Double-blind, randomized, parallel, placebo-controlled study of ibuprofen effects on thromboxane B2 concentrations in aspirin-treated healthy adult volunteers

Provider-directed analgesia for dental pain

INTRODUCTION

Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry.

AREAS COVERED

This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain.

EXPERT OPINION

Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.

Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed

BACKGROUND

This review provides a summary of the currently available clinical data on drug-drug interactions (DDIs) involving over-the-counter (OTC) medicines. It aims to educate and increase awareness among health care providers and to support decisions in daily practice.

METHODS

An extensive literature search was performed using bibliographic databases available through PubMed.gov. An initial structured search was performed using the keywords "drug-drug-interaction AND (over-the-counter OR OTC)," without further restrictions except for the language. The initial results were screened for all described DDIs involving OTC drugs, and further information was gathered specifically on these drugs using dedicated database searches and references found in the bibliography from the initial hits.

RESULTS

From more than 1200 initial hits (1972-June 2021), 408 relevant publications were screened for DDIs involving OTC drugs, leading to 2 major findings: first, certain types of drug regimens are more prone to DDIs or have more serious DDI-related consequences, such as antiretroviral, anti-infective, and oral anticancer therapies. Second, although most DDIs involve OTC drugs as the perpetrators, some prescription drugs (statins or phosphodiesterase-5 inhibitors) that currently have OTC status can be identified as the victims in DDIs. The following groups were identified to be frequently involved in DDIs: nonsteroidal anti-inflammatory drugs, food supplements, antacids, proton-pump inhibitors, H2 antihistamines, laxatives, antidiarrheal drugs, and herbal drugs.

CONCLUSIONS

The most significant finding was the lack of high-quality evidence for commonly acknowledged interactions. High-quality interaction studies involving different phenotypes in drug metabolism (cytochrome P450) and distribution (transporters) are urgently needed. This should include modern and critical drugs, such as oral anticancer medications and direct oral anticoagulants.

What the dental practitioner needs to know about pharmaco-therapeutic modalities of COVID-19 treatment: A review

BACKGROUND/PURPOSE

Several pharmacotherapeutic methods have been used for the treatment of COVID-19 with varying degrees of success. No definitive treatment or vaccine has been officially approved to-date. This review aimed to highlight COVID-19 pharmacotherapeutic agents that are relevant to dental practice in terms of their clinical indications in COVID-19 and dental practice, as well as their adverse effects as they impact the dental patient.

MATERIAL AND METHODS

Systematic search was performed using the following keywords combinations: Pharmacotherapy AND COVID-19 OR Pharmacotherapy AND SARS-CoV-2 OR Treatment AND COVID-19. Studies were categorized according to the type of pharmacotherapy used. Pharmacotherapeutic agents were extracted and only those relevant to dental practice were included for review.

RESULTS

For analysis, a total of 79 clinical trials research articles were included that included COVID-19 pharmacotherapeutic agents relevant to dental practice. Those were analgesics (paracetamol; non-steroidal anti-inflammatory agents); antibiotics (azithromycin, doxycycline, metronidazole); antivirals (penciclovir); and immunomodulatory agents (hydroxychloroquine, corticosteroids). While some COVID-19 drugs are less relevant to dental practice, as antivirals and hydroxychloroquine, their association with long-term adverse effects requires adequate knowledge among dental practitioners.

CONCLUSION

Many of COVID-19 pharmacotherapeutic agents are used to treat oral diseases particularly orofacial pain and inflammatory conditions. Furthermore, some of these drugs may induce adverse effects that complicate dental treatment. Thorough knowledge of COVID-19 therapy and its dental implications is essential for dental practitioners, and is expected to contribute to a better understanding and effective utilization of these therapeutic agents.

Cardiorenal Safety of OTC Analgesics

Over-the-counter analgesics are used globally for the relief of acute pain. Although effective, these agents can be associated with adverse effects that may limit their use in some people. In the early 2000s, observations from clinical trials of prescription-strength and supratherapeutic doses of nonselective and cyclooxygenase-2-selective nonsteroidal anti-inflammatory drugs (NSAIDs) raised safety concerns regarding the risk of cardiovascular adverse effects with the use of these medications. Subsequently, the US Food and Drug Administration mandated additional study of the cardiovascular safety of NSAIDs for a more comprehensive understanding of their risk. As these data were being collected, and based on a comprehensive review of prescription data and the recommendations of the US Food and Drug Administration Advisory Committee, the warning labels of over-the-counter NSAIDs were updated to emphasize the potential cardiovascular risks of these agents. The recently reported “Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen” (PRECISION) trial, in which participants with osteoarthritis or rheumatoid arthritis and underlying cardiovascular risk factors were treated with prescription-strength celecoxib, ibuprofen, or naproxen, revealed similar rates of cardiovascular events (death from cardiovascular causes including hemorrhagic death, nonfatal myocardial infarction, or nonfatal stroke) among the 3 treatment groups. Although informative, the cardiovascular safety findings derived from PRECISION cannot be extrapolated to the safety of the over-the-counter pain relievers ibuprofen and naproxen, given that the doses used were higher (mean [standard deviation]: ibuprofen, 2045 [246] mg; naproxen, 852 [103] mg) and the durations of use longer (∼20 months) than recommended with over-the-counter use of NSAIDs, which for ibuprofen is up to 10 days. This review discusses the cardiorenal safety of the most commonly used over-the-counter analgesics, ibuprofen, naproxen, and acetaminophen. Available data suggest that there is little cardiovascular risk when over-the-counter formulations of these agents are used as directed in their labels.

Short-term use of nonsteroidal anti-inflammatory drugs and adverse effects: An updated systematic review

BACKGROUND

In this article, the authors examine the available scientific evidence regarding adverse effects of short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). Short-term use was defined as 10 days or fewer.

METHODS

The authors reviewed randomized controlled clinical trials and cohort and case-controlled clinical studies published between 2001 and June 2015 in which the investigators reported on the safety of nonselective cyclooxygenase inhibitors and of cyclooxygenase-2 selective inhibitor NSAIDs.

RESULTS

The systematic review process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines allowed the authors to identify 40 studies that met the inclusion criteria.

CONCLUSIONS

On the basis of the available scientific evidence, NSAIDs may be considered relatively safe drugs when prescribed at the most effective dose and for the shortest duration of time, which was defined to be 10 days or fewer.

PRACTICAL IMPLICATIONS

Although the US Food and Drug Administration recommends the use of NSAIDs beyond 10 days to be accompanied by a consultation with a health care provider, the use of NSAIDs may be considered relatively safe when prescribed at the most effective dose and for the shortest duration of time, which was defined as 10 days or fewer. Exceptions would be for patients at risk of developing NSAID-exacerbated respiratory disease, patients with prior myocardial infarction who are receiving antithrombotic therapy, patients with asthma, and patients with a history of renal disease.

Antithrombotic drugs: pharmacology and implications for dental practice

Appropriate preoperative assessment of the dental patient should always include an analysis of the patient's medications. This article reviews the actions and indications for the various categories of antithrombotic medications and considers actual risks for postoperative bleeding and potential interactions with drugs the dental provider might administer or prescribe.

Confirmation of reported aspirin use in community studies: utility of serum thromboxane B2 measurement

Aspirin (ASA) is recommended for the prevention of cardiovascular disease; however, the compliance is low. Reported use may not reflect actual use. Serum thromboxane B2 (STxB2) measurement was evaluated to validate reported ASA use. Males aged 45 to 79 years and females aged 55 to 79 years completed a survey and STxB2 measurement (Thromboxane B2 EIA Kit; Cayman Chemical, Ann Arbor, Michigan). The 107 patients were grouped by use of ASA (56 ASA+ and 51 ASA-) and possible interfering medications (INT) such as nonsteroidal anti-inflammatory drugs. The STxB2 levels (ng/mL) were significantly lower in ASA users: ASA+ INT- 3.0 (0.7, 8.4), ASA+ INT+ 2.0 (0.8, 4.9), ASA- INT+ 176 (75, 390), and ASA- INT- 271 (199, 366). The INT use did not cause a significant difference in STxB2 levels. A STxB2 cut point of 25 ng/mL had high sensitivity (94.1%) and specificity (91.1%) for ASA use. The STxB2 was a reliable marker of ASA use and could be used to confirm ASA exposure in population-based health studies.

Adverse drug interactions

The potential for interactions with current medications should always be considered when administering or prescribing any drug. Considering the staggering number of drugs patients may be taking, this task can be daunting. Fortunately, drug classes employed in dental practice are relatively few in number and therapy is generally brief in duration. While this reduces the volume of potential interactions, there are still a significant number to be considered. This article will review basic principles of drug interactions and highlight those of greatest concern in dental practice.

Effect of maximum OTC doses of naproxen sodium or acetaminophen on low-dose aspirin inhibition of serum thromboxane B2

OBJECTIVES

This study evaluated the platelet inhibitory effects of low-dose enteric-coated aspirin (EC-ASA) when used concomitantly with maximum over-the-counter (OTC) doses of naproxen sodium (NAPSO) or acetaminophen to determine whether NAPSO and acetaminophen interfere with the anti-platelet effect of aspirin.

RESEARCH DESIGN AND METHODS

Phase I, randomized, open-label, multi-dose, three-period, parallel group, pharmacodynamic trial conducted in healthy male and female volunteers (n = 47 randomized subjects and n = 37 evaluable subjects), mean age 40.2 years. All subjects received 5 days of EC-ASA 81 mg once daily followed by 5 days of EC-ASA 81 mg once daily alone or co-administered with either NAPSO 220 mg three times daily or acetaminophen 1 g four times daily.

PRIMARY OUTCOME MEASURE

Inhibition of serum thromboxane B(2) (TXB(2)), as a marker of platelet cyclooxygenase-1 (COX-1) inhibition, measured on Day 11.

RESULTS

Mean inhibition of TXB(2) on Day 11 was >99% for subjects taking EC-ASA alone as well as for those who received EC-ASA co-administered with NAPSO or acetaminophen. For subjects taking EC-ASA monotherapy, mean serum TXB(2) inhibition was 99.7% (range 99.0-100%), for those taking EC-ASA with acetaminophen it was 99.6% (range 98.3-99.9%), and for those taking EC-ASA with NAPSO, mean serum TXB(2) inhibition was 99.7% (range 99.2-100%).

STUDY LIMITATION

Small sample size and open-label trial design.

CONCLUSIONS

The anti-platelet effect of EC-ASA 81 mg once daily was maintained following its co-administration with maximum OTC doses of NAPSO or acetaminophen.

Pain management: Part 1: Managing acute and postoperative dental pain

Safe and effective management of acute dental pain can be accomplished with nonopioid and opioid analgesics. To formulate regimens properly, it is essential to appreciate basic pharmacological principles and appropriate dosage strategies for each of the available analgesic classes. This article will review the basic pharmacology of analgesic drug classes, including their relative efficacy for dental pain, and will suggest appropriate regimens based on pain intensity. Management of chronic pain will be addressed in the second part of this series.

Platelet inhibitory effects of OTC doses of naproxen sodium compared with prescription dose naproxen sodium and low-dose aspirin

OBJECTIVES

Prescription dose naproxen has been reported to have an antiplatelet effect similar to low-dose aspirin (ASA). This study evaluated the platelet inhibitory effects of over-the-counter (OTC) doses of naproxen sodium (NAPSO) compared to that of a prescription dose of NAPSO and to low-dose enteric-coated aspirin (EC-ASA).

RESEARCH DESIGN AND METHODS

This was a phase I, open-label, randomized, placebo-controlled, two-way crossover, multi-dose, pharmacodynamic trial conducted in healthy male and female volunteers (n = 48, mean age = 41.7 years). All subjects received 7 days of either prescription dose NAPSO (550 mg twice daily), OTC doses of NAPSO (220 mg two or three times daily), or placebo twice daily (period 1). After a minimum 6-day washout period, all subjects then received 7 days of EC-ASA 81 mg once daily (period 2). All study medications were taken by mouth.

PRIMARY OUTCOME MEASURE

Inhibition of serum thromboxane B(2) (TXB(2)), as a marker of platelet cyclooxygenase-1 (COX-1) inhibition, measured 24 h after the day 7 morning dose. This was measured after both period 1 and period 2.

RESULTS

After 7 days of treatment in period 1, mean inhibition of TXB(2) was 47% for placebo and > or =98% for all doses of NAPSO. After 7 days of EC-ASA 81 mg, mean inhibition of TXB(2) was > or = 97% (period 2).

STUDY LIMITATIONS

Out-patient study setting.

CONCLUSIONS

These data suggest that OTC doses of NAPSO (220 mg two or three times daily) have an antiplatelet effect similar to EC-ASA 81 mg and to prescription dose NAPSO (550 mg twice daily).

Use of antiplatelet agents for prevention of ischemic stroke

Overall management to lower risk for ischemic stroke is multifaceted. Management includes measures to treat risk factors for accelerated atherosclerosis and stroke, antithrombotic therapies to lower the risk for thromboembolism, and surgery to treat a defined arterial or cardiac lesion. Treatment decisions are made on a case-by-case basis, with most patients receiving some combination of medication and recommendations for lifestyle modification. Some patients will also undergo surgical or endovascular interventions. This article discusses antithrombotic treatment for ischemic stroke prevention, placing major emphasis on the indications for and administration of antiplatelet therapy.

Cardiovascular drugs: implications for dental practice. Part 2--antihyperlipidemics and antithrombotics

Appropriate preoperative assessment of the dental patient should always include an analysis of the patient's medications. Cardiovascular diseases are the most common group of medical disorders that dentists encounter, and the number of drugs prescribed for managing these conditions is staggering. This justifiably raises concern and probable confusion regarding side effects and possible drug interactions with medications the dentist may deem necessary for dental care. This continuing education article is the second in a series that will address essential pharmacology of medications commonly prescribed for chronic medical care. A reasonable understanding of these agents will allow the dentist to better appreciate the medical status of their patients, to appreciate the actual risks associated with antithrombotic medications, and to avoid adverse interactions with drugs the dentist might administer or prescribe.

Effects of ibuprofen on the magnitude and duration of aspirin's inhibition of platelet aggregation: clinical consequences in stroke prophylaxis

This study was designed to measure the magnitude and duration of inhibition of platelet aggregation following doses of aspirin or ibuprofen alone or taken in combination in a group of healthy volunteers. Ten normal volunteer subjects underwent 3 randomized treatment sessions: aspirin 325 mg alone, ibuprofen 400 mg alone, and ibuprofen 400 mg, followed by dosing with aspirin 325 mg 2 hours thereafter. In addition, a confirmatory study was performed in patients. Over 27 months, a cohort of patients treated with aspirin for secondary stroke prophylaxis while concomitantly taking a nonsteroidal anti-inflammatory drug (NSAID) was identified. A significant reduction was found in both the magnitude and duration of aspirin's inhibitory effect on platelet aggregation when ibuprofen was given prior to aspirin administration in normal volunteer subjects. During a 27-month period, a cohort of 28 patients took regular daily doses of ibuprofen or naproxen. Of these 28 patients, 18 returned for follow-up testing in the absence of this pharmacodynamic interaction. None of these 18 patients demonstrated inhibition of platelet aggregation while on both NSAID and aspirin; however, all showed inhibition of aggregation following discontinuation of the NSAID. Notably, 13 of these 18 patients (72%) had experienced a recurrent ischemic episode while taking aspirin and NSAIDs concomitantly. These data suggest that ibuprofen prevents the irreversible inhibition of platelet aggregation produced by aspirin needed for secondary stroke prophylaxis, and this interaction can have clinical consequences for patients taking aspirin.

The antiplatelet effect of six non-steroidal anti-inflammatory drugs and their pharmacodynamic interaction with aspirin in healthy volunteers

Patients with cardiovascular disease taking aspirin and some nonsteroidal anti-inflammatory drugs (NSAIDs) appear to have increased vascular events. This study was conducted to compare the ex vivo antiplatelet effects of 6 commonly used NSAIDs and to determine whether these agents antagonize the effect of aspirin. Platelet function was assessed by Platelet Function Analyzer 100 closure time in normal subjects in a randomized, blinded, multiple-crossover study. Platelet function was measured 12 hours after the administration of each NSAID. The NSAID was then given 2 hours before aspirin 300 mg, and platelet function was reassessed 24 hours later. At 12 hours after the administration of naproxen and tiaprofenic acid, closure time was significantly prolonged, whereas the other NSAIDs did not cause significant prolongations. Compared with placebo plus aspirin, closure time was significantly reduced when ibuprofen, indomethacin, naproxen, or tiaprofenic acid was given before aspirin. In conclusion, ibuprofen, indomethacin, naproxen, and tiaprofenic acid all block the antiplatelet effect of aspirin. Sulindac and celecoxib did not demonstrate any significant antiplatelet effect or reduce the antiplatelet of aspirin and, therefore, of the NSAIDs evaluated may be the drugs of choice for patients requiring aspirin and NSAIDs.

Adverse drug interactions involving common prescription and over-the-counter analgesic agents

BACKGROUND

Eight analgesic preparations with approved indications for acute pain were among the top 200 drugs prescribed in the United States in 2006. In addition, an estimated 36 million Americans use over-the-counter (OTC) analgesics daily. Given this volume of use, it is not surprising that a number of drug interactions involving analgesic drugs have been reported.

OBJECTIVES

This article examines the pharmacologic factors that enhance the clinical relevance of potential drug interactions and reviews the literature on drug interactions involving the most commonly used analgesic preparations in the United States.

METHODS

A PubMed search was conducted for English-language articles published between January 1967 and July 2007. Among the search terms were drug interactions, acetaminophen, aspirin, ibuprofen, naproxen, celecoxib, NSAIDs, hydrocodone, oxycodone, codeine, tramadol, OTC analgesics, alcohol, ethanol, antihypertensive drugs, methotrexate, warfarin, SSRIs, paroxetine, fluoxetine, sertraline, citalopram, serotonin syndrome, MAOIs, and overdose. Controlled clinical trials, case-control studies, and case reports were included in the review.

RESULTS

A number of case reports and well-controlled clinical trials were identified that provided evidence of the relatively well known drug-drug interactions between prescription/OTC NSAIDs and alcohol, antihypertensive drugs, high-dose methotrexate, and lithium, as well as between frequently prescribed narcotics and other central nervous system depressants. In contrast, the ability of recent alcohol ingestion to exacerbate the hepatotoxic potential of therapeutic doses of acetaminophen is not supported by either case reports or clinical research. Use of ibuprofen according to OTC guidelines in patients taking cardioprotective doses of aspirin does not appear to interfere with aspirin's antiplatelet activity, whereas chronic prescription use of ibuprofen and other NSAIDs may interfere. Low-dose aspirin intake appears to abolish the gastroprotective effects of cyclooxygenase-2-selective inhibitors, including celecoxib. There is evidence of other less well known and potentially clinically significant drug-drug interactions, including the ability of selective serotonin reuptake inhibitors to inhibit the analgesic activity of tramadol and codeine through inhibition of their metabolic activation, to induce serotonin syndrome when used chronically in the presence of high doses of tramadol through synergistic serotonergic action, and to increase the potential for gastrointestinal bleeding associated with NSAID therapy through additive or supra-additive antiplatelet activity.

CONCLUSIONS

Considering the widespread use of analgesic agents, the overall incidence of serious drug-drug interactions involving these agents has been relatively low. The most serious interactions usually involved other interacting drugs with low therapeutic indices or chronic and/or high-dose use of an analgesic and the interacting drug.

An evidence-based update on nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), including both traditional nonselective NSAIDs and the selective cyclooxygenase (COX)-2 inhibitors, are widely used for their anti-inflammatory and analgesic effects. NSAIDs are a necessary choice in pain management because of the integrated role of the COX pathway in the generation of inflammation and in the biochemical recognition of pain. This group of drugs has recently come under scrutiny because of recent focus in the literature on the various adverse effects that can occur when applying NSAIDs. This review will provide an educational update on the current evidence of the efficacy and adverse effects of NSAIDs. It aims to answer the following questions: (1) are there clinically important differences in the efficacy and safety between the different NSAIDs, (2) if there are differences, which are the ones that are more effective and associated with fewer adverse effects, and (3) which are the effective therapeutic approaches that could reduce the adverse effects of NSAIDs. Finally, an algorithm is proposed which delineates a general decision-making tree to select the most appropriate analgesic for an individual patient based on the evidence reviewed.

Potential for drug-drug interactions in patients taking analgesics for mild-to-moderate pain and low-dose aspirin for cardioprotection

Millions of individuals in the United States take low-dose aspirin for cardioprotection. Physicians face a clinical dilemma when those same patients also have pain from arthritis or another condition. Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of gastrointestinal (GI) complications when used in conjunction with aspirin. In addition, NSAIDs, particularly ibuprofen, may interfere with the antithrombotic benefits of aspirin through competitive interaction with platelet cyclooxygenase-1 (COX-1). Evidence suggests that naproxen has antithrombotic effects; however, as with other NSAIDs, it poses a risk of gastrotoxicity. Selective COX-2 inhibitors reduce the risk of GI side effects, and although they inhibit platelet COX-1, it is to a far lesser extent than COX-2. However, it is unclear to what degree COX-2 inhibitors remain gastroprotective in the presence of aspirin. In addition, recent long-term trials have raised concerns about adverse cardiovascular events with prolonged use of both traditional and selective NSAIDs. Conversely, acetaminophen is well tolerated, has not been shown to contribute to gastrotoxicity when taken with aspirin, and has not been shown to interfere with the inhibition of platelet aggregation produced by aspirin. Acetaminophen is considered a first-line therapy for patients with mild-to-moderate joint pain.