Comparative study of analgesic efficacy and morphine-sparing effect of intramuscular dexketoprofen trometamol with ketoprofen or placebo after major orthopaedic surgery

How to Create an Orthopaedic Arthroplasty Database Project: A Step-by-Step Guide Part II: Study Execution

In recent years, the use of national databases in orthopaedic surgery research has grown substantially with database studies comprising an estimated ∼10% of all published lower extremity arthroplasty research. The aim of this review is to serve as a guide on how to: (1) design; (2) execute; and (3) publish an orthopaedic database arthroplasty project. In part II, we discuss how to collect data, propose a novel checklist/standards for presenting orthopaedic database information (SOPOD), discuss methods for appropriate data interpretation/analysis, and summarize how to convert findings to a manuscript (providing a previously published example study). Data collection can be divided into two stages: baseline patient demographics and primary/secondary outcomes of interest. Our proposed SOPOD is more orthopaedic-centered and builds upon previous standards for observational studies from the EQUATOR network. There are a host of statistical methods available to analyze data to compare baseline demographics, primary/secondary outcomes, and reduce type 1 errors seen in large datasets. When drafting a manuscript, it is important to consider and discuss the limitations of database studies, including their retrospective nature, issues with coding/billing, differences in statistical versus clinical significance (or relevance), lack of surgery details (approach, laterality, and implants), and limited sampling or follow-up. We hope this paper will serve as a starting point for those interested in conducting lower extremity arthroplasty database studies.

A review of dexketoprofen trometamol in acute pain

OBJECTIVE

Dexketoprofen trometamol is a modified non-selective COX inhibitor with a rapid onset of action that is available as both oral and parenteral formulations. The aim of this narrative review was to assess the efficacy and tolerability/safety of dexketoprofen trometamol in acute pain states using the best available published scientific evidence (randomized controlled clinical trials and systematic reviews/meta-analyses).

METHODS

Literature retrieval was performed via Medline, Embase and the Cochrane Library (from inception up to March 2017) using combinations of the terms "randomized controlled trials", "dexketoprofen", "celecoxib", "etoricoxib", "parecoxib" and "acute pain".

RESULTS

Single-dose dexketoprofen trometamol provides effective analgesia in the treatment of acute pain, such as postoperative pain (dental and non-dental surgery), renal colic, acute musculoskeletal disorders and dysmenorrhea, and reduces opioid consumption in the postoperative setting. It has a rapid onset of action (within 30 minutes) and is well tolerated during short-term treatment. Direct comparisons with COX-2 inhibitors are lacking; however, the efficacy and tolerability of single-dose dexketoprofen trometamol appears to be consistent with that seen with celecoxib, etoricoxib and parecoxib in the acute pain setting.

CONCLUSION

In conclusion, dexketoprofen trometamol appears to provide similar analgesic efficacy to COX-2 inhibitors when used to treat acute pain, has a rapid onset of action, is well tolerated, and has an opioid-sparing effect when used as part of a multimodal regimen in the acute pain setting.

Pre-emptive Diclofenac Versus Ketoprofen as a Transdermal Drug Delivery System: How They Face

Aim

To compare the analgesic efficacy of Diclofenac vis-a-vis Ketoprofen transdermal patch, in the management of immediate post-operative pain following orthognathic procedures.

Material and Method

A prospective, double-blinded, randomised controlled study was conducted among 50 subjects, between 2012 and 2015. These patients were diagnosed clinically and cephalometrically as skeletal and dental class II malocclusion and underwent bi-jaw surgical procedure. In total, 25 Diclofenac and 25 Ketoprofen transdermal patches, sealed in envelopes and numbered, were administered to subjects. The patches used, contained 100 mg of either Diclofenac or Ketoprofen and administered by a nurse prior to induction. Duration of analgesia, severity of pain using Visual Analog Scale, necessity of rescue analgesia (spontaneous pain > 5 on a 10-cm scale) and any other adverse effect associated with the drug were evaluated.

Results

Mean duration of analgesia was significantly higher in the Ketoprofen group (20 h), compared to Diclofenac group (13 h) (p = 0.001). Rescue analgesia was required in 12% of subjects who received Diclofenac patch, compared to 4% in Ketoprofen group. None of the subjects showed any allergic reactions.

Conclusion

The study was designed to evaluate the efficacy of transdermal patch in reduction of post-operative pain in subjects undergoing bi-jaw surgeries. Subjects in both groups were comfortable and returned to early function. However, Ketoprofen transdermal patch had an edge over the Diclofenac transdermal patch with respect to analgesic efficacy.

TAP-block as a component of multimodal analgesia for postoperative anesthesia in obstetrics and gynecology

Postoperative pain relief is still quite actual problem in medicine, particularly in obstetrics and gynaecology. The most appropriate method of adequate post-operative anesthesia is multimodal analgesia. This article describes the features of multimodal analgesia using TAP-block combined with NSAIDs in obstetric and gynaecological patients, advantages and disadvantages of this combination and our own experience of applying this method in our clinic.

An in vitro investigation of genotoxic effects of dexketoprofen trometamol on healthy human lymphocytes

Non-steroidal anti-inflammatory drugs are drugs with analgesic, antipyretic, and anti-inflammatory effects. This study uses in vitro methods to investigate the potential and unknown genotoxic effects of dexketoprofen trometamol, an active substance in painkillers, on healthy human lymphocytes. In this study, a cytokinesis-block micronucleus cytome assay is used to investigate potential clastogenic, aneugenic activity and to identify chromosome breakages caused by the active drug substance dexketoprofen trometamol; a comet assay is performed to identify the genotoxic damage resulting from DNA single-strand breaks; a real-time reverse transcription polymerase chain reaction panel system is used to evaluate the potential negative effects on the expression of the genes responsible for DNA damage assessment. Dexketoprofen trometamol induces toxic effects in healthy human lymphocytes at concentrations of 750-1000 µg/mL and above, and shows clastogenic, aneugenic activity by inducing micronucleus formations at exposures of 750-500 µg/mL. At concentration intervals of 1000, 500, 250, 100 µg/mL, dexketoprofen trometamol also resulted in DNA damage in the form of strand breaks, as demonstrated by highly significant increases in DNA tail length and density comet parameters when compared to spontaneous values. Human lymphocytes exposed to 750-100 µg/mL dexketoprofen trometamol were found to have significantly increased levels of expression of the XPC, XRCC6, PNKP genes in the DNA damage signaling pathway. It can be concluded that dexketoprofen trometamol may have cytotoxic, cytostatic, genotoxic effects on healthy human lymphocytes in vitro, depending on the concentration and duration of exposure. It is anticipated that this outcome will be supported by advanced studies.

The Cerebrospinal Fluid Distribution of Postoperatively Administred Dexketoprofen and Etoricoxib and Their Effect on Pain and Inflammatory Markers in Patients Undergoing Hip Arthroplasty

BACKGROUND AND OBJECTIVE

Based on earlier literature, etoricoxib may have a delayed analgesic effect in postoperative setting when analgesic efficacy of nonselective nonsteroidal anti-inflammatory drug dexketoprofen is rapid. This may be caused by slow penetration of etoricoxib into the central nervous system (CNS). Therefore we decided to determine the plasma and cerebrospinal fluid (CSF) pharmacokinetics and pharmacodynamics of dexketoprofen and etoricoxib in patients with hip arthroplasty.

METHODS

A total of 24 patients, scheduled for an elective primary hip arthroplasty were enrolled. After surgery, 12 subjects were randomized to received a single intravenous dose of dexketoprofen, and 12 subjects were given oral etoricoxib. Paired blood and CSF samples were taken up to 24 h for measurement of drug concentrations, interleukin (IL)-6, IL-1ra and blood for interleukin 10.

RESULTS

In CSF the highest measured concentration (C max) of dexketoprofen was 4.0 (median) ng/mL (minimum-maximum 1.9-13.9) and time to the highest concentration (t max) 3 h (2-5), and for etoricoxib C max 73 ng/mL (36-127) and t max 5 h (1-24), respectively. Opioid consumption during the first 24 postoperative hours was similar in the two groups. Dexketoprofen and etoricoxib had a similar effect on the postoperative inflammatory response. No significant differences considering pain relief or adverse events were found between the two groups.

CONCLUSION

Dexketoprofen and etoricoxib entered the CNS readily, already at 30 min after administration dexketoprofen was detected in the CSF in most subjects and etoricoxib after 60 min. A single dose of dexketoprofen and etoricoxib provided a similar anti-inflammatory and analgesic response after major orthopaedic surgery.

Evaluation of the Analgesic Efficacy of Dexketoprofen Added to Paracetamol

OBJECTIVE

Multimodal analgesic methods are preferred for the treatment of postoperative pain; as a result, the additive effects of analgesics are provided while probable side effects are avoided. The current study aimed to compare the effects of the combination of dexketoprofen and paracetamol with regard to postoperative pain therapy.

METHODS

Ninety-six patients who underwent non-malignant gynaecological laparotomy operations were included in this study. Patients were randomized into 3 groups. Group D received 50 mg intravenous dexketoprofen 15 minutes before the end of the operation and 8 and 16 hours after the operation. Group P received 1 g intravenous paracetamol and Group DP received the combination of 500 mg paracetamol and 25 mg dexketoprofen at the same time intervals. All patients received morphine infusion after operation. Total morphine consumption at 24 hours, visual analog scale, patient satisfaction and side effects were investigated.

RESULTS

Comparison of the visual analog scale scores revealed that the Group DP presented lower scores at 24th hours compared to the other groups; and the difference between Group DP and Group D was statistically significant. Total morphine consumption was not significantly different between the three groups. The minimum number of side effects was observed in the Group DP.

CONCLUSION

Co-administration of paracetamol, dexketoprofen and morphine provided good analgesia and fewer side effects in gynaecological abdominal surgery.

A Dose-Finding Study of Dexketoprofen in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Clinical Trial on Effects on the Analgesic Concentration of Oxycodone

Background

Dexketoprofen has been shown to provide efficient analgesia and an opioid-sparing effect after orthopedic surgery. In this dose-finding study, we evaluated the analgesic efficacy and opioid-sparing effect of dexketoprofen administered intravenously (i.v.) after laparoscopic cholecystectomy (LCC).

Methods

Twenty-four patients undergoing LCC were randomized to receive dexketoprofen 10 or 50 mg i.v. 15 min before the end of the surgery. Subjects were provided with 0.2 mg/kg of oxycodone at anesthesia induction. In the recovery room, pain was assessed with an 11-point numerical rating scale (NRS; score of 0 = no pain, score of 10 = most severe pain) every 10 min. When the NRS score was ≥3/10 at rest or ≥5/10 at wound compression, a plasma sample was taken for analysis of oxycodone [to determine the minimum effective concentration (MEC)], its metabolites, and dexketoprofen. After that, subjects were titrated with oxycodone 2 or 3 mg i.v. every 10 min until the NRS score was <3/10 at rest and <5/10 at wound compression. At this point, a second plasma sample was taken for analysis of oxycodone [minimum effective analgesic concentration (MEAC)], its metabolites, and dexketoprofen.

Results

At the onset of pain, the plasma oxycodone concentrations (MEC) were similar in the two groups: median 60 ng/mL (range 37–73) in the 10 mg group and median 52 ng/mL (range 24–79) in the 50 mg group. At the time of pain relief, the MEACs were 98 ng/mL (range 59–150) in the 10 mg group and 80 ng/mL (range 45–128) in the 50 mg group. The total doses of oxycodone needed to achieve pain relief were similar: 0.11 mg/kg (range 0–0.33) in the 10 mg group and 0.08 mg/kg (range 0–0.24) in the 50 mg group. Eleven subjects developed mild desaturation or a decreased respiratory rate after oxycodone titration.

Conclusion

In the present double-blinded, randomized clinical trial, the need for a rescue opioid analgesic, oxycodone, was similar with the two dose levels of dexketoprofen—10 and 50 mg i.v.—after LCC.

Comparison of Clinical Effects of Dexketoprofen and Paracetamol Used for Analgesia in Endoscopic Retrograde Cholangiopancreatography

OBJECTIVE

This study aimed to compare 50 mg dexketoprofen vs. 1 g paracetamol that were parenterally administered before endoscopic retrograde cholangiopancreatography (ERCP) under sedoanalgesia with comparable anaesthesia depth regarding haemodynamic, pain, narcotic analgesic requirement, recovery and post-procedural cognitive functions.

METHODS

Overall, 80 ASA I-III patients aged 18-75 years who were undergoing scheduled ERCP were randomly assigned into three groups. In all patients, the mini-mental test (MMT) was conducted before the procedure. No drug was administered to controls (Group C; n=26); patients were transferred to ERCP unite 30 min after parenteral dexketoprofen (50 mg) in group D (n=27) and paracetamol (1 g) in group P (n=27). The standard monitoring was applied. After intravenously administering loading doses of midazolam (0.02 mgkg) and propofol (1 mg kg(-1)), propofol infusion was administered at a dose of 2-4 mg kg(-1) h(-1) to maintain a bispectral index value of 50-70. Fentanyl (0.05 μg kg(-1)) was intravenously administered when patients experienced pain. Haemodynamic effects, additional analgesic requirement, adverse effects during procedure, time to reach Aldrete score of 9 and satisfaction of an endoscopist and patient were recorded. MMT was repeated 3 h after completing the procedure.

RESULTS

Fentanyl requirement during the procedure was significantly low in group D (p<0.05). Apnoea during the procedure and nausea after the procedure were least common in group D while significantly lower than group C (p<0.05). There was no significant difference with respect to MMT scores and endoscopist's satisfaction, while patient satisfaction was greater in group P.

CONCLUSION

Parenterally administered dexketoprofen provided better haemodynamic effect and pain control, thereby decreasing incidence of adverse events by reducing the requirement for narcotic analgesics.

Postarthroscopy analgesia using intraarticular levobupivacaine and intravenous dexketoprofen trometamol

PURPOSE

The aim of this prospective study was to determine the efficacy of intraarticular levobupivacaine with and without intravenous dexketoprofen trometamol for postarthroscopy analgesia.

METHODS

Sixty patients who underwent arthroscopic knee surgery were randomly assigned to three treatment groups. When the surgical procedure was completed, patients received the following treatments: group I (n = 20) patients received 20 mL intraarticular normal saline and 2 mL intravenous dexketoprofen trometamol (50 mg); group II (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous normal saline; and group III (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous dexketoprofen trometamol (50 mg). The visual analogue scale (VAS) was used, and the total analgesic consumption was assessed at 1, 2, 4, 6, 12, and 24 h post-operatively.

RESULTS

The VAS scores at 1, 2, 4, 6, 12, and 24 h post-operatively were significantly increased in group I and group II compared with group III (p < 0.05). The average VAS score during the first 24 h post-operatively was significantly lower in group III than in group I and group II (p < 0.001). Total meperidine consumption was significantly lower in group III than in groups I and II (p < 0.001).

CONCLUSION

Intraarticular levobupivacaine with adjuvant intravenous dexketoprofen trometamol administration provided better pain relief and less analgesic requirement after arthroscopic knee surgery during the first 24 h than that induced by dexketoprofen alone or levobupivacaine intraarticular alone.

LEVEL OF EVIDENCE

II.

Comparing early postoperative period analgesic effect of dexketoprofene trometamol and lornoxicam in mediastinoscopy cases

OBJECTIVE

In this study, we aimed comparing early postoperative period analgesic effectiveness and the effects on opioid consumption of intravenous dexketoprofen and lornoxicam that are given preemptively.

MATERIALS AND METHODS

Forty patients, planned elective mediastinoscopy, were included in this prospective randomized study. These patients were classified in two groups, group D for dexketoprofene trometamol and group L for lornoxicam, randomly. 20 minutes before the operation 50 mg dexketoprofene trometamol and 8 mg lornoxicam were injected intravenously for group D and group L respectively. In postoperative intensive care unit, pain scores, mean arterial pressures, heart rates and peripheric O2 saturations of patients were recorded at 0, 10, 20, 60, 90 and 120(th) minutes.

RESULTS

When we evaluate the VAS score of the groups, there was a significant decrease in group D in all measured timesstatistically compairing to group L (p<0.001). When both group were evaluated in itself according to 0 minute time, in group L there was a significant decrease at 10 minutes time (p<0.0001) but in group D there was not a significant decrease (p>0.05).

CONCLUSION

Since intravenous dexketoprofen, applied preemptively, has more potent analgesic effect and causing less opioid consumption in early postoperative period, is better than intravenous lornoxicam.

A high initial VAS score and sedation afteriv morphine titration are associated with the need for rescue analgesia

PURPOSE

Administration of sc morphine has been recommended two hours after the end of iv morphine titration in the postanesthesia care unit (PACU), but in some cases patients complain of pain earlier than this. We assessed pain after the end of iv morphine titration and studied the characteristics of patients who needed rescue sc morphine.

METHODS

Postoperative pain was assessed using the visual analogue scale (VAS; 0 to 100) and the threshold required to administer morphine in the PACU was a score of 30. VAS was measured every 15 min up to two hours after the end of iv morphine titration. Patients were divided into two groups, those who required sc morphine before two hours and those who did not. Data are expressed as mean +/- SD or odds ratio (OR; 95% confidence interval).

RESULTS

Four hundred and two patients were analyzed. Mean age was 51 +/- 19 yr, initial VAS 69 +/- 19, and the dose of iv morphine 11.7 +/- 6.6 mg. The number of patients requiring sc morphine within two hours was 84 (21%). These patients had more severe initial postoperative pain (73 +/- 20 vs 68 +/- 19, P < 0.05), and experienced sedation more frequently during morphine titration (45 vs 25%, P < 0.001). Using a multivariate analysis, occurrence of sedation during titration [OR 2.3 (1.4-3.8), P < 0.001] and an initial pain score > or = 60 [OR 1.9 (1.0-3.4), P < 0.05] were significantly associated with the need for rescue sc morphine.

CONCLUSION

Sedation during titration and an initial VAS > or = 60 are characteristics of the patients who require rescue (less than two hours) sc morphine after iv morphine titration.

The determination of histopathological and biochemical effects of the rabbit knee joint injected dexketoprofen trometamol

This study was conducted to investigate possible histopathological effects and biochemical reflections of intra-articular dexketoprofen trometamol. A total of 24 New Zealand rabbits were included in the study. Blood sampling was carried out from all animals on the first day, then they were randomly allocated either to the control group (Group C, n = 9) or the dexketoprofen trometamol group (Group D, n = 15). Group C underwent each two intra-articular injections of saline, 0.25 mL into right and 0.50 mL into left knee. Group D was injected 0.25 mL (6.25 mg) dexketoprofen trometamol into the right knee and 0.50 mL (12.5 mg) into the left. The groups were divided randomly into three. Tissue and blood samples were collected from Groups C1 and D1 on the first day, C2 and D2 on the second day and C3 and D3 on the 10th day of the study. Interleukin-1 (IL-1β), interleukin-6 (IL-6), tumour necrosis factor-alpha (TNF-α) and C-reactive protein (CRP) levels were studied. The histopathological examination of C and D groups did not present any deterioration. IL-6 basal levels were significantly higher in Group D2 compared with C2 and C3 compared with D3. Basal TNF-α levels were higher compared with day 1 in Group C1, and IL-6 and CRP levels were higher in Group D3. Also, none of the increases in these values are supported by histopathological evaluation results. Consequently, we suppose that dexketoprofen trometamol does not cause histopathological deterioration in articular cartilage of rabbits, and the increases in biochemical parameters exclusively are not clinically significant.

Evaluation of the effects of dexketoprofen trometamol on knee joınt: an in vivo & in vitro study

BACKGROUND & OBJECTIVES

Intra-articular (ia) injections of local anaesthetics and non-steroidal anti-inflammatory drugs (NSAID's) are simple and efficient to ensure post-operative analgesia but some of these have toxic effects on the synovium and cartilage. Dexketoprofen is recently introduced S-enantiomer of ketoprofen with a better analgesic and side effect profile. This study was done to evaluate the possible toxic effects of dexketoprofen trometamol on knee joint cartilage and symovium in vitro and in vivo.

METHODS

Forty one Sprague-Dawley rats were anaesthetized by ketamine. Dexketoprofen trometamol (0.25 ml) was injected into the right knee joint of the 35 rats and 0.25 ml serum physiologic into the left knee joint of the same animals. Six rats were sham operated. Thirty five animals were randomly divided into five equal groups. Seven animals were sacrified at 24th, 48th hours and 7th, 14th, and 21 st days of the injections. Haematoxylin eosin stained sections from the knee joints were evaluated for the signs of inflammation according to five point scale. Primary chondrocytes were isolated from the articular cartilages of rats for in vitro studies. Cells were exposed to 0.25 ml dexketoprofen trometamol or 0.25 ml dexketoprofen medium mixture at 1:1 ratio for 15, 30, 45 and 60 min. Cell viability was determined by 3-(4, 5- dimethylthiazole-2-yl)-2.5-diphenyl tetrazolium bromide (MTT) assay, 24, 48 and 72 h after drug treatment.

RESULTS

No significant histopathologic differences were found between dexketoprofen trometamol and physiologic serum (control) applied joints at all time intervals in in vivo study. Cell proliferation in dexketoprofen trometamol treated chondrocytes was inhibited for all time intervals compared to control. In dexketoprofen-medium mixture groups significant differences were only seen 24 h after the 30 and 45 min application of medium: drug mixture.

INTERPRETATION & CONCLUSIONS

Intra-articular application of dexketoprofen trometamol into the rat knee joints did not cause significant histopathological changes, but its in vitro application in primary chondrocyte culture caused significant cytotoxicity. The effects of dexketoprofen at different concentrations need to be further investigated in culture of rat and human chondrocytes.

Regression of experimentally induced endometriosis with a new selective cyclooxygenase-2 enzyme inhibitor

BACKGROUND

Cyclooxygenase-2 (COX-2) levels increase in women with endometriosis. COX-2, via increasing prostaglandin E2, contributes to an increase in vascular endothelial growth factor. In this way, COX-2 may contribute to the progression and continuity of endometriosis. We investigated the effect of dexketoprofen trometamol, a new selective COX-2 enzyme inhibitor, on experimentally induced endometriotic cysts.

METHODS

Experimental endometriotic cysts were created in 60 adult female Wistar albino rats. The rats were randomized to 2 equal groups, a control (group Con) and a dexketoprofen (group Dex) group. Six weeks later, cyst volumes were measured as in vivo (volume 1). Following volume 1 measurement, for 4 weeks group Con received 0.1 ml distilled water; group Dex received 0.375 mg dexketoprofen trometamol/0.1 ml distilled water, intramuscularly, twice a day. At the end of administration, the cyst volumes were remeasured (volume 2), and the cysts totally excised and weighed. Glandular (GT) and stromal tissues (ST) and natural killer (NK) cell contents in the cyst wall were scored.

RESULTS

NK cell content and volume 1 were not different between the 2 groups. Volume 2, cyst weight, and GT and ST contents in group Dex were significantly lower than those in group Con.

CONCLUSION

Dexketoprofen trometamol significantly reduced the development of experimentally induced endometriotic cysts both macroscopically and microscopically.

Comparison of analgesic efficacy of intravenous Paracetamol and intravenous dexketoprofen trometamol in multimodal analgesia after hysterectomy

BACKGROUND

[corrected] We aimed to evaluate analgesic efficacy, opioid-sparing, and opioid-related adverse effects of intravenous paracetamol and intravenous dexketoprofen trometamol in combination with iv morphine after total abdominal hysterectomy.

MATERIALS AND METHODS

Sixty American Society of Anesthesiologist Physical Status Classification I-II patients scheduled for total abdominal hysterectomy were enrolled to this double-blinded, randomized, placebo controlled, and prospective study. Patients were divided into three groups as paracetamol, dexketoprofen trometamol, and placebo (0.9% NaCl) due to their post-operative analgesic usage. Intravenous patient controlled analgesia morphine was used as a rescue analgesic in all groups. Pain scores, hemodynamic parameters, morphine consumption, patient satisfaction, and side-effects were evaluated.

RESULTS

Visual Analog Scale (VAS) scores were not statistically significantly different among the groups in all evaluation times, but decrease in VAS scores was statistically significant after the evaluation at 12(th) h in all groups. Total morphine consumption (morphine concentration = 0.2 mg/ml) in group paracetamol (72.3 ± 38.0 ml) and dexketoprofen trometamol (69.3 ± 24.1 ml) was significantly lower than group placebo (129.3 ± 22.6 ml) (P < 0.001). Global satisfaction scores of the patients in group placebo was significantly lower than group dexketoprofen trometamol after surgery and the increase in global satisfaction score was significant only in group placebo.

CONCLUSION

Dexketoprofen trometamol and Paracetamol didn't cause significant change on pain scores, but increased patients' comfort. Although total morphine consumption was significantly decreased by both drugs, the incidence of nausea and vomiting were similar among the groups. According to results of the present study routine addition of dexketoprofen trometamol and paracetamol to patient controlled analgesia morphine after hysterectomies is not recommended.

The effect of preoperative intravenous dexketoprofen trometamol on postoperative pain in minor outpatient urologic surgery

OBJECTIVE

The aim of this prospective double-blind randomized study was to compare the effectiveness of preoperative dexketoprofen trometamol for acute postoperative pain in patients undergoing minor outpatient urologic surgery.

MATERIAL AND METHODS

Sixty male patients (ASA I and II) undergoing varicocelectomy and testicular sperm extraction (TESE) with standard laryngeal mask airway (LMA) anesthesia were randomly divided into two groups. Patients in Group I (n=30) received 50 mg of dexketoprofen trometamol iv before induction, whereas patients in Group II (n=30) received saline. All patients received standard LMA anesthesia (propofol, sevoflurane and N2O/O2). Analgesic efficacy was evaluated by self-assessment of pain intensity (VAS) at regular intervals. Vital signs, side effects and time to reach a postanesthesia discharge score (PADS) of ≥9 were also recorded. Paracetamol 1 gr iv and tramadol 100 mg iv were used for rescue analgesia.

RESULTS

Demographic data and duration of surgery were similar in both groups. There was no significant difference between groups with respect to postoperative pain scores and side effects. Although more patients in Group II (60%) required rescue analgesia compared to Group I (33.3%), the difference did not reach statistical significance.

CONCLUSION

Preoperative IV use of dexketoprofen trometamol iv did not decrease the need for rescue analgesia in patients undergoing minor outpatient urological surgery.

Effects of multimodal analgesia with LowDose buprenorphine and meloxicam on fecal glucocorticoid metabolites after surgery in New Zealand white rabbits (Oryctolagus cuniculus)

Despite the increasing use of rabbits as companion animals and models for biomedical research, rabbits have not been extensively studied to identify an efficacious postsurgical analgesic that does not cause systemic complications. The synergy of NSAID and systemic opioids is well-documented, and their combined use reduces the amount of either drug required for adequate analgesia. We measured fecal corticosterone metabolites (FCM) in rabbits after a minimally invasive vascular cut-down procedure. Rabbits received buprenorphine (0.03 mg/kg SC every 12 h for 3 d), meloxicam (0.2 mg/kg SC every 24 h for 3 d), buprenorphine-meloxicam (0.01 mg/kg-0.1 mg/kg SC every 24 h for 3 d), or a single dose of 0.5% bupivacaine (0.5 mL) infused locally at the incision site. By day 3 after surgery, buprenorphine, meloxicam, and bupivacaine groups showed elevated FCM levels, which continued to rise until day 7 and then gradually returned to baseline by day 28. In the buprenorphine-meloxicam group, FCM was relatively unchanged until day 3, when treatment was discontinued, and then began to rise. Rabbits in the buprenorphine-meloxicam group gained more weight over the 28-d study than did those in the other 3 treatment groups. This study shows that in rabbits low-dose buprenorphine administered with meloxicam effectively mitigates the FCM response that develops after surgery without the adverse effects associated with higher doses.

Ilioinguinal-iliohypogastric nerve block with intravenous dexketoprofen improves postoperative analgesia in abdominal hysterectomies

BACKGROUND AND OBJECTIVE

In this study, our aim was to evaluate the effects of intravenous dexketoprofen trometamol with ilioinguinal and iliohypogastric nerve block on analgesic quality and morphine consumption after total abdominal hysterectomy operations.

METHODS

We conducted this randomized controlled clinical study on 61 patients. The study was conducted in the operation room, post-anesthesia care unit, and inpatient clinic. We randomly grouped the 61 patients into control group (group C), block group (group B) and dexketoprofen-block group (group DB). Before the skin incision performed after anesthesia induction, we performed ilioinguinal iliohypogastric block (group C given saline and group P and DB given levobupivacaine). In contrast to group C and B, group DB was given dexketoprofen. We administered morphine analgesia to all patients by patient-controlled analgesia (PCA) during the postoperative 24 hours. We recorded Visual Analogue Scale (VAS), satisfaction scores, morphine consumption and side effects during postoperative 24 hours.

RESULTS

We found the DB group's VAS scores to be lower than the control group and block group's (p < 0.05) values at postoperative 1(st), 2(nd), 6(th) and 12(th) hours. VAS scores of group C were higher than of group B at postoperative first 2 hours. Time to first PCA demand was longer, morphine consumption values were lower and satisfaction scores were higher in group DB than in the other two groups (p < 0.05).

CONCLUSIONS

Ilioinguinal-iliohypogastric nerve block with IV dexketoprofen increases patient satisfaction by decreasing opioid consumption, increasing patient satisfaction, which suggests that dexketoprofen trometamol is an effective non-steroidal anti-inflammatory analgesic in postoperative analgesia.

Analgesic properties of dexketoprofen trometamol

SUMMARY Dexketoprofen trometamol is the dextrorotary enantiomer of the NSAID ketoprofen formulated as a tromethamine salt. The purpose of administering 50% of the racemic mixture is to keep the same analgesic and anti-inflammatory effect while reducing the adverse events due to both enantiomers. This article describes the pharmacological properties and evaluates the analgesic effects of dexketoprofen trometamol reported in acute and chronic pain conditions. The main conclusions are that dexketoprofen trometamol appears as effective as the double dose of the racemic drug. However, the reduction of adverse effects still has to be demonstrated. In addition, the formulation as tromethamine salt appears beneficial regarding fast onset of analgesia in acute pain conditions.

Efficacy and Tolerability of Intramuscular Dexketoprofen in Postoperative Pain Management following Hernia Repair Surgery

Objective. To evaluate the safety and efficacy of intramuscular dexketoprofen for postoperative pain in patients undergoing hernia surgery. Methodology. Total 202 patients received single intramuscular injection of dexketoprofen 50 mg or diclofenac 50 mg postoperatively. The pain intensity (PI) was self-evaluated by patients on VAS at baseline 1, 2, 4, 6, and 8 hours. The efficacy parameters were number of responders, difference in PI (PID) at 8 hours, sum of analogue of pain intensity differences (SAPID), and onset and duration of analgesia. Tolerability assessment was done by global evaluation and adverse events in each group. Results. Dexketoprofen showed superior efficacy in terms of number of responders (P = .007), PID at 8 hours (P = .02), and SAPID( 0-8 hours ) (P < .0001). It also showed faster onset of action (42 minutes) and longer duration of action (6.5 hours). The adverse events were comparable in both groups. Conclusion. Single dose of dexketoprofen trometamol 50 mg given intramuscularly provided faster, better, and longer duration of analgesia in postoperative patients of hernia repair surgery than diclofenac 50 mg, with comparable safety.

Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review

Non-opioid analgesics, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), or cyclo-oxygenase 2 (COX-2) inhibitors are often given along with morphine as part of multimodal analgesia after major surgery. We have undertaken a systematic review and a mixed treatment comparison (MTC) analysis in order to determine explicitly which class of non-opioid analgesic, paracetamol, NSAIDs, or COX-2 inhibitors is the most effective in reducing morphine consumption and morphine-related adverse effects. Sixty relevant studies were identified. The MTC found that when paracetamol, NSAIDs, or COX-2 inhibitors were added to patient-controlled analgesia (PCA) morphine, there was a statistically significant reduction in morphine consumption: paracetamol [mean difference (MD) -6.34 mg; 95% credibility interval (CrI) -9.02, -3.65], NSAIDs (MD -10.18; 95% CrI -11.65, -8.72), and COX-2 inhibitors (MD -10.92; 95% CrI -12.77, -9.08). There was a significant reduction in nausea and postoperative nausea and vomiting with NSAIDs compared with placebo (odds ratio 0.70; 95% CrI 0.53, 0.88) but not for paracetamol or COX-2 inhibitors, nor for NSAIDs compared with paracetamol or COX-2 inhibitors. There was no statistically significant difference in sedation between any intervention and comparator. On the basis of six trials (n=695), 2.4% of participants receiving an NSAID experienced surgical-related bleeding compared with 0.4% with placebo. The MTC found that there is a decrease in 24 h morphine consumption when paracetamol, NSAID, or COX-2 inhibitors are given in addition to PCA morphine after surgery, with no clear difference between them. Similarly, the benefits in terms of reduction in morphine-related adverse effects do not strongly favour one of the three non-opioid analgesics.

Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands

BACKGROUND

Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment.

METHODS

The percentages of 190 American [100 after hip open reduction and internal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with The Netherlands after operative fracture treatment.

RESULTS

Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 77% of American and none of the Dutch patients were prescribed narcotics (p < 0.001). The multivariate model including country accounted for 11% of the variation in inpatient narcotic prescription (p < 0.001), and the model including country and surgeon accounted for 55% of the variation in outpatient narcotic prescription (p < 0.001). Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 82% of American patients and 6% of Dutch patients were prescribed narcotics (p < 0.001). Predictors included country and surgeon and they accounted for 20% of the variation in inpatient narcotics prescription (p < 0.001) and 49% of the variation in outpatient narcotic prescription (p < 0.001).

CONCLUSIONS

American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures.

Systematic review of dexketoprofen in acute and chronic pain

BACKGROUND

Dexketoprofen, an NSAID used in the management of acute and chronic pains, is licensed in several countries but has not previously been the subjected of a systematic review. We used published and unpublished information from randomised clinical trials (RCTs) of dexketoprofen in painful conditions to assess evidence on efficacy and harm.

METHODS

PubMed and Cochrane Central were searched for RCTs of dexketoprofen for pain of any aetiology. Reference lists of retrieved articles and reviews were also searched. Menarini Group produced copies of published and unpublished studies (clinical trial reports). Data were abstracted into a standard form. For studies reporting results of single dose administration, the number of patients with at least 50% pain relief was derived and used to calculate the relative benefit (RB) and number-needed-to-treat (NNT) for one patient to achieve at least 50% pain relief compared with placebo.

RESULTS

Thirty-five trials were found in acute pain and chronic pain; 6,380 patients were included, 3,381 receiving dexketoprofen. Information from 16 trials (almost half the total patients) was obtained from clinical trial reports from previously unpublished trials or abstracts. Almost all of the trials were of short duration in acute conditions or recent onset pain.All 12 randomised trials that compared dexketoprofen (any dose) with placebo found dexketoprofen to be statistically superior. Five trials in postoperative pain yielded NNTs for 12.5 mg dexketoprofen of 3.5 (2.7 to 4.9), 25 mg dexketoprofen of 3.0 (2.4 to 3.9), and 50 mg dexketoprofen of 2.1 (1.5 to 3.5). In 29/30 active comparator trials, dexketoprofen at the dose used was at least equivalent in efficacy to comparator drugs. Adverse event withdrawal rates were low in postoperative pain and somewhat higher in trials of longer duration; no serious adverse events were reported.

CONCLUSION

Dexketoprofen was at least as effective as other NSAIDs and paracetamol/opioid combinations. While adverse event withdrawal was not different between dexketoprofen and comparator analgesics, the different conditions and comparators studies precluded any formal analysis. Exposure was limited, and no conclusions could be drawn about safety in terms of serious adverse events like gastrointestinal bleeding or cardiovascular events.

Neutropenia, thrombocytopenia and hepatic injury associated with dexketoprofen trometamol therapy in a previously healthy 35-year-old woman

This case report describes a previously healthy 35-year-old woman, with an episode of fever, neutropenia, thrombocytopenia and elevation of biochemical markers of liver injury, 10 days after beginning drug therapy with dexketoprofen trometamol. Infectious and autoimmune causes of neutropenia, and viral or autoimmune hepatitis were excluded. The resolution following withdrawal of dexketoprofen trometamol confirms the possibility of an adverse drug reaction.

Comparison of intravenous dexketoprofen and dipyrone in acute renal colic

OBJECTIVE

The aim of this study was to assess the efficacy and safety of a single intravenous (i.v.) bolus of dexketoprofen trometamol compared with an i.v. infusion of dipyrone in patients with moderate to severe pain due to renal colic.

METHODS

A total of 308 patients with renal colic and visual analog scale (VAS) score >/=40 mm participated in a multicenter, randomized, double blind, double-dummy, parallel, and active-controlled study and were randomized to dexketoprofen 25 mg (n = 101), dexketoprofen 50 mg (n = 104), and dipyrone 2 g (n = 103).

RESULTS

Mean [+/- standard deviation (SD)] total pain relief (TOTPAR) scores were similar in the dexketoprofen 50 mg (15.3 +/- 8.6) and dipyrone (15.5 +/- 8.6) and slighly higher than in dexketoprofen 25 mg (13.5 +/- 8.6), although significant differences were not achieved. In the same way, patients in the dexketoprofen 50 mg and dipyrone groups showed higher scores in the sum of pain intensity differences (SPID) and the sum of analogue pain intensity differences (SAPID) than patients in the dexketoprofen 25 mg group, reaching statistical significance in comparison with dexketoprofen 25 mg and dipyrone for SPID and SAPID (p < 0.05). The time-effect course for pain intensity differences and pain relief showed significantly higher values for both doses of dexketoprofen during the first 30 min after drug administration (p < 0.05). Dexketoprofen 50 mg and dipyrone groups had 66% and 70%, respectively, of patients with at least 50% of maximum obtainable TOTPAR in comparison with 56% in the dexketoprofen 25 mg group. The study medications were well tolerated.

CONCLUSIONS

Dexketoprofen 50 mg administered as a single i.v. bolus was effective for the relief of moderate to severe pain in patients with renal colic, with a good safety profile and efficacy similar to i.v. dipyrone 2 g. Dexketoprofen produced analgesia that was faster in onset.

A Multicentre, Randomised, Double-Blind Study Comparing the??Efficacy and Tolerability of Intramuscular Dexketoprofen versus Diclofenac in the Symptomatic Treatment of Acute Low Back Pain

BACKGROUND

Low back pain is an important medical problem in Western industrialised countries. NSAIDs are one of the main options for symptomatic pain relief in the early management of this painful condition. Dexketoprofen is an NSAID belonging to the arylpropionic acid group that has demonstrated good analgesic efficacy and a good safety profile in different acute and chronic painful conditions.

METHODS

A randomised, double-blind, parallel, active controlled, multicentre study that included 370 outpatients with acute low back pain was conducted to compare the analgesic efficacy of dexketoprofen 50mg twice daily versus diclofenac 75mg twice daily administered intramuscularly for 2 days. Efficacy outcomes were assessment of pain intensity (PI) measured on a visual analogue scale, total PI scores from baseline to 6 hours after the first-dose administration (primary efficacy endpoint; SAPID(0-6)), score on a physical disability scale using the Roland Disability Questionnaire (RDQ), and use of rescue medication. Tolerability and safety were also assessed as secondary variables.

RESULTS

The adjusted mean (SAPID(0-6)) scores were very similar, 117.3 mm/h with dexketoprofen and 114.7 mm/h with diclofenac. The adjusted ratio of means was 1.023 and the lower 95% confidence limit was 0.81, demonstrating non-inferiority of dexketoprofen (defined by a lower limit of the 95% CI >0.80) in comparison with diclofenac (per-protocol analysis). The median change in the RDQ was -6 points for both groups (p = 0.69), showing an overall improvement on the disability scale. No significant differences between groups were observed regarding the percentage of patients needing rescue medication or in the mean values of pain after repeated doses (SAPID(0-last)). Dexketoprofen was well tolerated, with a reported incidence of adverse events similar to that of diclofenac. No serious adverse events were reported in either treatment group.

CONCLUSION

From the results of this study it can be concluded that dexketoprofen 50mg administered twice daily intramuscularly provides a clinically relevant analgesic effect with good tolerability after single and repeated doses in patients with acute severe low back pain.

Comparison of the Efficacy and Safety of Intravenously Administered Dexketoprofen Trometamol and Ketoprofen in the Management of Pain after Orthopaedic Surgery

OBJECTIVE

This study aimed to evaluate the analgesic efficacy and tolerability of dexketoprofen trometamol, a nonsteroidal anti-inflammatory drug, in comparison with that of racemic ketoprofen (both administered by intravenous infusion), in patients with postoperative pain.

METHODS

This was a multicentre, randomised, double-blind, parallel-group study. 252 patients with moderate to severe pain following hip or knee replacement surgery performed under general anaesthesia were randomly assigned to receive either dexketoprofen trometamol 50 mg or ketoprofen 100 mg, both administered by intravenous infusion every 8 hours over 2 days. A level of > or =40 mm on a 100 mm visual analogue scale (VAS) for pain was required for inclusion in the study. Pain intensity on the VAS at different time-points after the administration of the first dose was assessed and the sum of pain intensity differences (SAPID(0-8 h)) was calculated as the primary efficacy variable. The use of rescue medication, maximum pain intensity difference (PID(max)), time to PID(max) and safety were also evaluated.

RESULTS

The mean (+/- SE) adjusted SAPID(0-8 h) scores in the per-protocol population were 310.9 +/- 19.2 and 326.3 +/- 19.0 mm x h after dexketoprofen trometamol and ketoprofen treatment, respectively. The 95% CI for the difference between treatments (-59.1 to 28.3) was fully included within the range of equivalence of +/-65.3 mm x h. There were no significant differences with regard to secondary variables. The need for rescue analgesia was high in both groups; 81.3% of patients receiving dexketoprofen trometamol treatment and 87.1% receiving ketoprofen treatment required rescue analgesia. The time to achieve PID(max) was 284.7 and 308.5 min after dexketoprofen and ketoprofen, respectively. Treatment- related adverse events were experienced by 16% of patients in the dexketoprofen trometamol group compared with 21.3% in the ketoprofen group. Most patients were concomitantly treated with low-molecular-weight heparin (94.4%), and no haemorrhagic events related to the surgical procedure were reported. No adverse events related to renal function were detected during the study.

CONCLUSION

The two medications were equivalent in terms of analgesic activity in the management of postoperative pain after orthopaedic surgery. The high use of rescue analgesics indicates a need for a multimodal approach to analgesia in this type of surgery. Dexketoprofen trometamol appeared to show a trend towards a better tolerability profile compared with the racemic compound.

Analgesic efficacy of diclofenac in combination with morphine and paracetamol after mastectomy and immediate breast reconstruction

BACKGROUND

Breast cancer treatment with mastectomy and immediate breast reconstruction (IBR) is associated with intense pain in the primary post-operative period. The present prospective, placebo-controlled and double-blind study aimed to evaluate the analgesic efficacy of diclofenac, a non-steroid anti-inflammatory drug (NSAID), in combination with paracetamol and opioids. This was done by 64-h assessment of post-operative pain intensity, opioid consumption, blood loss, nausea and tiredness.

METHODS

Fifty women selected for mastectomy and IBR with submuscular implants with or without axillary lymph node dissection (ALND) were randomized to receive diclofenac 50 mg x 3 or placebo rectally in addition to oral paracetamol and intravenous opioids delivered using a patient-controlled analgesia (PCA) technique.

RESULTS

During the first 20 h post-surgery, patients who received diclofenac experienced significantly less pain when resting than those who received placebo. When moving, a non-significant estimated difference in pain in favour of diclofenac was also noted. Opioid consumption during the first 6 h post-operatively was 34% less with diclofenac than with placebo. Means (SD) were 16.9 (10.3) mg and 25.6 (10.2) mg, respectively (P = 0.007). After 64 h, the difference was no longer statistically significant. Post-operative bleeding was significantly higher with diclofenac than with placebo (P < 0.01). Nausea and tiredness did not differ between the groups.

CONCLUSIONS

The addition of NSAID to paracetamol and opioid-PCA reduced opioid consumption and improved pain relief during the first 20 h at rest but was not convincingly effective during mobilization. Post-operative blood loss was higher with diclofenac.

Endogenous opiates and behavior: 2003

This paper is the 26th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2003 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).

β-Phenylethylamines and the isoquinoline alkaloids

This review covers beta-phenylethylamines and isoquinoline alkaloids derived from them, including further products of oxidation. condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2002 to June 2003 is reviewed, with 568 references cited.