Frequent monthly use of selected non-prescription and prescription non-narcotic analgesics among U.S. adults

Physical activity intensity and markers of inflammation in those with non-alcoholic fatty liver disease

AIMS

To investigate associations between objectively measured light (LPA) and moderate-to-vigorous (MVPA) physical activity on plasma homocysteine and serum C-reactive protein (CRP) in individuals with Non-Alcoholic Fatty Liver Disease (NAFLD).

METHODS

This study was a secondary analysis using data from 2003 to 2006 National Health and Nutrition Examination Survey including a total of 983 individuals with NAFLD. Physical activity was assessed over 7 days with accelerometers. Participants were split into tertiles based on average daily minutes of LPA or MVPA and CRP and homocysteine were assessed across tertiles.

RESULTS

Adjusted plasma homocysteine and CRP were not different between groups regarding levels of LPA (Homocysteine: 1st tertile - 10.4 ± 0.7 µmol/L; 2nd tertile - 9.6 ± 0.4 µmol/L; 3rd tertile - 9.6 ± 0.4 µmol/L; p = 0.28; CRP: 1st tertile - 0.79 ± 0.12 mg/dL; 2nd tertile - 0.73 ± 0.09 mg/dL; 3rd tertile - 0.73 ± 0.09 mg/dL; p = 0.72). Adjusted CRP was significantly (p = 0.02) different across MVPA tertiles (1st: 0.87 ± 0.13 mg/dL; 2nd: 0.75 ± 0.10 mg/dL; 3rd:0.65 ± 0.09).

CONCLUSIONS

LPA does not appear to be effective at improving homocysteine or CRP levels in individuals with NAFLD. However, MVPA may be an effective therapy for decreasing CRP in NAFLD patients.

Killing pain? A prospective population-based study on trauma exposure in childhood as predictor for frequent use of over-the-counter analgesics in young adulthood. The HUNT study

Frequent and increasing use of over-the-counter analgesics (OTCA) is a public health concern. Pain conditions and psychological distress are related to frequent OTCA use, and as exposure to potentially traumatic events (PTE) in childhood appears to increase risk of experiencing such symptoms, we aimed to assess childhood PTEs and related symptoms in adolescence as predictors for frequent OTCA use in young adulthood. Prospective population survey data were used (n = 2947, 59.1% female, 10-13 years follow-up). Exposure to PTEs, symptoms of post-traumatic stress, anxiety and depression, musculoskeletal pain and headache were assessed in adolescence (13-19 years). Use of OTCA was assessed in young adulthood (22-32 years) and use of OTCA to treat musculoskeletal pain and headache served as separate outcomes in ordinal logistic regression analyses. Overall, exposure to childhood PTEs, particularly direct interpersonal violence, was significantly and consistently related to more frequent use of OTCA to treat musculoskeletal pain and headaches in young adulthood. Adjusting for psychological symptoms and pain attenuated associations, indicating that these symptoms are of importance for the relationship between traumatic events and OTCA use. These findings emphasize the need to address symptomatology and underlying causes at an early age.

The Impact of Diclofenac Gel on Ion Transport in the Rabbit (Oryctolagus cuniculus) Skin: An In Vitro Study

Diclofenac belongs to the non-steroidal anti-inflammatory drugs with analgesic, antipyretic and anti-inflammatory effects. Diclofenac administration on the skin may be associated with the appearance of side effects. The study aimed to evaluate the impact of diclofenac gel on transepithelial electrophysiological parameters of the 55 rabbit abdomen skin specimens. The electric parameters were analyzed in a modified Ussing chamber. The resistance (R) of the skin specimens treated with diclofenac gel significantly increased, which could be related to the reduction in the water content in intercellular spaces and, consequently, tighter adhesion of the cells. Increased electric potential (PD) was also observed in the skin specimens treated with diclofenac gel. The increase in both R and PD measured under stationary conditions was most likely caused by a transient and reversible increase in sodium ion transport, as the R and PD values decreased after the diclofenac gel was washed away. However, diclofenac gel did not affect the maximum and minimum PDs measured during stimulations. Therefore, it seems that diclofenac gel does not affect the perception of stimuli in the model system used.

Regular Acetaminophen Use and Blood Pressure in People With Hypertension: The PATH-BP Trial

BACKGROUND

Acetaminophen is widely used as first-line therapy for chronic pain because of its perceived safety and the assumption that, unlike nonsteroidal anti-inflammatory drugs, it has little or no effect on blood pressure (BP). Although observational studies suggest that acetaminophen may increase BP, clinical trials are lacking. We, therefore, studied the effects of regular acetaminophen dosing on BP in individuals with hypertension.

METHODS

In this double-blind, placebo-controlled, crossover study, 110 individuals were randomized to receive 1 g acetaminophen 4× daily or matched placebo for 2 weeks followed by a 2-week washout period before crossing over to the alternate treatment. At the beginning and end of each treatment period, 24-hour ambulatory BPs were measured. The primary outcome was a comparison of the change in mean daytime systolic BP from baseline to end of treatment between the placebo and acetaminophen arms.

RESULTS

One-hundred three patients completed both arms of the study. Regular acetaminophen, compared with placebo, resulted in a significant increase in mean daytime systolic BP (132.8±10.5 to 136.5±10.1 mm Hg [acetaminophen] vs 133.9±10.3 to 132.5±9.9 mm Hg [placebo]; P<0.0001) with a placebo-corrected increase of 4.7 mm Hg (95% CI, 2.9-6.6) and mean daytime diastolic BP (81.2±8.0 to 82.1±7.8 mm Hg [acetaminophen] vs 81.7±7.9 to 80.9±7.8 mm Hg [placebo]; P=0.005) with a placebo-corrected increase of 1.6 mm Hg (95% CI, 0.5-2.7). Similar findings were seen for 24-hour ambulatory and clinic BPs.

CONCLUSIONS

Regular daily intake of 4 g acetaminophen increases systolic BP in individuals with hypertension by ≈5 mm Hg when compared with placebo; this increases cardiovascular risk and calls into question the safety of regular acetaminophen use in this situation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01997112. URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2013-003204-40.

Ibuprofen and NSAID Use in COVID-19 Infected Patients Is Not Associated with Worse Outcomes: A Prospective Cohort Study

Introduction

Ibuprofen disappeared from the pharmacy shelves during the 2019 coronavirus (COVID-19) pandemic. However, a while later, information circulated that ibuprofen should be avoided as it could worsen COVID-19 symptoms. The aim of our study was to assess the association of acute and chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) with worse COVID-19 outcomes.

Methods

We did a prospective cohort study between April 12 and June 1, 2020. Adults consecutively diagnosed with COVID-19 were included. Information on NSAID use was collected through a telephone questionnaire, and patients were followed up for COVID-19 infection outcomes, including death, admission, severity, time to clinical improvement, oxygen requirement and length of stay.

Results

Acute use of ibuprofen was not associated with a greater risk of mortality relative to non-use (adjusted hazard ratio [HR] 0.632 [95% CI 0.073–5.441; P = 0.6758]). Chronic NSAID use was also not associated with a greater risk of mortality (adjusted HR 0.492 [95% CI 0.178–1.362; P = 0.1721]). Acute ibuprofen use was not associated with a higher risk of admission compared to non-NSAID users (adjusted odds ratio OR 1.271; 95% CI 0.548–2.953). NSAID users did not have a significantly longer time to clinical improvement or length of stay.

Conclusion

Acute or chronic use of ibuprofen and other NSAIDs was not associated with worse COVID-19 disease outcomes.

Electronic supplementary material

The online version of this article (10.1007/s40121-020-00363-w) contains supplementary material, which is available to authorized users.

Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications.

OBJECTIVE

To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs.

METHODS

Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations.

RESULTS

Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases.

CONCLUSION

NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.

Factors Affecting Quality of Life and Satisfaction in Patients with Arthritis after Change to a Fixed-Dose Naproxen/Esomeprazole Combination Drug

Background

In drug therapy for patients with arthritis, a naproxen/esomeprazole combination drug may be a tolerable choice because it can minimize gastrointestinal and cardiovascular adverse effects. The aim of this study was to investigate the changes in quality of life (QOL), medication adherence, and satisfaction after switch from the existing drug to the combination drug. In addition, we analyzed the correlation between the above-mentioned variables and the stratified demographic and medical data of the patients.

Methods

A prospective, noninterventional, observational study was conducted in 30 hospitals between May 2014 and July 2016. In total, 2,308 patients with osteoarthritis, 99 patients with rheumatoid arthritis, and 76 patients with ankylosing spondylitis were enrolled. Demographic information (age, sex, body mass index [BMI], alcohol consumption, and smoking) and medical information (type of arthritis, duration of disease, and comorbidities) were collected via a self-administered questionnaire. Patients were observed for more than three months after switching to the combination drug. Data on the QOL (EuroQoL 5-Dimension questionnaire [EQ-5D questionnaire]), medication adherence (Morisky Medication Adherence Scale [MMAS]), and satisfaction were collected at the first and last visits.

Results

A total of 2,483 patients enrolled at 30 hospitals completed the questionnaire. After the switch to the combination drug, the mean EQ-5D score improved from 0.72 ± 0.17 to 0.79 ± 0.14 (p < 0.001), and significant improvement was associated with female sex (p = 0.016), shorter disease duration (p < 0.001), and absence of comorbidities (p < 0.001). The mean MMAS score was 6.38 ± 1.77, indicating medium adherence. Satisfaction was significantly higher in female patients (p < 0.001), in patients with a shorter disease duration (p < 0.001), osteoarthritis (p = 0.003), and no comorbidities (p < 0.001). Serious drug-related adverse effects did not occur.

Conclusions

The overall QOL was improved with medium adherence after the switch to the combination drug. On the basis of the analysis of stratified data, sex, age, drinking, smoking, disease duration, comorbidities, and BMI might be associated with QOL, satisfaction, and adherence.

Regular use of aspirin and other non-steroidal anti-inflammatory drugs and breast cancer risk for women at familial or genetic risk: a cohort study

Background

The use of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with reduced breast cancer risk, but it is not known if this association extends to women at familial or genetic risk. We examined the association between regular NSAID use and breast cancer risk using a large cohort of women selected for breast cancer family history, including 1054 BRCA1 or BRCA2 mutation carriers.

Methods

We analyzed a prospective cohort (N = 5606) and a larger combined, retrospective and prospective, cohort (N = 8233) of women who were aged 18 to 79 years, enrolled before June 30, 2011, with follow-up questionnaire data on medication history. The prospective cohort was further restricted to women without breast cancer when medication history was asked by questionnaire. Women were recruited from seven study centers in the United States, Canada, and Australia. Associations were estimated using multivariable Cox proportional hazards regression models adjusted for demographics, lifestyle factors, family history, and other medication use. Women were classified as regular or non-regular users of aspirin, COX-2 inhibitors, ibuprofen and other NSAIDs, and acetaminophen (control) based on self-report at follow-up of ever using the medication for at least twice a week for ≥1 month prior to breast cancer diagnosis. The main outcome was incident invasive breast cancer, based on self- or relative-report (81% confirmed pathologically).

Results

From fully adjusted analyses, regular aspirin use was associated with a 39% and 37% reduced risk of breast cancer in the prospective (HR = 0.61; 95% CI = 0.33–1.14) and combined cohorts (HR = 0.63; 95% CI = 0.57–0.71), respectively. Regular use of COX-2 inhibitors was associated with a 61% and 71% reduced risk of breast cancer (prospective HR = 0.39; 95% CI = 0.15–0.97; combined HR = 0.29; 95% CI = 0.23–0.38). Other NSAIDs and acetaminophen were not associated with breast cancer risk in either cohort. Associations were not modified by familial risk, and consistent patterns were found by BRCA1 and BRCA2 carrier status, estrogen receptor status, and attained age.

Conclusion

Regular use of aspirin and COX-2 inhibitors might reduce breast cancer risk for women at familial or genetic risk.

Electronic supplementary material

The online version of this article (10.1186/s13058-019-1135-y) contains supplementary material, which is available to authorized users.

US National Health and Nutrition Examination Survey Arthritis Initiatives, Methodologies and Data

The US National Health and Nutrition Examination Survey (NHANES) has collected population-based, nationally representative examination, laboratory, and radiographic data for arthritis and musculoskeletal diseases for more than 50 years. The resulting body of data and publications are substantial, yet much data remain unpublished. This review provides a basic understanding of the design and capabilities of the NHANES survey, reviewing the major accomplishments in the area of arthritis and musculoskeletal diseases. Currently available US National Health and Nutrition Examination Survey arthritis-related datasets are identified. Guidelines for using these data, and opportunities for data analysis and designing future studies are presented.

Use of Prescription Medications That Potentially Interfere With Blood Pressure Control in New-Onset Hypertension and Treatment-Resistant Hypertension

BACKGROUND

Withdrawing medications that interfere with blood pressure (BP) is recommended in patients with uncontrolled BP, yet real-world use of such agents is not well characterized among individuals with hypertension. We aimed to evaluate the use of BP-interfering prescription medications among US patients with hypertension.

METHODS

This retrospective drug utilization study used medical and prescription claims (January 2008 to December 2014) in the MarketScan commercial claims database. We included adults, aged 18-65 years, with a hypertension diagnosis (International Classification of Diseases, Ninth Revision, code 401) and ≥1 antihypertensive medication fill. Two hypertension cohorts were examined-new antihypertensive drug users (incident hypertension) and patients requiring titration to a fourth antihypertensive (incident treatment-resistant hypertension [TRH]). Patient-level exposure to BP-interfering medications was assessed 6 months before and after the index date, defined as the first prescription fill of an antihypertensive drug or the first occurrence of overlapping use of ≥4 antihypertensive drugs.

RESULTS

We identified 521,028 patients with incident hypertension and 131,764 patients with incident TRH. The most prevalent BP-interfering prescription medications were nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophens, and hormones. Overall, 18.3% of the incident hypertension cohort and 17.6% of the incident TRH cohort initiated a BP-interfering medication following antihypertensive titration. Among patients previously taking a BP-interfering medication, 57.6% with incident hypertension and 64.9% with incident TRH refilled that medication after antihypertensive intensification.

CONCLUSIONS

The use of prescription BP-interfering medications, especially NSAIDs, is prevalent among patients requiring intensification of their antihypertensive regimen. Greater efforts to limit the use of these medications, where feasible, may be required among patients with uncontrolled hypertension.

Metabolomics Approach for Validation of Self-Reported Ibuprofen and Acetaminophen Use

Over-the-counter analgesic use is common and is typically assessed through self-report; therefore, it is subject to misclassification. Detection of drug metabolites in biofluids offers a viable tool for validating self-reported analgesic use. Thus, the aim of this study was to determine the utility of a metabolomics approach for the validation of acetaminophen and ibuprofen use in blood samples. Untargeted mass spectrometry-based metabolomics analysis was conducted in serum samples from 1547 women and plasma samples from 556 men. The presence of two metabolites each for acetaminophen and ibuprofen at levels at or above a defined cutoff value was used to determine concordance with self-reported use. For acetaminophen use based on the presence of both acetaminophen and acetamidophenylglucuronide, concordance was 98.5–100% among individuals reporting use today, and 79.8–91.4% for those reporting never or rare use. Ibuprofen use based on the presence of both carboxyibuprofen and hydroxyibuprofen resulted in concordance of 51.3–52.5% for individuals reporting use today and 99.4–100% for those reporting never or rare use. Our findings suggest that an untargeted metabolomics approach in blood samples may be useful for validating self-reported acetaminophen use. However, this approach appears unlikely to be suitable for validating ibuprofen use.

Pattern of Self Prescribed Analgesic Use in a Rural Area of Delhi: Exploring the Potential Role of Internet

INTRODUCTION

Analgesics are the most common self prescribed drugs. Although considered to be relatively safe, side effects are often seen when these drugs are used for prolonged period, in high doses or used where contraindicated. Majority of the consumers are not aware of the side effects. These days ample amount of information is available on web, it is important to explore its role in educating the population regarding the safe use of self prescribed analgesics.

AIM

To explore pattern of analgesic use, to identify population at risk of developing side effects related to analgesic use, awareness of side effects and potential role of internet to bring awareness about safe use of self prescribed analgesic drugs in a rural area of Delhi.

MATERIALS AND METHODS

A cross-sectional survey based study was done on 500 adults in the age group of 18-65 years of Madanpur Khadar area of South Delhi, India. Data collection was done by conducting visits to pharmacy shops from the people who were buying drugs without prescription and taking face to face interviews using a semi-structured questionnaire. Statistical analysis was performed using descriptive tests with Microsoft office excel 2007.

RESULTS

Results of our study showed that among all the self prescribed analgesics paracetamol (57%) was used most frequently followed by aspirin and other NSAIDs. It was found that 9.6% of the consumers were having associated co-morbid illness, 11.4% were simultaneously taking other drugs and 15.2% were alcoholics. Majority (65.4%) of the buyers were not aware about any kind of side effects of the analgesics. Internet friendly consumers were found to be 44%. Ability to use internet and education level were found to be directly related (r=0.802).

CONCLUSION

The pattern of analgesic consumption in the rural population of Delhi shows that a large number of consumers may be at risk of developing side effects of self prescribed analgesics. The awareness about the side effects is limited. A significant number of consumers are internet friendly. Hence, we recommend use of website/mobile apps as potential source of information in educating the population regarding the use of self prescribed analgesics.

IL-10 Gene Polymorphisms and Self-Medication With Over-the-Counter Nonsteroidal Anti-Inflammatory Drugs

Background:

Genetic influences on self-medication with over-the-counter (OTC) drugs merit investigation. For example, patients frequently use OTC nonsteroidal anti-inflammatory drugs (NSAIDs) to treat inflammation, but the inflammatory response is also affected by endogenous cytokines whose production varies across polymorphisms of their encoding genes. In the case of interleukin 10 (IL-10), literature suggests that a single nucleotide polymorphism (SNP) in the promoter region of the cytokine’s gene (-1082 A > G [rs1800896]) influences production with higher levels associated with G variant alleles.

Objective:

To demonstrate the feasibility of researching the role of genetics in self-medication by using existing national survey data to evaluate a possible association between OTC NSAID use and genotype at the -1082 SNP of the IL-10 gene.

Methods:

Statistical analyses were performed using data from 6,309 participants in the Third National Health and Nutrition Examination Survey (NHANES III).

Results:

OTC NSAID use (aspirin or ibuprofen) in the previous month was significantly more common among persons with AG or GG genotypes at the -1082 SNP. Odds of use consistently increased relative to the number of G alleles. This trend remained statistically significant (odds ratio = 1.14 per additional G allele, p = .02, 95% confidence interval [1.02, 1.27]) after adjustment for confounding.

Conclusions:

Analysis of population-based genetic data suggests an association between a common self-medication behavior and a specific genetic polymorphism. These findings broadly demonstrate that NHANES data provide opportunities to investigate such associations and specifically imply that potential interrelationships among OTC NSAID use, IL-10 genotype, and IL-10 cytokine levels deserve further study.

Low-dose aspirin use and survival in breast cancer patients: A nationwide cohort study

BACKGROUND

Preclinical evidence from breast cancer cell lines and animal models suggest that aspirin could have anti-cancer properties. In a large breast cancer patient cohort, we investigated whether post-diagnostic low-dose aspirin use was associated with a reduction in the risk of breast cancer-specific mortality.

METHODS

We identified 15,140 newly diagnosed breast cancer patients within the Scottish Cancer Registry. Linkages to the Scottish Prescribing Information System provided data on dispensed medications and breast cancer-specific deaths were identified from National Records of Scotland Death Records. Time-dependent Cox regression models were used to calculate hazard ratios (HR) and 95% CIs for breast cancer-specific and all-cause mortality by post-diagnostic low-dose aspirin use. HRs were adjusted for a range of potential confounders including age at diagnosis, year of diagnosis, cancer stage, grade, cancer treatments received, comorbidities, socioeconomic status and use of statins. Secondary analysis investigated the association between pre-diagnostic low-dose aspirin use and breast cancer-specific and all-cause mortality.

RESULTS

Post-diagnostic users of low-dose aspirin appeared to have increased breast cancer-specific mortality compared with non-users (HR 1.44, 95% CI 1.26, 1.65) but this association was entirely attenuated after adjustment for potential confounders (adjusted HR 0.92, 95% CI 0.75, 1.14). Findings were similar in analysis by increasing duration of use and in analysis of pre-diagnostic low-dose aspirin use.

CONCLUSION

In this large nationwide study of breast cancer patients, we found little evidence of an association between post-diagnostic low-dose aspirin use and cancer-specific mortality.

Acetaminophen toxicity in rat and mouse hepatocytes in vitro

CONTEXT

Acetaminophen (APAP) hepatotoxicity is often studied in primary cultures of hepatocytes of various species, but there are only few works comparing interspecies differences in susceptibility of hepatocytes to APAP in vitro.

OBJECTIVES

The aim of our work was to compare hepatotoxicity of APAP in rat and mouse hepatocytes in primary cultures.

MATERIALS AND METHODS

Hepatocytes isolated from male Wistar rats and C57Bl/6J mice were exposed to APAP for up to 24 h. We determined lactate dehydrogenase (LDH) activity in culture medium, activity of cellular dehydrogenases (WST-1) and activity of caspases 3 in cell lysate as markers of cell damage/death. We assessed content of intracellular reduced glutathione, production of reactive oxygen species (ROS) and malondialdehyde (MDA). Respiration of digitonin-permeabilized hepatocytes was measured by high resolution respirometry and mitochondrial membrane potential (MMP) was visualized (JC-1).

RESULTS

APAP from concentrations of 2.5 and 0.75 mmol/L induced a decrease in viability of rat (p < 0.001) and mouse (p < 0.001) hepatocytes (WST-1), respectively. In contrast to rat hepatocytes, there was no activation of caspase-3 in mouse hepatocytes after APAP treatment. Earlier damage to plasma membrane and faster depletion of reduced glutathione were detected in mouse hepatocytes. Mouse hepatocytes showed increased glutamate + malate-driven respiration in state 4 and higher susceptibility of the outer mitochondrial membrane (OMM) to APAP-induced injury.

CONCLUSION

APAP displayed dose-dependent toxicity in hepatocytes of both species. Mouse hepatocytes in primary culture however had approximately three-fold higher susceptibility to the toxic effect of APAP when compared to rat hepatocytes.

Novel N-substituted indole Schiff bases as dual inhibitors of cyclooxygenase-2 and 5-lipoxygenase enzymes: Synthesis, biological activities in vitro and docking study

Two new series of N-substituted indole derivatives 4a-l and 5a-h were synthesized. Their chemical structures were confirmed using spectroscopic tools including IR, (1)H NMR, (13)C NMR mass spectroscopy and elemental analyses. The results showed no significant cytotoxic activity on either cancer or normal human cells. Anti-inflammatory activity for all target compounds was evaluated in vitro. Compounds 5a-h were found to have better anti-inflammatory activity than 4a-l. The inhibitory activity of COX-2 and 5-LOX were tested for 5a-h. Three compounds, 5c, 5d and 5f showed excellent COX-2 inhibitory activity with IC50 ranging from 0.98 to 1.23 μM compared to the reference celecoxib (1.54 μM). These compounds had a reasonable selectivity index between 7.03 and 8.05. Additionally, p-methylbenzoyl derivative 5g (IC50 = 5.78 μM) had superior 5-LOX inhibitory activity, higher than quercetin. 5e was close to quercetin in its LOX inhibitory activity. Compounds 5a-h were docked inside the active site of COX-2 and 5-LOX enzymes.

Seasonality in acute liver injury? Findings in two health care claims databases

BACKGROUND

Presumed seasonal use of acetaminophen-containing products for relief of cold/influenza ("flu") symptoms suggests that there might also be a corresponding seasonal pattern for acute liver injury (ALI), a known clinical consequence of acetaminophen overdose.

OBJECTIVE

The objective of this study was to determine whether there were any temporal patterns in hospitalizations for ALI that would correspond to assumed acetaminophen use in cold/flu season.

METHODS

In the period 2002-2010, monthly hospitalization rates for ALI using a variety of case definitions were calculated. Data sources included Truven MarketScan(®) Commercial Claims and Encounters (CCAE) and Medicare Supplemental and Coordination of Benefits (MDCR) databases. We performed a statistical test for seasonality of diagnoses using the periodic generalized linear model. To validate that the test can distinguish seasonal from nonseasonal patterns, we included two positive controls (ie, diagnoses of the common cold [acute nasopharyngitis] and influenza), believed to change with seasons, and two negative controls (female breast cancer and diabetes), believed to be insensitive to season.

RESULTS

A seasonal pattern was observed in monthly rates for common cold and influenza diagnoses, but this pattern was not observed for monthly rates of ALI, with or without comorbidities (cirrhosis or hepatitis), breast cancer, or diabetes. The statistical test for seasonality was significant for positive controls (P<0.001 for each diagnosis in both databases) and nonsignificant for ALI and negative controls.

CONCLUSION

No seasonal pattern was observed in the diagnosis of ALI. The positive and negative controls showed the expected patterns, strengthening the validity of the statistical and visual tests used for detecting seasonality.

Simultaneous quantification of acetaminophen and five acetaminophen metabolites in human plasma and urine by high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry: Method validation and application to a neonatal pharmacokinetic study

Drug metabolism plays a key role in acetaminophen (paracetamol)-induced hepatotoxicity, and quantification of acetaminophen metabolites provides critical information about factors influencing susceptibility to acetaminophen-induced hepatotoxicity in clinical and experimental settings. The aims of this study were to develop, validate, and apply high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry (HPLC-ESI-MS/MS) methods for simultaneous quantification of acetaminophen, acetaminophen-glucuronide, acetaminophen-sulfate, acetaminophen-glutathione, acetaminophen-cysteine, and acetaminophen-N-acetylcysteine in small volumes of human plasma and urine. In the reported procedures, acetaminophen-d4 and acetaminophen-d3-sulfate were utilized as internal standards (IS). Analytes and IS were recovered from human plasma (10μL) by protein precipitation with acetonitrile. Human urine (10μL) was prepared by fortification with IS followed only by sample dilution. Calibration concentration ranges were tailored to literature values for each analyte in each biological matrix. Prepared samples from plasma and urine were analyzed under the same HPLC-ESI-MS/MS conditions, and chromatographic separation was achieved through use of an Agilent Poroshell 120 EC-C18 column with a 20-min run time per injected sample. The analytes could be accurately and precisely quantified over 2.0-3.5 orders of magnitude. Across both matrices, mean intra- and inter-assay accuracies ranged from 85% to 112%, and intra- and inter-assay imprecision did not exceed 15%. Validation experiments included tests for specificity, recovery and ionization efficiency, inter-individual variability in matrix effects, stock solution stability, and sample stability under a variety of storage and handling conditions (room temperature, freezer, freeze-thaw, and post-preparative). The utility and suitability of the reported procedures were illustrated by analysis of pharmacokinetic samples collected from neonates receiving intravenous acetaminophen.

Patterns of antiplatelet agent use in the US

BACKGROUND

The American Society of Gastrointestinal Endoscopy (ASGE) published updated guidelines in 2009 to help endoscopists manage the treatment of their patients who have been prescribed antiplatelet therapy (APT).

STUDY AIM

To assess the use of APT among endoscopists, and to identify factors guiding their use of APT while treating their patients.

METHOD

A survey questionnaire was distributed to endoscopists at two national meetings to assess their usage of APT while treating patients during the peri-endoscopic period.

RESULTS

The survey was provided to 400 attendees of whom 239 (60 %) responded. Only 30 % of respondents followed the ASGE guidelines for treating their patients and 26 % percent of respondents withheld all APT before engaging in any patient procedure. Endoscopists' decisions appeared to be influenced by their own particular experiences rather than any specific APT usage guidelines (46 % vs 22 %; P < 0.05). As expected, more endoscopists (P < 0.05) continued APT for patients who underwent low risk procedures (90 %) than for patients who underwent high risk procedures (47 %). Approximately 50 % of the respondents did not perform high risk procedures for patients prescribed aspirin therapy.

CONCLUSIONS

About one-fourth of endoscopists surveyed discontinued APT treatment of patients who underwent any endoscopic procedure, and one-half of them discontinued use of non-steroidal anti-inflammatory drug treatment of patients who underwent a high risk endoscopic procedure. Inappropriate withdrawal of APT medications may expose patients to unnecessary risks, and efforts to improve endoscopists' application of ASGE guidelines for the use of APT to treat patients during the peri-endoscopic period are warranted.

Quantification of a biomarker of acetaminophen protein adducts in human serum by high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry: clinical and animal model applications

The aims of this study were to develop, validate, and apply a high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry (HPLC-ESI-MS/MS) method for quantification of protein-derived 3-(cystein-S-yl)-acetaminophen (APAP-Cys) in human serum. Formation of acetaminophen (APAP) protein adducts is thought to be a critical, early event in the development of APAP-induced hepatotoxicity, and quantification of these protein adducts in human serum represents a valuable tool for assessment of APAP exposure, metabolism, and toxicity. In the reported procedure, serum samples were first dialyzed or passed through gel filtration columns to remove APAP-Cys not covalently bound to proteins. Serum eluates were then subjected to enzymatic protease digestion to liberate protein-bound APAP-Cys. Norbuprenorphine-D3 was utilized as an internal standard (IS). APAP-Cys and IS were recovered from digested serum by protein precipitation with acetonitrile, and sample extracts were analyzed by HPLC-ESI-MS/MS. The method was validated by assessment of intra- and inter-assay accuracy and imprecision on two different analytical instrument platforms. APAP-Cys could be accurately quantified from 0.010 to 10μM, and intra- and inter-assay imprecision were <15% on both analytical instruments. APAP-Cys was stable in human serum for three freeze-thaw cycles and for 24h at ambient temperature. Extracted samples were stable when stored in refrigerated autosamplers for the typical duration of analysis or when stored at -20°C for six days. Results from process efficiency and matrix effect experiments indicated adequate recovery from human serum and insignificant ion suppression or enhancement. The utility and sensitivity of the reported procedure were illustrated by analysis of clinical samples collected from subjects taking chronic, therapeutic doses of APAP. Applicability to other biological matrices was also demonstrated by measurement of protein-derived APAP-Cys in plasma collected from APAP-treated mice, a common animal model of APAP-induced hepatotoxicity.

Synthesis and biological evaluation of novel indole-2-one and 7-aza-2-oxindole derivatives as anti-inflammatory agents

Sepsis, a typically acute inflammatory disease, is the biggest cause of death in ICU (intensive care unit). Novel anti-inflammatory alternatives are still in urgent need. In this study, we designed and synthesized 30 indole-2-one and 7-aza-2-oxindole derivatives based on the skeleton of tenidap, and their anti-inflammatory activity was determined by evaluating the inhibitory potency against lipopolysaccharide (LPS)-stimulated tumor necrosis factor (TNF)-α and interleukin (IL)-6 release in RAW264.7 macrophages. Quantitative SAR (structure-activity relationship) analysis revealed that a high molecular polarizability and low lipid/water partition coefficient (ALogP) in indole-2-one are beneficial for anti-inflammatory activity. Moreover, compounds 7i and 8e inhibited the expression of TNF-α, IL-6, COX-2, PGES, and iNOS in LPS-stimulated macrophages, and 7i exhibited a significant protection from LPS-induced septic death in mouse models. These data present a series of new indole-2-one compounds with potential therapeutic effects in acute inflammatory diseases.

Ulcer and bleeding complications and their relationship with dyspeptic symptoms in NSAIDs users: a transversal multicenter study

OBJECTIVES

To evaluate the prevalence of lesions and digestive complications secondary to the use of non-steroidal anti-inflammatory drugs (NSAIDs), the clinical profile seen for digestive complaints and the relation with the endoscopic findings.

METHODS

Prospective, multicentric, open study, evaluating consecutively 1231 patients, divided as follows: group I - NSAID and group II - non-NSAID. All patients answered questionnaire to evaluate the onset, the type of clinical complaint, the use of medication and possible complications associated to digestive bleeding. RESULTS. A total of 1213 patients were evaluated. Among them, 65% were female and 13.1% were smokers; 15.6% mentioned they ingested alcoholic beverages. The main signs and symptoms reported were epigastralgy and pyrosis (67% and 62%, respectively). The upper gastrointestinal (UGI) endoscopy was normal in 3.9% in group I and in 10.7% in group II (p < 0.001). Patient who do not use NSAID will be 2.5 times more likely to have normal UGI endoscopy (p = 0.001). The presence of erosive or ulcer lesions in the stomach and duodenum was more frequent in group I. The incidence of lesions in the stomach when compared to the duodenum is observed (erosions: 49.12% vs. 13.60%, p = 0.001; ulcers: 14.04% vs. 11.84%, p = 0.05). The risk of digestive bleeding is 12 times higher (6.14% vs. 0.51%) in those who used NSAIDs, and the stomach is the site in which bleeding occurs more frequently. Conclusions. The frequency of gastric ulcer, duodenal ulcer and digestive bleeding was higher in patients who used NSAIDs. There was no connection found between endoscopic findings and dyspeptic symptoms.

Post-diagnostic prescriptions for low-dose aspirin and breast cancer-specific survival: a nested case-control study in a breast cancer cohort from the UK Clinical Practice Research Datalink

INTRODUCTION

Recent observational studies indicate that post-diagnostic use of aspirin in breast cancer patients may protect against cancer progression perhaps by inhibiting cyclooxygenase-2 dependent mechanisms. Evidence also supports a crucial role for interactions between tumour cells and circulating platelets in cancer growth and dissemination, therefore, use of low-dose aspirin may reduce the risk of death from cancer in breast cancer patients.

METHODS

A cohort of newly diagnosed breast cancer patients (1998 to 2006) were identified in the UK Clinical Practice Research Datalink (and confirmed by cancer registry linkage). Cancer-specific deaths were identified up to 2011 from Office for National Statistics mortality data. A nested case-control analysis was conducted using conditional logistic regression to compare post-diagnostic aspirin exposure using General Practice prescription data in 1,435 cases (breast cancer deaths) with 5,697 controls (matched by age and year of diagnosis).

RESULTS

After breast cancer diagnosis, 18.3% of cancer-specific deaths and 18.5% of matched controls received at least one prescription for low-dose aspirin, corresponding to an odds ratio (OR) of 0.98 (95% CI 0.83, 1.15). Adjustment for potential confounders (including stage and grade) had little impact on this estimate. No dose response relationship was observed when the number of tablets was investigated and no associations were seen when analyses were stratified by receipt of prescriptions for aspirin in the pre-diagnostic period, by stage at diagnosis or by receipt of prescriptions for hormone therapy.

CONCLUSIONS

Overall, in this large population-based cohort of breast cancer patients, there was little evidence of an association between receipt of post-diagnostic prescriptions for low-dose aspirin and breast cancer-specific death. However, information was not available on medication compliance or over-the-counter use of aspirin, which may have contributed to the null findings.

Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury

BACKGROUND & AIMS

Patients with risk factors for gastrointestinal (GI) disorders who continuously use nonsteroidal anti-inflammatory drugs (NSAIDs) also should take gastroprotective agents (GPAs), such as proton pump inhibitors (PPIs). However, it is not clear how many physicians continue to prescribe GPAs to these patients, and whether stopping the GPA prescription increases GI complications.

METHODS

We performed a retrospective, observational, longitudinal study using a validated electronic database of representative general practitioners in France. We analyzed data for 1856 patients at risk for GI events (>65 y, past history of GI ulcer, or receiving antiplatelet agents) who received prescriptions for an NSAID and PPI from 2007 to 2009. Kaplan-Meier curves were used to determine the probability of still being prescribed a GPA at 12 and 24 months after the first prescription. Multivariate logistic regression analysis was used to identify factors associated with nonpersistence. GI complication rates were compared using the Student t test.

RESULTS

The probability of still being prescribed a PPI along with an NSAID 1 year after the study began was 77.5% (95% confidence interval [CI], 75.6%-79.4%) and 68.3% after 2 years (95% CI, 66.1%-70.4%). Risk factors for no longer receiving a prescription for a PPI included switching to a cyclooxygenase-2-selective inhibitor (hazard ratio [HR], 2.50; 95% CI, 1.91-3.28; P < .001) or to a nonselective NSAID (HR, 1.63; 95% CI, 1.33-1.99; P < .001), and female sex (HR, 1.25; 95% CI, 1.05-1.45; P < .05). In 50% of these cases, the PPI was reintroduced within 6 months, without a specific reason in 70% of the cases. The risk for upper GI injury was higher among patients with discontinued prescriptions for PPIs (odds ratio, 1.45; 95% CI, 1.06-2.09; P = .02).

CONCLUSIONS

Within 2 years after prescribing a PPI, physicians do not renew this prescription for approximately 33% of patients receiving continuous NSAIDs. This increases the risk for GI adverse events among these patients.

Prevalence of oral glucocorticoid usage in the United States: a general population perspective

OBJECTIVE

There is little information on oral glucocorticoid use in the general US population. Previously, there have been published estimates of glucocorticoid use in countries outside of the US. This study aimed to estimate the prevalence of glucocorticoid use, duration of use, and concomitant use of antiosteoporosis pharmaceuticals in the US population age ≥20 years.

METHODS

Data from 5 cycles (1999-2008) of the National Health and Nutrition Examination Survey (NHANES) were used to provide nationally representative weighted estimates. Oral glucocorticoids and concomitant use of antiosteoporosis pharmaceuticals (bisphosphonates, calcitonin, calcium, hormone replacement therapies, teriparatide, and vitamin D) were analyzed.

RESULTS

There were 356 NHANES respondents ages ≥20 years who reported use of an oral glucocorticoid in the combined cycles between 1999 and 2008. The weighted prevalence of oral glucocorticoid use was 1.2% (95% confidence interval [95% CI] 1.1-1.4) from 1999-2008, corresponding to 2,513,259 persons in the US. The mean duration of oral glucocorticoid use was 1,605.7 days (95% CI 1,261.2-1,950.1), and 28.8% (95% CI 22.2-35.4) of oral glucocorticoid users reported use for ≥5 years. Concomitant use of a bisphosphonate was reported by 8.6% (95% CI 5.1-11.7) of oral glucocorticoid users, and 37.9% (95% CI 31.7-44.0) reported usage of any antiosteoporosis pharmaceutical.

CONCLUSION

Based on NHANES data from 1999-2008, it is estimated that the prevalence of glucocorticoid use in the US is 1.2%, with a long duration of use and infrequent use of antiosteoporotic medications compared to other estimates.

Using the theory of planned behavior to predict self-medication with over-the-counter analgesics

Millions of people worldwide use over-the-counter analgesics on a regular basis; yet little is known about how decisions to self-medicate are made. This study used the theory of planned behavior to explore the influence of beliefs about medicines (Beliefs about Medicines Questionnaire) and individual pain experience as predictors of intent to self-medicate. Both emerged as significant predictors of intent to self-medicate. Furthermore, intent to self-medicate significantly predicted reported use of analgesics. These findings indicate that use of over-the-counter pain medication is more likely when the value of the pain relief is greater than concerns about harm.

Analgesic use and the risk of hearing loss in women

Use of analgesics is common and is associated with increased risk of hearing loss in men; however, the relation has not been examined prospectively in women. The authors prospectively examined the relation between frequency of aspirin, ibuprofen, and acetaminophen use and risk of hearing loss among 62,261 women aged 31-48 years at baseline (1995) in Nurses' Health Study II. The outcome was self-reported hearing loss (n = 10,012), and the follow-up period was 1995-2009. Cox proportional hazards regression was used to adjust for potential confounders. During 764,247 person-years of follow-up, ibuprofen use and acetaminophen use were independently associated with increased risk of hearing loss, but aspirin use was not. For ibuprofen, the multivariate-adjusted relative risk of hearing loss was 1.13 (95% confidence interval (CI): 1.06, 1.19) for use 2-3 days/week, 1.21 (95% CI: 1.11, 1.32) for use 4-5 days/week, and 1.24 (95% CI: 1.14, 1.35) for use ≥6 days/week (P-trend < 0.0001), compared with use less than once per week. For acetaminophen, the corresponding relative risks were 1.11 (95% CI: 1.02, 1.19), 1.21 (95% CI: 1.07, 1.37), and 1.08 (95% CI: 0.95, 1.22), respectively (P-trend = 0.0007). In this study, use of ibuprofen or acetaminophen (but not aspirin) 2 or more days per week was associated with an increased risk of hearing loss in women.

Nonsteroidal anti-inflammatory drugs and other analgesic use and bladder cancer in northern New England

A few epidemiologic studies have found that use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with reduced risk of bladder cancer. However, the effects of specific NSAID use and individual variability in risk have not been well studied. We examined the association between NSAIDs use and bladder cancer risk, and its modification by 39 candidate genes related to NSAID metabolism. A population-based case-control study was conducted in northern New England, enrolling 1,171 newly diagnosed cases and 1,418 controls. Regular use of nonaspirin, nonselective NSAIDs was associated with reduced bladder cancer risk, with a statistically significant inverse trend in risk with duration of use (ORs of 1.0, 0.8, 0.6 and 0.6 for <5, 5-9, 10-19 and 20+ years, respectively; p(trend) = 0.015). This association was driven mainly by ibuprofen; significant inverse trends in risk with increasing duration and dose of ibuprofen were observed (p(trend) = 0.009 and 0.054, respectively). The reduced risk from ibuprofen use was limited to individuals carrying the T allele of a single nucleotide polymorphism (rs4646450) compared to those who did not use ibuprofen and did not carry the T allele in the CYP3A locus, providing new evidence that this association might be modified by polymorphisms in genes that metabolize ibuprofen. Significant positive trends in risk with increasing duration and cumulative dose of selective cyclooxygenase (COX-2) inhibitors were observed. Our results are consistent with those from previous studies linking use of NSAIDs, particularly ibuprofen, with reduced risk. We observed a previously unrecognized risk associated with use of COX-2 inhibitors, which merits further evaluation.

Inappropriate nonsteroidal anti-inflammatory drug use: prevalence and predictors

INTRODUCTION

Inappropriate nonsteroidal anti-inflammatory drug (NSAID) use can occur by using more than one prescription or over-the-counter NSAID or exceeding the manufacturer's recommended dosage. There are risks associated with inappropriate NSAID use; however, the prevalence and predictors of inappropriate NSAID use are unknown. The study objectives are to estimate the prevalence of inappropriate NSAID use and identify characteristics associated with inappropriate use.

METHODS

We identified 6877 patients at 2 Veterans Affairs Medical Centers through pharmacy records who filled 3 or more NSAID prescriptions in 6 months. We randomly selected 2535 patients and mailed them a survey about NSAIDs, gastroprotective medications, gastrointestinal (GI) symptoms, and pain. Inappropriate NSAID users either took 2 or more NSAIDs for 3 days or more or exceeded the maximum daily recommended dosage of 1 or more NSAID in the past week. Data were also collected from medical records.

RESULTS

Approximately 1572 patients (62%) returned the survey, and 1250 reported NSAID use in the past week. Approximately 32% (n = 400) used NSAIDs inappropriately, including taking 2 or more NSAIDs (n = 173), exceeding the highest daily recommended dosage (n = 161) or both (n = 66). Being a minority (odds ratio = 1.62, P < 0.001) and having an income of $20,000 (odds ratio = 1.70, P < 0.001) or lesser both predicted inappropriate NSAID use. Inappropriate NSAID use was associated with more GI symptoms (β = 0.57, P < 0.001) and higher levels of pain (β = 0.85, P < 0.001).

CONCLUSIONS

Inappropriate NSAID use is prevalent. Providers should consider counseling all patients about NSAID use, especially patients with GI problems or pain problems.

Characterization of acetaminophen overdose-related emergency department visits and hospitalizations in the United States

PURPOSE

To estimate the number of acetaminophen overdose-related emergency department (ED) visits and hospitalizations in the United States, characterize these by intentionality, age, and gender, and compare the strengths and limitations of the utilized databases.

METHODS

We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Electronic Injury Surveillance System (NEISS) to estimate the number of relevant ED visits in the United States between 2000 and 2007, and the National Hospital Discharge Survey (NHDS) to estimate the number of relevant hospitalizations in the United States between 1991 and 2006. National estimates and their standard errors were calculated using information provided in each database. We used the standard United States population in 2000 to calculate age-adjusted rates.

RESULTS

We estimate an annual average of 44,348 (NHAMCS, 2000-2007) or 78,414 (NEISS, 2006-2007) acetaminophen overdose-related ED visits and 33,520 (NHDS, 2000-2006) hospitalizations. For 2000-2006 we calculated an age-adjusted rate of 13.9 acetaminophen overdose-related hospitalizations per 100,000 US population, with the highest rate (15.7) occurring from 2005 to 2006. Between 1991 and 2006, there was no decrease noted in hospitalizations for intentional or unintentional overdoses. The majority of overdoses reported in NEISS (69.8%) and NHDS (74.2%) were classified as intentional (suicides or suicidal gestures), whereas in NHAMCS, intentionality was evenly distributed.

CONCLUSIONS

Our results suggest that acetaminophen overdose, both intentional and unintentional, remains a significant public health concern. With an understanding of their methodological characteristics and limitations, these national databases can be useful tools to characterize acetaminophen overdose-related ED visits and hospitalizations.

Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis

OBJECTIVE

To analyse the available evidence on cardiovascular safety of non-steroidal anti-inflammatory drugs.

DESIGN

Network meta-analysis.

DATA SOURCES

Bibliographic databases, conference proceedings, study registers, the Food and Drug Administration website, reference lists of relevant articles, and reports citing relevant articles through the Science Citation Index (last update July 2009). Manufacturers of celecoxib and lumiracoxib provided additional data.

STUDY SELECTION

All large scale randomised controlled trials comparing any non-steroidal anti-inflammatory drug with other non-steroidal anti-inflammatory drugs or placebo. Two investigators independently assessed eligibility.

DATA EXTRACTION

The primary outcome was myocardial infarction. Secondary outcomes included stroke, death from cardiovascular disease, and death from any cause. Two investigators independently extracted data.

DATA SYNTHESIS

31 trials in 116 429 patients with more than 115 000 patient years of follow-up were included. Patients were allocated to naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib, lumiracoxib, or placebo. Compared with placebo, rofecoxib was associated with the highest risk of myocardial infarction (rate ratio 2.12, 95% credibility interval 1.26 to 3.56), followed by lumiracoxib (2.00, 0.71 to 6.21). Ibuprofen was associated with the highest risk of stroke (3.36, 1.00 to 11.6), followed by diclofenac (2.86, 1.09 to 8.36). Etoricoxib (4.07, 1.23 to 15.7) and diclofenac (3.98, 1.48 to 12.7) were associated with the highest risk of cardiovascular death.

CONCLUSIONS

Although uncertainty remains, little evidence exists to suggest that any of the investigated drugs are safe in cardiovascular terms. Naproxen seemed least harmful. Cardiovascular risk needs to be taken into account when prescribing any non-steroidal anti-inflammatory drug.

Demographic, medical, and behavioral characteristics associated with over the counter non-steroidal anti-inflammatory drug use in a population-based cohort: results from the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Three types of non-steroidal anti-inflammatory drugs (NSAIDs) can be obtained both over the counter (OTC) and by prescription in the United States. OTC NSAID use is not recorded in prescription claims databases; this might lead to differential misclassification of NSAID exposure status in studies that use computerized pharmacy databases to study NSAID use.

OBJECTIVE

To evaluate characteristics of OTC versus prescription NSAID users.

METHODS

This analysis is set within the Multi-Ethnic Study of Atherosclerosis (MESA) study; a prospective cohort study of 6814 adults from four ethnic groups (European descent, Asian, African-American, and Hispanic) with a mean age of 62 years. The cohort was restricted to those who initiated NSAID use (aspirin, ibuprofen, or naproxen) during follow-up. We compared information about age, sex, ethnicity, body mass index, smoking, diabetes, medication use, education, income, health insurance status, and exercise between groups.

RESULTS

OTC NSAID use was prevalent at baseline (25% aspirin, 9% ibuprofen, and 2% naproxen). Compared to prescribed NSAID use, OTC NSAID use was lower for users of non-European descent for all classes: aspirin (p < 0.0001), ibuprofen (p < 0.0001), and naproxen (p = 0.0094). For aspirin, differences were seen for male gender (relative risk (RR): 0.92; 95%confidence interval (CI): 0.86-0.98), use of lipid lowering drugs (RR: 0.88; 95%CI: 0.80-0.96), low income (RR: 0.89; 95%CI: 0.81-0.97), and participants one standard deviation above average in intentional exercise (RR: 1.03; 95%CI: 1.01-1.05).

CONCLUSIONS

OTC NSAID use is prevalent in an older multi-ethnic population and OTC users differ from prescription NSAID users. Caution should be exercised when using prescribed NSAIDs as a proxy for NSAID use.

Synthesis and biological evaluation of 3-[4-(amino/methylsulfonyl)phenyl]methylene-indolin-2-one derivatives as novel COX-1/2 and 5-LOX inhibitors

Fourteen new 3-[4-(amino/methylsulfonyl)phenyl]methylene-indolin-2-one derivatives were synthesized. Six compounds displayed potent inhibitory activities against COX-1/2 and 5-LOX with IC(50) in the range of 0.10-9.87 μM. Particularly, 10f exhibited well balanced inhibitory action on these enzymes (IC(50)=0.10-0.56 μM). More importantly, 10f and several other compounds had comparable or stronger anti-inflammatory and analgesic activities, but better gastric tolerability in vivo, as compared with darbufelone mesilate and tenidap sodium. Therefore, our findings may aid in the design of new and safe anti-inflammatory reagents for the intervention of painful inflammatory diseases, such as rheumatoid arthritis at clinic.

Impact of Nonresective Operations for Complicated Peptic Ulcer Disease in a High-Risk Population

Over the past two decades, surgery for complicated peptic ulcer disease has evolved to a “less-is-more” approach due predominately to improved medical therapy. This study sought to determine whether a nonresective operative strategy has been an effective and prudent approach. A 20-year retrospective evaluation was conducted to compare outcomes of patients from the first decade (1990-1999) with those from the more recent decade (2000-2009). In all, 50 patients underwent surgery for complications of peptic ulcer disease, 36 in the early period and 14 in the later period, with 94 per cent being urgent or emergent. Acid-reducing procedures (vagotomy) decreased significantly from 29 to 7 over the two periods ( P = 0.04), as did gastric resections from 23 to 3 ( P = 0.01). The prevalence of H. pylori and use of NSAIDs both increased from 28 per cent to 36 per cent and 31 per cent to 43 per cent, respectively. Postoperative mortality remained unchanged, 22 per cent vs 7 per cent ( P = 0.41) over the two periods. Resections and definitive acid-reducing procedures continue to decline with no increase in adverse outcomes. This more moderate operative approach to complicated peptic ulcer surgery is appropriate given the trend towards lower mortality and improved medical treatment. In our high-risk veteran population, overall perioperative mortality, length of stay, and reoperations have been reduced.

Factors associated with a continuous regular analgesic use - a population-based study of more than 45,000 Danish women and men 18-45 years of age

PURPOSE

Widespread use of and serious adverse effects associated with use of analgesics accentuates the need to consider factors related to analgesic use. The objective of this study was to describe continuous regular analgesics use and examine factors associated with a continuous regular analgesic use.

METHODS

The study was based on data from two surveys and included a random sample of women and men aged 18-45 years from the general Danish population. Information on analgesics use, self-rated health, demographic and lifestyle factors was collected using a self-administered questionnaire. A total of 28,000 women and 33 000 men were invited to participate and 22,199 women (response-rate 81.4%) and 23,080 men (response-rate 71.0%), respectively, were included in the study. Data were analyzed using multivariate logistic regression.

RESULTS

We found that 27% of the women and 18% of the men reported a regular monthly use of at least seven analgesic tablets during the last year (continuous regular analgesics use). Besides poor self-rated health we found in both sexes that increasing age, poor self-rated fitness, and smoking were related to a continuous regular analgesics use. Nulliparity, low level of education, overweight/obesity, binge drinking, and abstinence were associated with a continuous regular analgesics use for women, while underweight and marital/cohabiting status were associated with a continuous regular analgesics use only for men.

CONCLUSIONS

Regular monthly analgesic use during the last year was generally prevalent. Besides self-rated health, several socio-demographic and lifestyle factors were associated with a continuous regular analgesic use, although with some gender differences.

Suppression of hypothalamo-hypophyseal-adrenocortical system function as the cause of aggravation of the ulcerogenic action of indomethacin on the stomach after administration of pharmacological doses of hydrocortisone

We report testing of the suggestion that aggravation of the actions of glucocorticoid treatment on the formation of indomethacin-induced erosions may be mediated by inadequate production of glucocorticoid hormones resulting from the suppression of the hypothalamo-hypophyseal-adrenocortical system (HHACS) in these conditions. Administration of indomethacin (25 mg/kg, s.c.) to rats after 24 h of starvation was used to induce gastric erosions. The effects of hydrocortisone given at pharmacological doses on the indomethacin-induced formation of gastric erosions and plasma corticosterone levels were studied one and four weeks after hormone administration. Indomethacin induced increases in plasma corticosterone levels, which were almost completely prevented one week after hydrocortisone administration. The formation of indomethacin-induced erosions was aggravated one week after administration of hydrocortisone, though replacement therapy with corticosterone, which imitates the normal increase in corticosterone, prevented this aggravation. Return of both the increased corticosterone level and the normal sensitivity of the gastric mucosa to the ulcerogenic action of indomethacin occurred four weeks after hydrocortisone administration. These results provide evidence that suppression of HHACS function may be responsible for the aggravation of the action of glucocorticoid treatment on the formation of erosions after administration of indomethacin.

Prescription rates of protective co-therapy for NSAID users at high GI risk and results of attempts to improve adherence to guidelines

BACKGROUND

Protective co-therapy is recommended in NSAID users with GI risk factors, but adherence is poor.

AIM

To assess the proportion of NSAID users receiving co-therapy and strategies to improve adherence.

METHODS

Arthritis patients > or =50 years of age received etoricoxib or diclofenac in a double-blind randomized trial. Reminders that high-risk patients (age > or = 65; previous ulcer/haemorrhage; corticosteroid, anticoagulant, aspirin use) should receive co-therapy were given at study initiation. Free PPI was provided. An intervention midway through the study included a written reminder and required written response regarding co-therapy.

RESULTS

16,244/23,504 (69%) patients had GI risk factors. Pre-intervention, co-therapy was most common with previous ulcer/haemorrhage [706/1107 (64%)] and 3-4 risk factors [331/519 (64%)]. In the 10,026 patients enrolled pre-intervention and remaining in the study > or =6 months after, co-therapy in high-risk patients increased from 2958/6843 (43%) to 4177/6843 (61%) (difference = 18%; 95% CI 16%,19%). The increase was greater outside the US (22%; 19%,24%) than in the US (15%; 13%,17%).

CONCLUSIONS

Less than 50% of NSAID users with GI risk factors are given protective co-therapy--even if prescribers are given reminders and cost is not an issue. Direct communication requiring written response significantly increased adherence to guidelines, but achieving higher levels of adherence will require additional strategies.

Use of analgesics in adults with pain complaints: prevalence and associated factors, Turkey

OBJECTIVE

Use of analgesics has been increasingly recognized as a major public health issue with important consequences in Turkey. The objective of the study was to determine the prevalence and patterns of analgesics usage and associated factors in adults with pain complaints.

METHODS

A cross-sectional study was conducted in 15 cities selected from five demographic regions in Turkey. The study sample population comprised 1.909 adults 18-65 age groups suffering from pain. The sampling method was multi-step stratified weighted quota-adjusted sampling. Data were collected by face-to-face interviews using a semi-structured survey questionnaire consisting of 28 questions. Odds ratios were produced by logistic regression analyses.

RESULTS

The prevalence of analgesic use was 73.1%, and it was higher in females (75.7%; p<0.05), in subjects 45-54 years (81.4%; p<0.05), in subjects in rural areas (74.6%; p<0.05), in subjects in northern region (84.3%; p<0.05), in illiterate subjects (79.1%; p>0.05), and in subjects of lower socioeconomic status (74.1%; p>0.05). One in ten of the participants used non-prescription analgesics. Non-prescription analgesics were more prevalent among the 55-65 age groups (18.1%; p<0.05), among female (11.6%; p>0.05), among the urban population (10.7%; p>0.05), and in subjects of lower middle socioeconomic status (13.2%; p<0.05). Logistic regression showed statistically significant ORs only for age groups, duration of education, socioeconomic status, and demographic regions (p<0.05).

CONCLUSIONS

The results showed that the prevalence of analgesic use and prescription analgesic use is high in Turkey, and their use is related to sociodemographic characteristics.