Effectiveness of ibuprofen plus paracetamol combination on persistence of acute musculoskeletal disorders in primary care patients

Relative effectiveness and gastrointestinal safety of NSAIDs being prescribed for upper respiratory tract infections: an explorative cohort study in primary care

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to control pain, inflammation, and fever in upper respiratory tract infections (URTIs).

AIM

To explore the relative effectiveness and gastrointestinal (GI)-related safety of individual NSAIDs to control symptoms of URTIs.

METHOD

Using an Italian primary care data source, we identified patients aged ≥ 15 years who were newly prescribed NSAIDs for URTIs between 2013 and 2022. Switching to another NSAID for the same indication within the 30-day follow-up was a proxy for drug effectiveness. The study outcome for GI safety analysis was upper gastrointestinal bleeding (UGIB).

RESULTS

In a cohort of 57,971 patients, the most prevalent subgroups were those treated with ketoprofen (39.5%) and dexibuprofen/ibuprofen (22.4%). Ketoprofen showed the lowest rate of switching to another NSAID [Hazard Ratio (HR) 0.40 (95% CI 0.20-0.83)] against acetylsalicylic acid/coxibs/diclofenac. Dexibuprofen/ibuprofen showed similar results [HR 0.50 (95% CI 0.22-1.10)], with no significant association. Ketoprofen and dexibuprofen/ibuprofen were prescribed as lysine and arginine salts in 85 and 6% of URTIs sufferers, respectively. Across NSAIDs, we did not find any significant difference in the risk of UGIB.

CONCLUSION

Our findings indicated that various NSAIDs may exhibit differing levels of effectiveness in treating URTIs, particularly those formulated for quick onset of action. No NSAIDs-UGIBs association was found. Further prospective, larger studies are needed to confirm these findings.

Paracetamol Combination Therapy for Back Pain and Osteoarthritis: A Systematic Review and Meta-Analyses

BACKGROUND AND OBJECTIVE

Although paracetamol (acetaminophen) combined with other analgesics can reduce pain intensity in some pain conditions, its effectiveness in managing low back pain and osteoarthritis is unclear. This systematic review investigated whether paracetamol combination therapy is more effective and safer than monotherapy or placebo in low back pain and osteoarthritis.

METHODS

Online database searches were conducted for randomised trials that evaluated paracetamol combined with another analgesic compared to a placebo or the non-paracetamol ingredient in the combination (monotherapy) in low back pain and osteoarthritis. The primary outcome was a change in pain. Secondary outcomes were (serious) adverse events, changes in disability and quality of life. Follow-up was immediate (≤ 2 weeks), short (> 2 weeks but ≤ 3 months), intermediate (> 3 months but < 12 months) or long term (≥ 12 months). A random-effects meta-analysis was conducted. Risk of bias was assessed using the original Cochrane tool, and quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Twenty-two studies were included. Pain was reduced with oral paracetamol plus a non-steroidal anti-inflammatory drug (NSAID) at immediate term in low back pain (paracetamol plus ibuprofen vs ibuprofen [mean difference (MD) - 6.2, 95% confidence interval (CI) -10.4 to -2.0, moderate evidence]) and in osteoarthritis (paracetamol plus aceclofenac vs aceclofenac [MD - 4.7, 95% CI - 8.3 to - 1.2, moderate certainty evidence] and paracetamol plus etodolac vs etodolac [MD - 15.1, 95% CI - 18.5 to - 11.8; moderate certainty evidence]). Paracetamol plus oral tramadol reduced pain compared with placebo at intermediate term for low back pain (MD - 11.7, 95% CI - 19.2 to - 4.3; very low certainty evidence) and osteoarthritis (MD - 6.8, 95% CI - 12.7 to -0.9; moderate certainty evidence). Disability scores improved in half the comparisons. Quality of life was infrequently measured. All paracetamol plus NSAID combinations did not increase the risk of adverse events compared to NSAID monotherapy.

CONCLUSIONS

Low-to-moderate quality evidence supports the oral use of some paracetamol plus NSAID combinations for short-term pain relief with no increased risk of harm for low back pain and osteoarthritis compared to its non-paracetamol monotherapy comparator.

Experimental and Machine-Learning-Assisted Design of Pharmaceutically Acceptable Deep Eutectic Solvents for the Solubility Improvement of Non-Selective COX Inhibitors Ibuprofen and Ketoprofen

Deep eutectic solvents (DESs) are commonly used in pharmaceutical applications as excellent solubilizers of active substances. This study investigated the tuning of ibuprofen and ketoprofen solubility utilizing DESs containing choline chloride or betaine as hydrogen bond acceptors and various polyols (ethylene glycol, diethylene glycol, triethylene glycol, glycerol, 1,2-propanediol, 1,3-butanediol) as hydrogen bond donors. Experimental solubility data were collected for all DES systems. A machine learning model was developed using COSMO-RS molecular descriptors to predict solubility. All studied DESs exhibited a cosolvency effect, increasing drug solubility at modest concentrations of water. The model accurately predicted solubility for ibuprofen, ketoprofen, and related analogs (flurbiprofen, felbinac, phenylacetic acid, diphenylacetic acid). A machine learning approach utilizing COSMO-RS descriptors enables the rational design and solubility prediction of DES formulations for improved pharmaceutical applications.

Paracetamol for multimodal analgesia

Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.