Gastrointestinal blood loss in arthritic patients receiving chronic dosing with etodolac and piroxicam

A combination therapy of nanoethosomal piroxicam formulation along with iontophoresis as an anti-inflammatory transdermal delivery system for wound healing

Inflammation accounts as one of the major phases in wound healing, while prolonged and chronic inflammation may lead to adverse pathological conditions. Therefore, transdermal delivery of nonsteroidal anti-inflammatory (NSAIDs) such as encapsulated piroxicam into a nanocarrier seems to be promising. For the first time, a nanoethosomal piroxicam of <200 nm was prepared and combined with iontophoresis. Results showed that there was a critical point at the concentration of 5 mg lecithin with the smallest particle size. Besides, lecithin concentration had direct and inverse linear relationships with turbidity and pH of nanocarriers, respectively. Moreover, as there was no linear relationship between the lecithin concentration and particle size, the effect of lecithin concentration was dominant on turbidity compared with particle size. It seems that a pH higher than 5.5 disturbed the linear relationship of pH and entrapment efficacy percentage (EE%) while at the pH range of 4 to 5.5, the relationship was linear and EE% gradually decreased with increasing pH. These data showed that an optimised nanocarrier with special physicochemical properties is dominant to the just particle size. Besides, ex vivo permeation studies in rat skin showed that there was no significant difference between the permeation of free drug and ethosomal ones. However, iontophoresis significantly enhanced ethosomal piroxicam permeation compared with the free drug. Overall, these data emphasise the superiority of iontophoresis for the transdermal delivery of nanoethosomal medications while nanoethosomal delivery without iontophoresis did not show significant transdermal potential. To sum up, transdermal nanoethosomal piroxicam along with iontophoresis seems to be promising in wound healing.

Clinical use of etodolac for the treatment of lumbar disc herniation

This paper reports a non-comparative multicentre study designed to assess the usefulness of a non-steroidal anti-inflammatory agent--etodolac--for the treatment of lumbar disc herniation. The efficacy and safety of etodolac were evaluated based on the changes of symptoms and signs of the patients, including the following parameters: low back pain, leg pain and tingling, gait, the straight-leg-raising test, sensory disturbance, motor disturbance, restriction of activities of daily living (ADL), urinary bladder function, and patients' impressions at each hospital on the initial day, and at one week and two weeks after the start of administration of etodolac, in a total of 88 patients. The overall improvement was noted as a 'marked' in 5% and 13%, 'moderate' or better in 31% and 54%, 'slight' or better in 82% and 84%, 'no change' in 12% and 9%, and 'aggravated' in 6% and 7%, at one and two weeks after administration, respectively. The only adverse drug reaction reported was stomach pain in one of the 81 patients. It can be concluded that etodolac is an effective and well-tolerated non-steroidal anti-inflammatory agent in the treatment of lumbar disc herniation.

Double-blind, placebo-controlled comparison of the safety and efficacy of orally administered etodolac and nabumetone in patients with active osteoarthritis of the knee

This 4-week, randomized, double-blind, double-dummy, placebo-controlled, parallel-group, multicenter study was designed to compare the efficacy and safety of etodolac and nabumetone in the treatment of patients with active osteoarthritis (OA) of the knee. Ninety-one patients received etodolac 400 mg twice daily, 89 received nabumetone 1500 mg once daily, and 90 received placebo. Both active treatments significantly improved the patients' condition relative to baseline (P < or = 0.001) at all evaluations during treatment and relative to placebo (P < or = 0.05) by visit 4. Improvement relative to placebo in investigator's global assessments was earlier in the etodolac group (ie, by visit 3) than in the nabumetone group. At visit 4, improvement in investigator's and patient's global assessment scores, and in the distribution of investigator's assessment scores, was significantly (P < or = 0.05) greater in the etodolac group than in the nabumetone group. Other than hypokalemia, which occurred only in three patients in the nabumetone group (P = 0.035), there were no significant differences among the groups in the frequency of study events or premature discontinuation from the study as a result of study events. Study events considered at least possibly treatment related were reported for 26 patients in the etodolac group (28.6%), 20 in the nabumetone group (22.5%), and 23 in the placebo group (25.6%). The most frequently reported symptoms for all groups were dyspepsia, nausea, and headache. Four patients treated with nabumetone (4.5%) had elevations in aspartate aminotransferase or alanine aminotransferase during treatment. The results of this study show that etodolac 400 mg twice daily is at least as effective as nabumetone 1500 mg once daily and is equally well tolerated in the treatment of patients with active OA of the knee; etodolac may have an earlier onset of action and/or a relatively greater efficacy in patient and investigator global assessments than nabumetone.

Worldwide experience with etodolac (Lodine) 300 mg b.i.d. in the treatment of osteoarthritis

Worldwide experience with the conventional formulation of etodolac (300 mg b.i.d.) was reviewed in 12 randomized, double-blind, parallel-group studies in patients with osteoarthritis (OA) of the hip or knee. The studies were conducted in 13 countries at 59 sites, and 1289 patients were enrolled. The results of 9 comparative and 3 placebo-controlled clinical studies were examined to compare the efficacy and safety of etodolac versus piroxicam, naproxen, indomethacin, indomethacin sustained-release (SR), and diclofenac SR. Efficacy assessments were made at pretreatment screening, baseline, and every 2 weeks thereafter during treatment until study completion up to 4, 6, or 8 weeks. The primary efficacy assessments were the patient's and physician's global evaluations, pain intensity and night pain, or joint tenderness and walking pain. Safety was assessed with reference to study events, reports of laboratory results, and vital signs measurements. Patients in all active treatment groups showed prompt response to therapy. According to the physicians' global evaluation, at least 64% of all etodolac-treated patients and 62% of all active-reference preparation-treated patients had improved by the end of the study. Similar results were seen in the patients' global evaluation. All of the study drugs were well tolerated. Eight (8%) percent of the etodolac-treated patients withdrew because of study events. The proportions of patients treated with active reference preparations and placebos who withdrew because of study events ranged from 3% to 18%.(ABSTRACT TRUNCATED AT 250 WORDS)

The safety profile of sustained-release etodolac

The safety profile of a new sustained-release (SR) form of etodolac was evaluated in 539 young and elderly patients with osteoarthritis or rheumatoid arthritis. Four long-term, open-label studies were conducted in nine different countries totaling 3,827 patient-months' exposure to etodolac SR. Patients were treated with either 400 mg or 600 mg etodolac SR once a day for up to 52 weeks. Withdrawals due to adverse reactions were low, occurring in only 5% (26/539) of all patients. The most common drug-related study events were GI-related, occurring in < 8% of patients. Elderly persons (> or = 65 years of age) were not at greater risk for adverse reactions or drug-related study events than were younger patients. Serious GI-related study events were rare (0.2%). The low level of serious GI effects was consistent with a separate study measuring gastrointestinal (GI) blood loss. Etodolac SR produced significantly less GI blood loss than naproxen in normal subjects. Because of its favorable safety profile, etodolac SR can serve as an alternative to conventional etodolac, providing the convenience of once-daily administration.

Drug treatment of arthritis. Update on conventional and less conventional methods

Nonsteroidal anti-inflammatory drugs comprise an important class of medications that reduce the signs and symptoms of osteoarthritis and rheumatoid arthritis. They bring relief to millions of people but do not eliminate underlying disease. Disease-modifying antirheumatic drugs also bring relief, but these drugs are often ineffective and not well tolerated. Failure to provide long-term benefits combined with the high toxicity of most of the disease-modifying agents has prompted a search for more effective treatments. New methods using modern technologies have generated much enthusiasm and hold promise for the future. In the meantime, administration of nonsteroidal anti-inflammatory drugs and judicious use of disease-modifying agents remain the cornerstone of therapy for arthritis.

Double-blind comparison of etodolac SR and diclofenac SR in the treatment of patients with degenerative joint disease of the knee

An on-going multi-centre, double-blind, parallel-group study is being carried out to compare the efficacy and tolerability of sustained-release (SR) formulations of etodolac and diclofenac in patients with degenerative joint disease (osteoarthritis) of the knee. An interim analysis of the findings has been made for 64 patients from two centres which have now completed their part in the study. Thirty-two patients were randomly assigned to receive 600 mg etodolac SR once daily for 4 weeks; the remaining 32 patients received 100 mg diclofenac SR. Primary efficacy assessments rated on a 5-point categorical scale were patient and physician overall assessments of the patient's condition, night pain and pain intensity. Secondary efficacy parameters included weight-bearing pain, stiffness duration, joint tenderness on pressure, degree of swelling and erythema, degree of knee flexion and time to walk 15 metres. The results showed that for both etodolac SR and diclofenac SR treatment groups there was an improvement from baseline in all efficacy parameters at the last visit and no statistically significant difference was observed between treatments. However, although not statistically significant, the improvement rate in the patient's condition at Week 2 was slightly greater in the etodolac SR treatment group, suggesting that improvement may occur more rapidly with etodolac SR than with diclofenac SR. With regard to tolerability, 5 patients in the etodolac SR treatment group and 3 in the diclofenac SR group withdrew from the study because of adverse reactions. Two events (dyspepsia and mouth ulceration) in the etodolac SR group and 4 events (headache, glossitis, depression and insomnia) in the diclofenac SR group were considered to be definitely drug-related. Dyspepsia was reported by 3 patients (1 withdrawal) treated with etodolac SR and by 4 patients (2 withdrawals) treated with diclofenac SR. A statistically significant decrease was observed in haemoglobin and haematocrit values after 4 weeks of treatment in the diclofenac SR group, but this was not considered to be clinically important. In addition, there were no clinically significant changes in blood chemistry and urinalysis for either treatments. In conclusion, the results of the present study indicate that 600 mg etodolac SR once daily for 4 weeks is effective in the treatment of patients with degenerative joint disease of the knee, as is 100 mg diclofenac SR. In addition, both drugs have comparable tolerability profiles.

Comparison of the effects of etodolac SR and naproxen on gastro-intestinal blood loss

A single-blind, open-label controlled study was carried out in 30 healthy male volunteers to compare gastro-intestinal blood loss before, during and after treatment with a new, sustained-release formulation of the non-steroidal anti-inflammatory agent etodolac (etodolac SR) or with naproxen. Subjects remained at the study centre for 21 days and received placebo twice daily from Days 1 to 7 after which they were assigned at random to receive etodolac SR either as a single 600 mg or 1200 mg daily dose or naproxen (500 mg twice daily) for 7 days and then placebo again until the end of the study. There were 10 subjects in each of the three treatment groups. Gastro-intestinal blood loss was measured by the 51Cr-tagged erythrocyte method and was averaged for Days 4 to 7 (pre-treatment baseline), Days 11 to 14 (treatment period), and Days 17 to 20 (post-treatment period). The mean daily gastro-intestinal blood loss during the treatment period was significantly greater for the naproxen-treated group (1.20 ml/day) than for the 600 mg etodolac SR group (0.38 ml/day) and the 1200 mg etodolac SR group (0.45 ml/day). These results show that etodolac SR in doses of 600 mg and 1200 mg/day causes significantly less gastro-intestinal blood loss than does naproxen 500 mg twice daily.

Etodolac. A reappraisal of its pharmacology and therapeutic use in rheumatic diseases and pain states

Etodolac is a nonsteroidal anti-inflammatory drug (NSAID) effective in the treatment of rheumatoid arthritis, osteoarthritis and ankylosing spondylitis, and in the alleviation of postoperative pain. Etodolac also provides relief of other types of pain, including that arising from gouty conditions and traumatic injury. In all indications, etodolac appears to be at least as effective as other NSAIDs. The incidence of clinical adverse effects other than abdominal pain and dyspepsia is similar to that observed with placebo, and etodolac has been associated with a low rate of gastrointestinal ulceration and other serious events. Data from preliminary animal studies have suggested that etodolac may provide more selective inhibition of prostaglandin synthesis at sites of inflammation than some other currently available NSAIDs. Thus, available evidence indicates that etodolac, with its low incidence of gastrointestinal events, is an effective and well tolerated alternative to other NSAIDs in the treatment of arthritic diseases and pain of various aetiologies and should be considered a first-line therapy.

A double-blind gastroscopic evaluation of the effects of etodolac and naproxen on the gastrointestinal mucosa of rheumatic patients

The aim of this clinical, endoscopical study was to evaluate the therapeutic efficacy and the gastric tolerability of etodolac, a new anti-inflammatory, non-steroidal drug, compared with naproxen. The study was conducted on 48 patients suffering from rheumatoid arthritis. 44 of whom completed the trial. After an initial oesophagogastroduodenoscopy to exclude the presence of gastric mucosal lesions, patients were randomly allocated to double-blind treatment with either etodolac 200 mg b.i.d. or naproxen 500 mg b.i.d. for a period of 4 weeks. Endoscopic control followed this treatment period. Both drugs proved effective in relieving clinical symptoms, without a statistically significant difference. Gastric mucosal lesions were observed in 15% of etodolac-treated patients and in 46% of patients treated with naproxen (P less than 0.05) (95% CI 0.01-0.60). Painful dyspepsia was observed in 15% of patients treated with etodolac vs. 38% of patients on naproxen therapy. This study demonstrates that etodolac is at least as active as naproxen in relieving rheumatic symptoms, and its administration results in a significantly lower degree of gastric damage.

Double-blind comparison of etodolac and piroxicam in patients with rheumatoid arthritis

A study was carried out to compare the efficacy and tolerability of etodolac and piroxicam in patients with rheumatoid arthritis. Sixty patients entered this double-blind, parallel study and after a wash-out period of up to 2 weeks were randomly assigned to receive 200 mg etodolac twice daily or 20 mg piroxicam once daily for 12 weeks. Efficacy and tolerability assessments were made after 2, 4, 6, 8 and 12 weeks. Patients in the etodolac group demonstrated statistically significant improvement in the number of tender joints and the duration of morning stiffness after 12 weeks, as did the piroxicam-treated patients. In addition, the etodolac-treated patients had significant improvement according to the patients' and physician's global evaluations, pain intensity, number of swollen joints, and grip strength. There were significant differences between therapies favouring etodolac for the assessments of the number of tender joints and the physician's global evaluation by the end of the study. Forty-seven percent (47%) of 15 etodolac-treated patients compared with 7% of 15 piroxicam-treated patients showed improvement according to the physician's global evaluation at Week 12. Similarly, the patients' global evaluation showed that 40% of etodolac-treated patients and 19% of piroxicam-treated patients had improved by the end of therapy. Both therapies were well tolerated. There were no significant differences between groups in the incidence of any adverse reactions or the frequency of withdrawals.

Lornoxicam, indomethacin and placebo: comparison of effects on faecal blood loss and upper gastrointestinal endoscopic appearances in healthy men

Forty-five healthy men aged 21-34 years took part in a double-blind, parallel-group, placebo-controlled study of the effects of 28 days' treatment with lornoxicam 4 mg twice daily or indomethacin 50 mg twice daily on faecal blood loss and the endoscopic appearances of gastric and duodenal mucosa. After an initial endoscopic examination, subjects received, intravenously, on day 0, autologous erythrocytes labelled with 51Cr. Complete daily faecal collections were then made from days 6-12, 20-26 and 34-40. The drug treatments or placebo were given from days 13-41. Faecal blood loss was calculated from 51Cr-specific activity of blood and faeces. Endoscopy was repeated 4-8 hours after the last dose of medication; mucosal appearance was graded on a 5-point scale. Lornoxicam caused no more adverse events than placebo; indomethacin caused more indigestion and central nervous system effects, and one subject in this group was withdrawn from the study. Median total blood losses during the pre-treatment and the second and fourth weeks of treatment were respectively 3.33, 3.95 and 5.71 ml for lornoxicam, 2.87, 7.04 and 7.75 ml for indomethacin, and 4.55, 3.64 and 4.13 ml for placebo. Differences between treatments were not statistically significant (P = 0.081 for second week of treatment, P = 0.383 for fourth week of treatment; Kruskal-Wallis test). The effect of chlortenoxicam on faecal blood loss in this study was thus intermediate between placebo and indomethacin, but within- and between-subject variability was such that the differences were not statistically significant. Endoscopic findings were normal in most subjects before and after all treatments, but indomethacin was associated with a slightly greater deterioration in endoscopic score and was the only treatment associated with Grade 3 appearance (in a single patient) in post-treatment endoscopy.

International experience with etodolac therapy for rheumatoid arthritis: an interim report of comparative efficacy

Etodolac, a nonsteroidal anti-inflammatory drug (NSAID) of the pyranocarboxylic acid family, has been tested in international clinical trials as a therapy for rheumatoid arthritis (RA). Preliminary results of 8- to 12-week double-blind trials indicate that etodolac therapy (200 mg twice a day) compared favorably with piroxicam therapy (20 mg once a day) and diclofenac therapy (50 mg three times a day) as measured by improvement in scores of five efficacy assessments: number of painful joints, number of swollen joints, physician's global assessment, patient's global assessment, and pain intensity. Etodolac also was as effective as naproxen (500 mg twice a day) as measured by improvement in scores in the five efficacy assessments. The observation that etodolac is as efficacious as three commonly used NSAIDs should interest clinicians who attempt to tailor NSAID therapy to the needs of individual RA patients, since etodolac has previously demonstrated an excellent safety profile. However, these trials must be completed to verify these preliminary results in a greater number of patients.

Theoretical mechanism for the gastrointestinal safety of etodolac: selective sparing of cytoprotective prostaglandins

The high concentrations of pro-inflammatory prostaglandins (PGs) produced in the joint during the initial stage of inflammation can be decreased by inhibiting their biosynthesis with nonsteroidal anti-inflammatory drugs (NSAIDs). The commonly encountered gastrointestinal intolerance in human subjects treated with NSAIDs is generally attributed to inhibition of PG synthesis in gastric mucosa, where the natural role of locally biosynthesized PGs is to protect the mucosa from necrosis upon exposure to noxious agents. The action of an ideal NSAID should therefore be tissue specific, i.e., it should inhibit PG formation at the sites of inflammation but not in gastric mucosa, where PGs are needed for cytoprotection. We believe that etodolac, a new, structurally distinct NSAID, meets this criterion, inhibiting PG synthesis in a tissue-specific fashion. Experimental data supporting this interpretation were obtained in rats by demonstrating that daily administration of orally effective anti-inflammatory doses of etodolac had no significant effect on gastric mucosal PGE2 or prostacyclin levels (measured as the stable metabolite, 6-keto-PGF1 alpha). In contrast, naproxen, piroxicam, and aspirin caused a statistically significant PG depletion. The results obtained in rats thus support the view that the favorable gastrointestinal safety profile of etodolac in human patients may be attributable to selective sparing of the cytoprotective PGs in gastric mucosa.

Etodolac, a new nonsteroidal anti-inflammatory drug: gastrointestinal microbleeding and endoscopic studies

A review of the literature is presented on the gastrointestinal effects of etodolac, a new nonsteroidal anti-inflammatory drug (NSAID), as evaluated in both microbleeding and endoscopic studies. In four microbleeding studies, gastrointestinal blood loss in healthy subjects was estimated by a 51Cr-erythrocyte labeling method before drug treatment, after 7 days of treatment with NSAIDs including etodolac, and 1 week after the last day of treatment. In these 7-day studies, the gastrointestinal blood loss seen with etodolac (600 to 1200 mg/day) was similar to that seen with placebo and significantly (p less than 0.05) less than that seen with aspirin (2600 mg/day), naproxen (750 mg/day), ibuprofen (2400 mg/day), or indomethacin (200 mg/day). Naproxen, ibuprofen, and indomethacin caused mean daily blood losses in excess of 1 ml/day over baseline values. The increase with aspirin was 4 to 5 ml/day. In contrast, the greatest mean daily increase in blood loss with etodolac therapy was 0.2 ml. In a 4-week study of etodolac (600 and 1000 mg/day) and piroxicam (20 mg/day) given to patients with osteoarthritis or rheumatoid arthritis, blood loss seen with etodolac was comparable to that seen with placebo and significantly less than that seen with piroxicam. Gastrointestinal irritation was also assessed by endoscopy after 1 week of NSAID or placebo treatment. Endoscopy scores after etodolac treatment (up to 1200 mg/day) were similar to scores at baseline and after placebo and were significantly lower than scores following treatment with aspirin (3900 mg/day), indomethacin (200 mg/day), ibuprofen (2400 mg/day), or naproxen (100 mg/day). The effects of etodolac (600 or 1000 mg/day) and diclofenac (150 mg/day) were not different from each other or from baseline. These data indicate that etodolac, in these studies, did not cause clinically significant gastrointestinal microbleeding or visible gastric injury. By the criteria used in these studies, etodolac is less irritating to the gastrointestinal tract than aspirin, indomethacin, ibuprofen, naproxen, or piroxicam, and compares favorably with diclofenac.

A review of the antiarthritic efficacy and safety of etodolac

Etodolac (Lodine, Ramodar, Ultradol), an anti-inflammatory, analgesic agent, is the first of a new class of nonsteroidal anti-inflammatory drugs (NSAIDs), the pyranocarboxylic acids. A review of the literature on numerous clinical studies showed that etodolac (200 to 600 mg/day) is effective in the treatment of osteoarthritis and rheumatoid arthritis. Etodolac has also been shown to be very well tolerated. In double-blind studies, there were no significant differences in the incidences of new patient complaints except for indigestion between etodolac-treated groups and placebo-treated groups. Gastrointestinal microbleeding associated with etodolac was comparable to that with placebo and was significantly less than that associated with other commonly used NSAIDs, such as ibuprofen, indomethacin, piroxicam, and naproxen. The results of laboratory tests, including a detailed analysis of hepatic and renal function, have revealed few abnormalities, most of which were clinically unimportant. When administered to healthy subjects, etodolac had no pharmacokinetic interactions with three other drugs that are highly bound to serum protein: warfarin, glyburide, and phenytoin.