Oral analgesia by non-steroidal anti-inflammatory drug zaltoprofen to manage cystoscopy-related pain: A prospective study

Population Pharmacokinetic Modeling of Zaltoprofen in Healthy Adults: Exploring the Dosage Regimen

Zaltoprofen is a drug used for various pain and inflammatory diseases. Scientific and quantitative dosage regimen studies regarding its clinical application are scarce. This study aimed to discover effective covariates related to interindividual pharmacokinetic variability through population pharmacokinetic modeling for zaltoprofen and to explore dosage regimens. The bioequivalence results of healthy Korean males, biochemical analysis, and CYP2C9 genotyping information were utilized in modeling. The established model has been sufficiently verified through a bootstrap, goodness-of-fit, visual predictive check, and normalized prediction distribution error. External data sets derived from the literature were used for further model validation. The final model could be used to verify the dosage regimen through multiple exposure simulations according to the numerical change of the selected covariates. Zaltoprofen pharmacokinetics could be explained by a two-compartment with a first-order absorption model. Creatinine clearance (CrCL) and albumin were identified as effective covariates related to interindividual zaltoprofen pharmacokinetic variability, and they had positive and negative correlations with clearance (CL/F), respectively. The differences in pharmacokinetics between individuals according to CYP2C9 genetic polymorphisms (*1/*1 and *1/*3) were not significant or valid covariates. The model simulation confirmed that zaltoprofen pharmacokinetics could significantly differ as the CrCL and albumin levels changed within the normal range. Steady-state plasma exposure to zaltoprofen was significantly reduced in the group with CrCL and albumin levels of 130 mL/min and 3.5 g/dL, respectively, suggesting that dose adjustment may be necessary. This study is useful to guide precision medicine of zaltoprofen and provides scientific quantitative judgment data for its clinical applications.

Pain reduction methods during transurethral cystoscopy

Transurethral cystoscopy (CS) is a common urological procedure, performed mostly for diagnostic but also for therapeutic purposes. Although CS is generally well tolerated, some patients describe the pain related to the procedure as high or even “unbearable”. As a result, many patients fear and avoid both primary and/or follow-up cystoscopies. This may lead to uncontrolled progression of neoplastic disease. Therefore, it is crucial to maximally increase the comfort of the patient and to implement safe and effective analgesia before the procedure. Providing the patients with appropriate care during CS can encourage them to comply with diagnostic schedules and improve their prognosis. The aim of this review is to analyze the available literature on various methods of pain reduction during transurethral CS. The PubMed electronic database limited to English articles published until January 2021 was used in the process. Meta-analyses, systematic reviews, randomized controlled trials, clinical trials, prospective randomized studies, multicenter comparisons, reviews and retrospective comparisons were used. As a result, 65 articles were included in this review.

Efficiency of intracavitary levobupivacaine infusion for pain management during cystoscopic procedures: A randomised study

AIM

This study evaluated the effect of intracavitary levobupivacaine infusion diluted with locally applied isotonic solution for pain control in cystoscopy.

METHODS

Included in this study are 100 patients who had previously undergone transurethral tumour resection for bladder tumour and were followed up by cystoscopy. The patients were randomised into five groups (n = 20). In the first, second, third, and fourth groups, 4, 6, 8, and 10 mL of levobupivacaine HCl (5.0 mg/mL) were mixed with 26, 24, 22, and 20 mL of isotonic solution, respectively. Hence, the total mixture was 30 mL for each group. The fifth group was the control group. In this group, the standard method commonly used in most clinics was utilised. That is, a gel containing Cathejell-2% lidocaine (25 mg lidocaine) was applied for local analgesia. Cystoscopic interventions were performed with a 17.5 Fr rigid cystoscope and 0°, 30°, and 70° lens. During cystoscopy and 30 min later, the pain status of patients was assessed using the Visual Analogue Scale (VAS) and patient satisfaction was questioned.

RESULTS

The mean VAS score during and after the cystoscopy procedure was significantly lower in the levobupivacaine groups compared with the lidocaine group. In addition, patient satisfaction in the levobupivacaine groups was significantly higher than in the lidocaine group. No drug-related side-effects were observed in all groups.

CONCLUSION

Thus, levobupivacaine is a more effective drug than lidocaine alone to control pain during cystoscopy. The use of levobupivacaine is recommended to prevent possible complications of general anaesthesia by eliminating the need for the aforementioned as well as its cost-saving advantage.

Is bladder tumour fulguration under local anaesthesia more painful than cystoscopy only?

Objectives: To prospectively register self-reported pain levels associated with office cystoscopy with or without bladder tumour biopsy and fulguration.Patients and methods: During a 15-month period, patients examined with cystoscopy under local anaesthesia graded their pain level using the Visual Analogue Scale (VAS). All patients were examined in the lithotomy position and lidocaine gel was used in all. A bladder instillation or a submucosal injection of lidocaine was given mainly in patients treated with extirpation of larger tumours.Results: The pain perception was graded by the patients as none (VAS = 0) or mild (VAS = 1-3) in 86% of the 1,314 cystoscopies. Fewer patients (65% out of 258) reported VAS 0-3 when cystoscopy with biopsy and fulguration of bladder tumour was performed. More than 97% of all patients stated that they would prefer treatment under local anaesthesia in the case of a future recurrence.Conclusion: The VAS-scores after diagnostic cystoscopy are in accordance with those previously reported, with the absolute majority reporting no or mild pain. Patients treated with extirpation of bladder tumours reported higher levels of pain but still within acceptable limits. This confirms the potential of treating most patients with small-sized bladder tumour recurrences under local anaesthesia.

A comparative experimental study of analgesic activity of a novel non-steroidal anti-inflammatory molecule - zaltoprofen, and a standard drug - piroxicam, using murine models

Purpose

Pain is an unpleasant sensation, but a protective mechanism of our body. It is the most common medical complaint requiring a visit to a physician. The new non-steroidal anti-inflammatory drug (NSAID) - zaltoprofen, is a preferential COX-2 inhibitor. It also inhibits bradykinin-induced nociceptive responses by blocking the B2 receptor-mediated pathway in the primary sensory neurons. The present study was conducted to evaluate and compare the anti-nociceptive activity of zaltoprofen with a conventional NSAID - piroxicam, in a mouse model of acute pain using hot plate and tail flick tests.

Materials and methods

Twenty-four adult Swiss albino mice (20-25 g) of either sex were used in this study. Oral zaltoprofen and piroxicam were used as test and standard drugs respectively. Anti-nociceptive activity was evaluated and compared using hot plate and tail flick tests.

Results

In comparison to the control group (vehicle), zaltoprofen showed a significant increase in reaction time at various time periods in the hot plate and tail flick tests. In the hot plate method, zaltoprofen groups (15 and 20 mg/kg) showed a significant elevation in pain threshold in comparison to control group (vehicle) (p<0.001). In the tail flick model also, zaltoprofen groups (15 and 20 mg/kg) showed a significant increase in the reaction time in comparison to control group (vehicle). In both the analgesiometer assays, zaltoprofen was found to be non-inferior compared to a standard drug - piroxicam (positive control).

Conclusion

Our study concludes that zaltoprofen is an effective analgesic agent in various pain models. Our results support that zaltoprofen has therapeutic potential for treating pain disorders and is non-inferior to a standard drug - piroxicam.

Anaesthesia of the posterior urethra and pain reduction during cystoscopy - a randomized controlled trial

Introduction

Standard intra-urethral instillation of anaesthetic gel may not sufficiently exclude pain perception during cystoscopy.

Aim

To evaluate the impact of the anaesthesia within the posterior urethra on pain intensity related to cystoscopy in men.

Material and methods

One hundred and twenty-seven men undergoing cystoscopy were prospectively enrolled in the study. Patients were randomly assigned to the experimental or control group (66 vs. 61 patients). Intra-urethral instillation of 2% lidocaine gel was done in both groups. In the experimental group, the posterior urethra was additionally anaesthetized with distribution of the lidocaine gel by catheterisation. The study endpoints were pain intensity at successive time points of the procedure assessed on a numeric rating scale, overall pain intensity assessed on a Likert scale, the need for analgesics during 6 h after the procedure, and the frequency of urinary tract infections (UTIs) during 14 days after the procedure.

Results

Pain perception during cystoscopy did not differ significantly between the two groups (p > 0.05). However, after 6 h patients in the experimental group were more likely to declare that the cystoscopy was painless (81.8% vs. 70.2%, relative risk = 1.17). The need for analgesics and the incidence of UTI were similar in both groups (p > 0.05). Statistically significant differences regarding pain perception were observed depending on patients’ age and the number of transurethral procedures performed in the past, with no relation to type of anaesthesia (p < 0.05).

Conclusions

Anaesthesia of the posterior urethra is not more efficacious in reducing pain related to cystoscopy than standard instillation of anaesthetic gel. However, it improves the general perception of the procedure, and hence may positively influence patients’ compliance.

Prospective evaluation of anxiety, pain, and embarrassment associated with cystoscopy and urodynamic testing in clinical practice

INTRODUCTION

We sought to prospectively assess anxiety, pain, and embarrassment associated with diagnostic cystoscopy and multi-channel urodynamic study (UDS).

METHODS

All consecutive patients undergoing diagnostic cystoscopy or UDS in our department over a period of nine months were asked to participate. Two anonymous auto-administered questionnaires were specifically designed to collect basic epidemiological data, document medical history, and assess the quality of information provided, along with prevalence and level (0-10 numerical visual analog rating scale) of anxiety, pain, and embarrassment experienced before and/or during the procedures. Statistical analysis was carried out to identify underlying factors that could have influenced patients' experience and ascertain potential correlations between anxiety, pain, and embarrassment.

RESULTS

101 and 185 patients were respectively evaluated immediately after cystoscopy and UDS. Multivariate analysis repeatedly showed statistical correlations between anxiety, pain, and embarrassment, with regard to prevalence and level of intensity in both cystoscopy and UDS populations. Males and young patients were more likely to present anxiety, pain, or embarrassment during cystoscopy and UDS. Interestingly, patients who reported having received complete information before cystoscopy were significantly more likely to experience anxiety (62.6% vs. 20.0%; p=0.009).

CONCLUSIONS

The present study demonstrated the major impact of gender and age on patients' experience. Interestingly, information provided before cystoscopy was reported to have a negative impact on patients' perception of anxiety; this could be partly prevented by optimizing the way information is provided to patients.

Effect of diclofenac suppository on pain control during flexible cystoscopy-A randomized controlled trial

TRIAL DESIGN: To compare the difference in pain score during flexible cystoscopy between patients undergoing the procedure with plain lubricating gel  only and plain gel with diclofenac suppository in a randomized control trial.

METHODS:  A total of 60 male patients with an indication of flexible cystoscopy were enrolled in a prospective, randomized controlled study. Patients were randomized in two groups. In group “A”, patients received diclofenac suppository one hour prior to the procedure while group “B” did not receive diclofenac suppository. Both groups received 10 ml of intra-urethral  plain gel for lubrication during flexible cystoscopy. Pain score was recorded immediately after the procedure using the visual analogue scale (VAS). Pre- and post-procedure pulse rate and systolic blood pressure was also recorded. Statistical analyses were performed using chi-square test and student t-test. Regression analysis was performed to address the confounding variables.

RESULTS: Both groups were comparable for variables including age, duration of procedure, level of operating surgeon and indication of procedure. Most common indication for flexible cystoscopy was removal of double J stent. There was a statistically significant difference in the mean pain score between two groups ( p = 0.012).  The difference in post-procedure mean pulse rate in the two groups was statistically significant ( p= 0.01) however there was no difference observed in mean post procedure systolic blood pressure. Regression analysis showed that none of the confounding variables were significantly affecting pain perception.

CONCLUSIONS: Intra rectal diclofenac suppository is simple and effective pre-emptive analgesia. We recommend its routine use during flexible cystoscopy for better pain control.

Efficacy of preprocedural diclofenac in men undergoing double J stent removal under local anesthesia: A double-blind, randomized control trial

Introduction:

Double J (DJ) stents are often removed under local anesthesia using a rigid cystoscope. Patients experience significant pain during this procedure and also continue to have discomfort during voiding for a few days. We assessed the efficacy and safety of preemptive oral diclofenac in pain relief in patients undergoing DJ stent removal (DJSR) by rigid cystoscopy compared to placebo.

Methods:

Consecutive consenting male patients undergoing DJSR under local anesthesia between March 2014 and July 2015 were enrolled. Patients were randomized to receive 75 mg oral diclofenac (Group A) or placebo (Group B) 1 h before procedure by double-blind randomization. Intraurethral 2% lignocaine gel (25 ml) was used in both groups. Pain during rigid cystoscopy, pain at the first void, and at 24 h after cystoscopy was assessed using visual analog scale (VAS) (0–100). Adverse reactions to diclofenac and episodes of acute urinary retention, if any, were assessed (Trial registered at clinicaltrials.gov: NCT02598102).

Results:

A total of 121 males (Group A [n = 62]; Group B [n = 59]) underwent stent removal. The median (Interquartile range) VAS during the procedure in Group A was 30 (30) and Group B was 60 (30) (P < 0.001), at first void was 30 (30) and 70 (30) (P < 0.001) and at 24 h postoperatively was 20 (20) and 40 (20) (P < 0.001). The incidence of epigastric pain, nausea, vomiting, and acute urinary retention was comparable in the two groups (P > 0.05).

Conclusions:

A single oral dose of diclofenac administered 1 h before DJSR using rigid cystoscope under intraurethral lignocaine anesthesia decreases pain significantly during and up to 24 h postprocedure with minimal side effects.

Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men

OBJECTIVE

To evaluate pain perception in men undergoing flexible or rigid diagnostic cystoscopy.

METHODS

This is a prospective multi-institutional analysis of men undergoing cystoscopy in 4 European departments of urology. Pain perception was assessed with an 11-point numeric rating scale. Pain categories were as follows: no (0 points), mild (1-3), moderate (4-6), and severe pain (7-10). Assessment of pain was before, during cystoscopy, and at days 1, 4, and 7 of follow-up.

RESULTS

A total of 300 cystoscopies were analyzed (150 rigid and 150 flexible). Men undergoing flexible cystoscopy were more frequently free of pain (58.7% vs 24%; P <.0001). Mild pain (54% vs 30.7%; P <.0001) and moderate pain (18.7% vs 9.3%; P = .02) were more common with rigid devices. No significant differences were prevalent in severe pain perception (3.3% vs 1.3%; P = .25). Patients, who had previous experience with cystoscopy reported similar pain levels as patients naïve to cystoscopy, regardless if rigid (P = .92) or flexible (P = .26) devices were used. Pain decreased to the baseline during the 1-week follow-up after both, flexible and rigid cystoscopy. In multivariate regression analyses, rigid cystoscopy was an independent predictor for not being pain free (odds ratio [OR] = 0.15; confidence interval [CI] = 0.08-0.28; P <.0001), for experiencing mild pain (OR = 2.57; CI = 1.57-4.19; P <.0001), and for moderate pain (OR = 2.39; CI = 1.13-5.07; P = .02). Severe pain was seldom with both devices, and thus, no statistical difference was found.

CONCLUSION

Flexible diagnostic cystoscopy caused less pain than rigid cystoscopy in men. Patient's previous experience with cystoscopy did not influence pain sensation. The type of cystoscope itself was identified as an independent risk factor of pain perception.

Is diagnostic cystoscopy painful? Analysis of 1,320 consecutive procedures

OBJECTIVE

To prospectively evaluate self-reported pain levels associated with diagnostic cystoscopy.

MATERIALS AND METHODS

Patients who underwent diagnostic cystoscopy and subsequently graded their pain level during the procedure were enrolled. Pain was graded on a Likert visual analog scale (VAS) of 1-10 where 0 = no pain and 10 = excruciating unbearable pain. Local lidocaine gel 2% was used as intraurethral lubricant.

RESULTS

Data from 1320 consecutive cystoscopies (929 males, 391 females, age range 15-93 years) between 6/2009-1/2010 were analyzed. This was the first cystoscopy for 814 patients. The overall mean VAS was 2.74 ± 1.51 (range 0-9) for rigid cystoscopy and 2.48 ± 1.53 (range 0-10) for flexible cystoscopy (P = 0.004). The reported mean pain level for first-time cystoscopy was significantly higher than that for repeat cystoscopy (2.8 ± 1.6 vs. 2.2 ± 1.4, P < 0.001), regardless of gender or type of cystoscope. Men reported significantly higher pain levels than women 2.6 ± 1.5 vs. 2.4 ± 1.4 (P < 0.04). The highest mean pain level was reported by men (3.4 ± 1.6) and women (2.5 ± 1.6) for rigid cystoscopy compared to flexible cystoscopy (2.5 ± 1.4 and 1.1 ± 1.9, respectively, P < 0.001). Pain levels > 5 were reported in 75 (5.7%) cystoscopies.

CONCLUSIONS

Cystoscopy was not associated with distressing levels of pain. Pain levels during first cystoscopies were higher than those for repeated ones. Using a flexible cystoscope is associated with a lower pain level in both men and women and it should be used for both genders.