microbleeding studies, gastrointestinal blood loss in healthy subjects was estimated by a 51Cr-erythrocyte labeling method before drug treatment, after 7 days of treatment with NSAIDs including etodolac, and 1 week after the last day of treatment. In these 7-day studies, the gastrointestinal blood loss seen with etodolac (600 to 1200 mg/day) was similar to that seen with placebo and significantly (p less than 0.05) less than that seen with aspirin (2600 mg/day), naproxen (750 mg/day), ibuprofen (2400 mg/day), or indomethacin (200 mg/day). Naproxen, ibuprofen, and indomethacin caused mean daily blood losses in excess of 1 ml/day over baseline values. The increase with aspirin was 4 to 5 ml/day. In contrast, the greatest mean daily increase in blood loss with etodolac therapy was 0.2 ml. In a 4-week study of etodolac (600 and 1000 mg/day) and piroxicam (20 mg/day) given to patients with osteoarthritis or rheumatoid arthritis, blood loss seen with etodolac was comparable to that seen with placebo and significantly less than that seen with piroxicam. Gastrointestinal irritation was also assessed by endoscopy after 1 week of NSAID or placebo treatment. Endoscopy scores after etodolac treatment (up to 1200 mg/day) were similar to scores at baseline and after placebo and were significantly lower than scores following treatment with aspirin (3900 mg/day), indomethacin (200 mg/day), ibuprofen (2400 mg/day), or naproxen (100 mg/day). The effects of etodolac (600 or 1000 mg/day) and diclofenac (150 mg/day) were not different from each other or from baseline. These data indicate that etodolac, in these studies, did not cause clinically significant gastrointestinal microbleeding or visible gastric injury. By the criteria used in these studies, etodolac is less irritating to the gastrointestinal tract than aspirin, indomethacin, ibuprofen, naproxen, or piroxicam, and compares favorably with diclofenac.

Prevention of gastroduodenal injury induced by chronic nonsteroidal antiinflammatory drug therapy

The fact that nonsteroidal antiinflammatory drugs (NSAIDs) damage the gastroduodenal mucosa is now accepted as NSAID use has been associated with a disproportionately high frequency of upper gastrointestinal bleeding and perforation of gastric and duodenal ulcers. More than 10% of patients receiving NSAIDs chronically will have a gastric ulcer on any given day, a point prevalence of ulcer disease 5-10 times higher than in patients who are not taking NSAIDs. Endoscopic studies comparing the effect of acute administration of NSAIDs on the gastroduodenal mucosa in normal volunteers have failed to predict which NSAIDs would be safest when administered chronically. All of the newer NSAIDs appear to be similar in their propensity to cause chronic mucosal damage, including peptic ulceration. Recent studies have suggested that in those starting NSAID therapy, prophylactic cotreatment with H2-receptor antagonists or sucralfate has minimal or no effect on preventing the development of NSAID-induced gastric ulcers, although duodenal ulcers may be reduced. Nonsteroidal antiinflammatory drug-induced gastric ulcers are also not prevented by drug formulations that prevent or markedly reduce the amount of active NSAID in the stomach. Cotreatment with the synthetic prostaglandin misoprostol was associated with a marked reduction in gastric ulcer development in patients with osteoarthritis receiving NSAIDs chronically, suggesting that prevention of prostaglandin generation in the gastric mucosa may play a pivotal role in NSAID-induced gastric ulcers.

A review of gastric ulcer and gastroduodenal injury in normal volunteers receiving aspirin and other non-steroidal anti-inflammatory drugs

Studies in normal volunteers from our laboratory and by other investigators have demonstrated that non-steroidal anti-inflammatory agents (NSAIDs) can significantly damage the gastroduodenal mucosa. This damage is maximal with plain and buffered aspirin products. The injury produced by non-aspirin NSAIDs in anti-inflammatory doses is less than with aspirin but depends primarily on the dosages used. Pro-drugs and enteric-coated aspirin tend to produce less injury. The incidence of gastric ulcer in 1064 normal volunteers studied in our laboratory over a period of 7 years is reviewed. Seventy-two (6.7%) normal subjects developed a gastric ulcer after 7 days of therapy with anti-inflammatory doses of these drugs. The largest number of ulcers were seen with plain and buffered aspirin, and the lowest number with the lower anti-inflammatory doses of the non-aspirin NSAIDs.

Clinical differences among nonsteroidal antiinflammatory drugs: implications for therapeutic substitution in ambulatory patients

The practice of therapeutic substitution, i.e., replacing one drug with another chemically different drug from the same therapeutic class, represents an important therapeutic modification with potential clinical significance far beyond that of generic substitution. Adverse consequences following therapeutic substitution of nonsteroidal antiinflammatory drugs (NSAID) is of special concern because of substantial differences among these agents in pharmacokinetic, pharmacological, and clinical properties. Therapeutic substitution of NSAID for ambulatory patients may result in compromised clinical outcome because (1) patient response is unpredictable and selection of the optimal agent must be tailored for each patient; (2) substantial differences exist in adverse reaction profiles; (3) drug interaction studies are lacking; and (4) selection of an agent must be individualized to ensure compliance with the dosing regimen. Cost savings achieved through therapeutic substitution of NSAID may be lost by additional overall treatment costs due to adverse reactions or suboptimal therapy. The occurrence of adverse or suboptimal effects in ambulatory patients is more likely if NSAID are substituted without full knowledge of the patient's medical history and clinical status. Communication between the pharmacy and prescribing physician regarding a patient's specific needs is essential for rational substitution among NSAID.

Double-blind, placebo-controlled endoscopic comparison of the mucosal protective effects of misoprostol versus cimetidine on tolmetin-induced mucosal injury to the stomach and duodenum

Ninety normal volunteers were entered into a double-blind, placebo-controlled study to compare the efficacy of misoprostol (200 micrograms q.i.d.) vs. cimetidine (300 mg q.i.d.) in protecting the gastric and duodenal mucosa from tolmetin-induced (400 mg q.i.d.) injury. After 6 days of treatment, the degree of mucosal injury between treatments was compared by endoscopy, using a predetermined rating scale of 0 (normal mucosa) to 4+ (greater than 25 hemorrhages or erosions or an invasive ulcer). Utilizing a score of less than or equal to 2+ (2-10 hemorrhages or erosions) as a therapeutic success, the overall success rates were 8/30 (26.7%) for placebo, 19/30 (63.3%) for cimetidine, and 27/29 (93.1%) for misoprostol (p less than 0.001). Pairwise comparisons were also significant: misoprostol vs. placebo (p less than 0.001), misoprostol vs. cimetidine (p = 0.006), and cimetidine vs. placebo (p = 0.004). A separate analysis of the gastric scores alone revealed success rates identical to those in the overall evaluation; however, success rates in the duodenum for both misoprostol (29/29) and cimetidine (29/30) were extremely high and did not differ. It is concluded that misoprostol is highly effective and significantly better than cimetidine in protecting the gastric mucosa from tolmetin-induced injury; however, both agents were highly protective in the duodenum.

Lack of correlation between fecal blood loss and drug-induced gastric mucosal lesions

Increased fecal blood loss was produced in healthy volunteers by the administration of two nonsteroidal anti-inflammatory drugs (NSAID), naproxen or fenflumizole. Basal as well as drug-induced gastrointestinal blood loss was measured using 51Cr erythrocyte labeling. Median rise in daily fecal blood loss was 432%. All subjects were endoscoped at the initiation and at the completion of the study. Endoscopic findings were assessed quantitatively by two observers in two different ways. All subjects but three had gastric mucosal lesions at follow-up endoscopy. There was a good correlation between the endoscopic assessments but no statistical correlation between the endoscopic assessment and the increase in fecal blood loss. The data suggest that factors other than gastric mucosal lesions have to be taken into account when investigating NSAID-induced gastrointestinal bleeding.

Clinical spectrum of the upper gastrointestinal effects of nonsteroidal anti-inflammatory drugs. Natural history, symptomatology, and significance

Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve rheumatic pain and are in extensive use. Symptomatic complications of NSAIDs requiring the discontinuation of their use occur in 2 to 10 percent of patients with rheumatic diseases in sharp contrast to the common asymptomatic problems of gastroduodenal erosions, ulcerations, and bleeding, with resulting anemia in more than 40 percent of these patients. Opinions concerning the clinical significance of these complications are not uniform. The natural history of the effects of NSAIDs on the gastroduodenal mucosa reveals a sequence of initial subepithelial hemorrhage over a 24-hour period followed by gastroduodenal erosions and ulcerations in the next two weeks. From one week to three months, gastroduodenal erosions and ulcerations disappear in about half of the patients as an adaptation to continuing NSAID ingestion occurs. Hemorrhage may occur at any time in most patients and in a small minority (1 percent) it is massive. Non-aspirin NSAIDs (NANSAIDs) exhibit significantly fewer complications than do aspirin. These complications, however, demand considerable clinical attention and are ordered in a constant hierarchy, suggesting variable risks of complications among agents. NSAIDs are a blessing for those who have chronic pain, but that blessing does not prevent significant asymptomatic complications in the same patients. Prophylaxis for high-risk groups, such as women over the age of 65 years, should be subjected to study.

Management of NSAID-induced gastrointestinal lesions

Mucosal lesions in the g.i. tract due to ASA and other nonsteroidal anti-inflammatory drugs are well-known in clinical practice. Though the gastroduodenal mucosa is the area most commonly investigated, several recent reports focus on lesions in the small and large intestine as well. Despite considerable efforts in the field, none of the new substances developed in the past few years have proven convincingly superior to existing drugs. Instead, other approaches are being evaluated: Bypassing of the gastroduodenal mucosa through enteric coating and slow release formulations have been suggested, but the possibility of transferring the deleterious effects to distal parts of the gastrointestinal tract by such formulation modifications calls for extensive evaluation of this area, before these formulations can be applauded as advantageous in this group of patients. Co-administration of protective substances has also been advocated, and, despite somewhat contradictory results, protection has been reported by H2-antagonists alone or in combination with antacids, as well as by cytoprotective agents like Sucralfate, and prostaglandin analogues.

Effects of flurbiprofen and aspirin on the gastric and duodenal mucosa. An endoscopic comparison

A single-blind, randomized endoscopic tolerance study was conducted to compare daily doses of flurbiprofen (Ansaid, Upjohn) at 100, 150, and 200 mg per day with 2,600 mg of aspirin per day. Ten normal volunteers were enrolled in each of the flurbiprofen groups, and five were enrolled in the aspirin group. Analysis of the mean gastric mucosal injury scores obtained on day eight revealed statistically significant lower mean scores (p = 0.05) in the 100-mg and 150-mg flurbiprofen treatment groups when compared with the 200-mg flurbiprofen group and the aspirin group. No significant differences were found between any of the treatment groups in duodenal mucosal injury scores. Mean scores for gastric mucosal injury in the three groups receiving flurbiprofen showed a definite dose relationship. The aspirin-treated subjects had significantly decreased uric acid levels (p = 0.006) and a significantly higher incidence of tinnitus (p = 0.04) compared with the flurbiprofen treatment groups. There was a poor correlation between subjective symptomatology and endoscopic pathologic findings.

A double-blind study of prophylactic effect of misoprostol on lesions of gastric and duodenal mucosa induced by oral administration of tolmetin in healthy subjects

Tolmetin, a nonsteroidal antiinflammatory drug, is known to induce edema, submucosal hemorrhage, and erosions of the gastrointestinal tract when administered at recommended doses. The purpose of our study was to determine whether misoprostol prevented or reduced the severity of duodenal and gastric mucosal injury induced by tolmetin. Following endoscopic screening, 60 healthy male and female subjects were assigned at random to one of two treatment groups. One group was treated with tolmetin (2000 mg/day, in four divided doses) and misoprostol (200 micrograms four times daily); the other with tolmetin and placebo. Both drugs were administered for six and a quarter days. On the seventh day, 2 hr after the last dose, an endoscopic examination of the gastric and duodenal mucosa was repeated, and the results graded. Subjects with 10 or fewer hemorrhages or erosions were considered treatment successes; those with 11 or more erosions, plus any other lesions, were considered treatment failures. A total of 59 subjects completed the study. One withdrew because of an unsuspected pregnancy. In regard to the gastric mucosa, seven of 29 (24%) placebo subjects were considered treatment successes. In the misoprostol group, 27 of 30 (90%) were treatment successes. This difference is statistically significant at the P less than 0.0001 level. The overall damage to the duodenal mucosa caused by tolmetin is less than that to the gastric mucosa, with the misoprostol-treated subjects having significantly less damage than the placebo subjects (P less than 0.001). Side effects were common in both groups, but almost all were mild, gastrointestinal in origin, and did not require treatment or withdrawal from the study.(ABSTRACT TRUNCATED AT 250 WORDS)

What's new in steroid and nonsteroid drug effects on gastroduodenal mucosa?

A survey is given on the damaging effect of acetylsalicylic acid, other nonsteroidal antiinflammatory drugs and corticosteroids on the gastroduodenal mucosa. The results of blood loss studies and endoscopic investigations are reviewed. Also, the histologic aspects of such damage are discussed. Modern concepts of the pathophysiology of these lesions stress the cytoprotective role of endogenous prostaglandins. Epidemiologic data strongly support an association between frequent and heavy intake of acetylsalicylic acid and gastric ulcer as well as gastrointestinal bleeding, whereas the association with duodenal ulcers is far less clearly established. Conclusive evidence is currently unavailable proving the superiority of other nonsteroidal antiinflammatory drugs in this regard. The ulcerogenic potency of corticosteroids at least in the small or medium dose range probably has been overstated in the past. Intensive ulcer therapy making use of H2 receptor antagonists often allows healing of small ulcers with a diameter up to 1 cm despite continued treatment with low dose corticosteroids or nonsteroidal antiinflammatory drugs, whereas continuation of these drugs is associated with very poor healing in ulcers larger than this size. The danger of perforation has to be taken into consideration.

Endoscopic studies of gastric and duodenal injury after the use of ibuprofen, aspirin, and other nonsteroidal anti-inflammatory agents

The toxic effects of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) were endoscopically evaluated in several studies conducted between 1975 and 1983 and involving 843 normal volunteers. Anti-inflammatory doses of acetylsalicylic acid (2,400 and 3,900 mg/day) consistently produced significantly more mucosal injury than did any of the newer NSAIDs. Buffering did not reduce the degree of damage. Little or no mucosal injury was seen with placebo, "pro drugs," enteric-coated aspirin, or 1,200 mg/day of ibuprofen (Motrin, Upjohn). However, varying degrees of generally dose-dependent mucosal injury were evident with larger doses of ibuprofen, naproxen, tolmetin sodium, and indomethacin. The amount of mucosal damage after 2,400 mg/day of ibuprofen did not increase when 4,800 mg daily was administered. Duodenal injury corresponded to gastric injury, but it was generally less severe. Short-term studies of one to three days indicated that ibuprofen produced little or no injury when given at a dose of 2,400 mg for one day or 1,600 mg/day for three days. No relation was noted between subjective symptoms and endoscopic findings.

Comparative efficacy of fenoprofen calcium and zomepirac sodium in postsurgical dental pain

The relative analgesic efficacy of zomepirac sodium 100 mg and fenoprofen calcium 200 mg was evaluated in patients with pain due to surgical removal of dental impactions. This is the first study to make a direct comparison of their effectiveness. This study is especially important since zomepirac sodium was recently removed from the market as an analgesic for acute pain. Zomepirac sodium was extremely popular among clinicians and was considered the most effective of the peripherally acting analgesics. Patients were requested to take a single dose of study medication when they had moderate to severe pain. The study medications were identical in appearance and randomly allocated under double-blind conditions. The medication was evaluated over the next 4 hours according to subjective analgesic measurement scales. The primary measures of efficacy included total pain relief ( TOTPAR ), sum pain intensity difference ( SPID ), overall evaluation, and time to remedication . Of the 136 patients entered, 117 were included in the efficacy analysis. Both active agents demonstrated marked superiority to placebo (p less than 0.001) for all efficacy measures but were inseparable from each other. The mean analgesic efficacy values for both zomepirac sodium and fenoprofen calcium were almost identical. The nineteen subjects who reported side effects were evenly distributed among the three groups. No serious side effects occurred. The results of this study indicate that fenoprofen calcium 200 mg and zomepirac sodium 100 mg are equally efficacious, with similar onset, peak, and total analgesic effects.

Antiprostaglandin synthetase activity of nonsteroidal anti-inflammatory drugs and gastrointestinal micro-bleeding: a comparison of flurbiprofen with benoxaprofen

By using 51Cr-labelled erythrocytes and 141Ce-labelled microspheres to correct for daily variations in faecal output, gastrointestinal microbleeding was measured in hospital patients with rheumatoid arthritis before and after administration of 2 propionic acid derivatives. These were flurbiprofen and benoxaprofen, respectively a potent and a weak prostaglandin synthetase inhibitor. Increased faecal blood loss occurred consistently with flurbiprofen and not with benoxaprofen. Our results provide indirect evidence for the cytoprotective effect of prostaglandins on the gastrointestinal mucosa in man. The quantitative correlation between faecal occult blood loss as measured by the above techniques and the Haemoccult slide test is also discussed.

Gastroscopic evaluation of the effect of aspirin and oxaprozin on the gastric mucosa

Oxaprozin, a new long-acting, antiinflammatory agent, and aspirin were compared utilizing gastroscopic evaluation and photography of the gastric mucosa in a double-blind, crossover study in normal volunteers. Submucosal hemorrhages or mucosal bleeding was observed in seven of eight subjects on aspirin and in only two of eight on oxaprozin (P = 0.061). Adverse effects were experienced by seven of eight subjects after the aspirin treatment period--tinnitus in five and gastrointestinal symptoms in four. Only one patient had mild diarrhea on oxaprozin. The incidence of adverse effects was found significantly higher with aspirin therapy (P less than 0.001). No laboratory abnormalities of clinical significance were attributed to either drug administration. Results after ten days of treatment show that oxaprozin in therapeutic dose levels (1200 mg once a day) produces significantly fewer changes in the gastric mucosa than aspirin (975 mg administered four times a day, total daily dose 3.9 Gm) in the same subjects, who received both drugs in this double-blind, crossover experiment with a four-week washout period between treatments.