Clinical pharmacology and use of nonsteroidal anti-inflammatory drugs

Pain Management and Conscious Sedation for the Pediatric Patient

Pain management in children was previously ignored primarily because of myths and misconceptions about childhood pain. Undertreatment of pain was once a common and accepted practice. However, in recent years, with increased knowledge and understanding coupled with improved pain assessment tools, health care providers are more conscious about providing adequate and safe analgesia to children. Because of the differences in patient response to various pharmacological agents, it is important to understand the pharmacokinetic and pharmacodynamic differences of the various agents. Choices of pain management should be individualized, and adjustments should be made based on the patient's clinical condition. Conscious sedation before diagnostic and therapeutic procedures should be approached with caution. Deaths and complications related to conscious sedation therapy have prompted the development of guidelines for safer and more effective pharmacological interventions. The recently published guidelines include recommendations for skilled personnel, continuous monitoring, appropriate use of drugs, and ability to manage unforeseen complications. Selection of the most appropriate sedatives should take into consideration the type of procedure, the patient's clinical condition, and the desired level and duration of consciousness. Similar to pain management, individualization is crucial. This article will discuss the principles of pain management and conscious sedation in children. Facts and scientific findings will be presented to discredit the myths and misconceptions often associated with pediatric pain. Various pain assessment tools will be summarized. The newly published sedation guidelines set forth by the American Academy of Pediatrics Committee on Drugs will be briefly discussed. Furthermore, commonly used agents will be reviewed. Copyright © 1996 by W.B. Saunders Company

Aspirin in pregnancy

Aspirin, acetylsalicylic acid, is the most frequently consumed drug in pregnancy, taken mostly without a prescription because of headache or a minor ailment. Numerous preparations containing acetylsalicylic acid are freely available over the counter under a variety of proprietary names, and in many cases pregnant women and their doctors may be unaware that aspirin is being taken.

[Ibuprofen in childhood: evidence-based review of efficacy and safety]

Ibuprofen is the non-steroidal anti-inflammatory drug most prescribed for the treatment of fever and moderate pain in childhood. Its analgesic and antipyretic efficacy is now well documented: at equal doses ibuprofen appears slightly more effective than acetaminophen in the treatment of fever and is equivalent for analgesia. However, adverse effects should be taken into account in the choice between ibuprofen and acetaminophen. Lot of studies (case reports, cohort studies, case-control studies and one multicenter double-blind randomized control trial) have reported ibuprofen adverse effects at therapeutics doses. These data suggest there is an increased risk of invasive group A streptococcal infection after chickenpox and of acute renal failure in case of hypovolemia after a treatment by ibuprofen. Gastroduodenal and hemorrhagic adverse events could also happen, but the causality with ibuprofen is not demonstrated. Therefore, ibuprofen is not recommended for the treatment of fever or moderate pain during chickenpox or during a disease with a risk of dehydration, until other pharmacoepidemiology studies more accurately quantify the risk of adverse events of ibuprofen in children.

The isolated and combined effects of selected physical activity and ibuprofen on delayed-onset muscle soreness

Delayed-onset muscle soreness refers to the skeletal muscle pain that is experienced following eccentric exercise. The aim of the present study was to examine the physiological effects of physical activity with or without ibuprofen on delayed onset muscle soreness. Forty-four non-athletic male volunteers (age 24.3 +/- 2.4 years) were randomly assigned to one of four groups: physical activity (n = 11), ibuprofen (n = 11), physical activity and ibuprofen (combination, n = 11), or control (n = 11). The physical activity programme comprised 5 min of walking and jogging, 10 min of static stretching of the hands and shoulder girdle, and 5 min of concentric movements with sub-maximal contractions. The total amount of ibuprofen consumed by a single individual was 2800 mg; this was taken from 1 h before the eccentric actions up to 48 h after it. Delayed onset muscle soreness was induced by performing 70 eccentric contractions of the biceps muscle of the non-dominant side on a modified arm curl machine. Perceived muscle soreness, maximal eccentric contraction, creatine kinase enzyme activity and elbow range of motion were assessed 1 h before and 1, 24 and 48 h after the eccentric actions. The results indicated that, after the eccentric actions, soreness increased (P < 0.001) across time in all groups, with the highest values being recorded at 24 h. At 24 and 48 h, greater soreness (P < 0.001) was observed in the control group than in the physical activity and combination groups. After the eccentric actions, creatine kinase increased and was elevated (P < 0.001) compared with baseline in all groups, with values returning to baseline in the physical activity and combination groups by 48 h. However, creatine kinase in the control and ibuprofen groups was still significantly higher than at baseline after 48 h. Creatine kinase was higher (P < 0.001) in the control group than in physical activity and combination groups at 24 and 48 h. There was also a reduction (P < 0.001) in elbow range of motion across time. This reduction in elbow range of motion was greater (P < 0.001) in the control and ibuprofen groups than in the physical activity and combination groups at 1, 24 and 48 h. The reduction in maximum eccentric contraction was greater (P < 0.001) in the control and ibuprofen groups than in the physical activity group at 24 and 48 h and the combination group at 48 h. In conclusion, the results add to our understanding of the effects of physical activity and the combination of physical activity and ibuprofen in reducing the severity of muscle soreness induced by eccentric exercise. Physical activity conducted before eccentric exercise alleviates muscle soreness. Our results indicate that physical activity with or without ibuprofen helps to prevent delayed-onset muscle soreness.

The effect of topical non-steroidal anti-inflammatory cream on the incidence and severity of cutaneous burns following external DC cardioversion

INTRODUCTION

Cutaneous burns are a common cause of morbidity following direct current (DC) cardioversion. We designed a study to determine whether the application of non-steroidal anti-inflammatory cream prior to cardioversion reduces their incidence and severity.

MATERIALS AND METHODS

Two hours before elective DC cardioversion, we randomised 55 patients to receive ibuprofen 5% cream or placebo cream over sternal and apical pad sites, with patients acting as their own controls. Two hours after cardioversion an independent blinded observer measured skin temperature, erythema index, and minimum sensory and pain detection thresholds at sternal and apical pad sites. Visual analogue pain score (VAS) for each site was recorded at 2 h and 24 h post-cardioversion.

RESULTS

There was a statistically significant difference between pain measured by VAS, skin temperature and pain detection threshold measured at pad sites with pre-applied ibuprofen 5% cream and those with pre-applied aqueous cream, after elective DC cardioversion.

CONCLUSION

Prophylactic application of topical ibuprofen 5% cream 2h prior to elective DC cardioversion reduces pain and inflammation. Consideration should be given to use of prophylactic application of topical ibuprofen as routine treatment for elective DC cardioversion.

Pediatric Rheumatology for the Adult Rheumatologist I

Treatment of children with rheumatic diseases has advanced with novel therapeutics and the use of early aggressive treatment to achieve better long-term functional outcome. Many of the current treatments in pediatric rheumatology are based on studies in adults on medications without U.S. Food and Drug Administration labeling for pediatric use. This is not ideal because the pharmacokinetics (absorption, distribution, metabolism, and elimination) of many medications when used in children vary according to age, somatic growth, sexual maturity, and ontogeny of drug-metabolizing enzymes. Special dosing, administration considerations, and toxicity screening are reviewed for the more commonly used medications. Vaccinations for children on antirheumatic drugs are also discussed. Continued study of the long-term impact of medications and biologic treatments on children is necessary, but given the paucity of children with rheumatic diseases, this will require multicentered trials and collaborations. Lastly, this article reviews recent regulatory and legislative action on pediatric drug testing. Passage of the Pediatric Research Equity Act of 2003, which requires testing of pharmaceuticals in children, will facilitate more rational use of drugs in pediatric rheumatic diseases in the future.

Effect of Ibuprofen Use on Delayed Onset Muscle Soreness of the El bow Flexors

This study evaluated the effectiveness of ibuprofen in treating delayed onset muscle soreness (DOMS) of the elbow flexors when taken prior to and following exercise. Twenty subjects received either 2,400 mg/day ibuprofen or a placebo four times per day. Subjects performed intense eccentric exercise of the elbow flexors to elicit DOMS. Concentric and eccentric peak torque production against an isokinetic resistance of 0.52 radls, range of motion at the elbow, and subjective soreness of the elbow flexors were measured. ANOVA indicated no significant group-by-time interaction for concentric peak torque, eccentric peak torque, or pain. A significant interaction was revealed for range of motion. There was a significant difference within each group's ROM but no interaction between groups. It was concluded that the use of 2,400 mg/day ibuprofen prior to and following intense eccentric exercise was no more effective than a placebo in treating DOMS of the elbow flexors.

Pediatric pain management (Part I)

This article is the first in a two-part series on pediatric pain management. It contains primarily a general discussion of pediatric pain, myths and misconceptions about pediatric pain, and the use of nonnarcotic analgesics for pain control. In the second article, the use of narcotic analgesics for the pediatric population will be discussed.

Chronic pain and the child with juvenile rheumatoid arthritis

This article presents a summary of nursing issues concerning the assessment and management of pain in children with juvenile rheumatoid arthritis (JRA). Following a brief description of the difference between acute and chronic pain and a description of JRA, the developmental issues relating to pain assessment in this population are discussed. Three pain assessment tool alternatives are presented. Finally, current strategies for pain relief and treatment of children with JRA are presented.

Inhibition by cyclo-oxygenase inhibitors of interleukin-6 production by human peripheral blood mononuclear cells

The effects of cyclo-oxygenase inhibitors on interleukin-6 (IL-6) production by human peripheral blood mononuclear cells were examined. Indomethacin and Y-9223, a novel cyclo-oxygenase inhibitor, inhibited the increases in the IL-6 level in the culture medium of both mitogen-stimulated adherent cells and non-adherent cells fractionated from mononuclear cells. Northern blotting showed that the mitogen-induced increase in the expression of IL-6 mRNA was inhibited by indomethacin and Y-9223, indicating that these agents inhibit IL-6 biosynthesis. Aspirin, ibuprofen, and phenylbutazone also inhibited IL-6 production by adherent cells stimulated with lipopolysaccharide (LPS). There was, however, no direct relationship between inhibition of IL-6 and prostaglandin E2 (PGE2) production by these agents. The addition of PGE2 corresponding to the amount produced by adherent cells stimulated with LPS slightly increased IL-6 production by unstimulated adherent cells, but to a lower level than that reached with LPS. An anti-PGE2 antibody partially blocked IL-6 production by adherent cells stimulated with LPS. These results suggest that, in addition to the inhibition of PGE2 production, other mediators including cyclooxygenase products or other action mechanisms are involved in the inhibition of IL-6 production by these drugs.