Nimesulide in the treatment of patients intolerant of aspirin and other NSAIDs

Current complications and treatment of aspirin-exacerbated respiratory disease

INTRODUCTION

Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.

Use of nonsteroidal anti-inflammatory drugs in patients with aspirin hypersensitivity : safety of cyclo-oxygenase-2 inhibitors

This article provides information on the pathogenesis of aspirin hypersensitivity, cross-sensitivity, and cross-tolerance of different NSAIDs in patients with respiratory types of reactions. Hypersensitivity to aspirin may affect 5-20% of patients with chronic asthma and an unknown fraction of patients with chronic urticaria-angioedema. These patients develop cross-reactions to other, chemically non-related, NSAIDs with strong inhibitory activity towards cyclo-oxygenase (COX)-1 (e.g. indomethacin, naproxen, ketoprofen). Avoidance of aspirin and all cross-reacting NSAIDs as well as education of patients are crucial. As an alternative antipyretic or analgesic drug, aspirin-sensitive asthmatic patients may take acetaminophen (paracetamol) in low or moderate doses (<1000mg). Preferential COX-2 inhibitors (nimesulide, meloxicam) are tolerated by the majority but not all hypersensitive patients. Selective COX-2 inhibitors (celecoxib and rofecoxib [withdrawn from the market]) are well tolerated by almost all aspirin-sensitive asthmatic patients. In patients with coronary artery disease requiring treatment with aspirin, desensitization to aspirin may be an alternative approach. Thus, for the majority of patients with asthma and hypersensitivity to aspirin or other NSAIDs, an alternative anti-inflammatory drug can be found. However, in each individual case physicians must consider the choice of an alternative NSAID carefully.

Are drug provocation tests still necessary to test the safety of COX-2 inhibitors in patients with cross-reactive NSAID hypersensitivity?

BACKGROUND

COX-2 inhibitors are safe alternatives in patients with cross-reactive non-steroidal anti-inflammatory drug (NSAID) hypersensitivity. These drugs are recommended to these patients after negative drug provocation tests (DPTs). However, cumulative data on encouraging results about the safety of COX-2 inhibitors in the majority of these patients bring the idea as to whether a DPT is always mandatory for introducing these drugs in all patients with cross-reactive NSAID hypersensitivity.

OBJECTIVE

To document the safety of COX-2 inhibitors currently available and to check whether or not any factor predicts a positive response.

METHODS

This study included the retrospective analysis of cases with cross-reactive NSAID hypersensitivity who underwent DPTs with COX-2 inhibitors in order to find safe alternatives. DPTs were single-blinded and placebo controlled.

RESULTS

The study group consisted of 309 patients. COX-2 inhibitors were well tolerated in the majority of the patients [nimesulide: 91.9%; meloxicam: 90.2%; rofecoxib: 94.9%; and celecoxib: 94.9%)]. Twenty-five patients (30 provocations) reacted to COX-2 inhibitors. None of the factors were found be associated with positive response.

CONCLUSION

Our results suggest to follow the traditional DPT method to introduce COX-2 inhibitors for finding safe alternatives in all patients with cross-reactive NSAID hypersensitivity before prescription as uncertainty of any predictive factor for a positive response continues. However, these tests should be performed in hospital settings in which emergency equipment and experienced personnel are available.

Safety of high-dose rofecoxib in patients with aspirin-exacerbated respiratory disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is characterized by progressive sinusitis, nasal polyposis, and asthma that begins and continues in the absence of exposure to aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Cross-sensitivity to all NSAIDs that inhibit cyclooxygenase-1 (COX-1) occurs in these individuals. Reactions to aspirin and NSAIDs in patients with AERD are largely due to inhibition of COX-1. Despite accumulating data on the safety of COX-2 selective inhibitors in AERD, concern still remains that high doses of a COX-2 inhibitor may be sufficient to induce a cross-reaction.

OBJECTIVE

To determine whether high-dose rofecoxib cross-reacts in patients with AERD and asthma.

METHODS

Sixty asthmatic patients underwent blinded placebo-controlled oral challenges with 50 mg of rofecoxib. Aspirin sensitivity was subsequently confirmed in all patients with the use of single-blinded aspirin challenges.

RESULTS

None of the 60 patients experienced any symptoms, changes in nasal examination results, or declines in lung function during rofecoxib challenge. All 60 patients experienced respiratory reactions to aspirin challenge, with a mean provoking dose of 57 mg. The exact 1-sided 95% confidence interval for the underlying probability of 50 mg of rofecoxib inducing respiratory cross-reactions in patients with AERD is 0 to 0.05, or 0% to 5%.

CONCLUSIONS

These results confirm the lack of cross-reactivity of aspirin and the highly selective COX-2 inhibitors in AERD. We suggest that it is time for the labeling of highly selective COX-2 inhibitors to reflect these data and for the warning that patients with AERD in particular and asthmatic patients in general avoid selective COX-2 inhibitors to be removed.

Cyclooxygenase isozymes: the biology of prostaglandin synthesis and inhibition

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent one of the most highly utilized classes of pharmaceutical agents in medicine. All NSAIDs act through inhibiting prostaglandin synthesis, a catalytic activity possessed by two distinct cyclooxygenase (COX) isozymes encoded by separate genes. The discovery of COX-2 launched a new era in NSAID pharmacology, resulting in the synthesis, marketing, and widespread use of COX-2 selective drugs. These pharmaceutical agents have quickly become established as important therapeutic medications with potentially fewer side effects than traditional NSAIDs. Additionally, characterization of the two COX isozymes is allowing the discrimination of the roles each play in physiological processes such as homeostatic maintenance of the gastrointestinal tract, renal function, blood clotting, embryonic implantation, parturition, pain, and fever. Of particular importance has been the investigation of COX-1 and -2 isozymic functions in cancer, dysregulation of inflammation, and Alzheimer's disease. More recently, additional heterogeneity in COX-related proteins has been described, with the finding of variants of COX-1 and COX-2 enzymes. These variants may function in tissue-specific physiological and pathophysiological processes and may represent important new targets for drug therapy.

Immune Tolerance to Drugs. (II).: Long–Term Tolerability of Nimesulide in Patients with NSAID Hypersensitivity

Nimesulide is well-tolerated as an alternative to nonsteroidal antiinflammatory drugs (NSAIDs) in patients with a previous adverse reaction to other classes of NSAIDs. However, there is little information in the literature about its long-term tolerability. The study was carried out on 625 patients who had experienced adverse reactions to one or more NSAIDs. All patients received and tolerated peroral challenges with nimesulide. On the first day, patients were given an equivalent number of placebo doses to the planned number of nimesulide doses. In a successive session, the test was administered by means of increasing doses of nimesulide at 30 min intervals until the common daily therapeutic dose of 100 mg was reached (10 mg-20 mg-30 mg-40 mg). A questionnaire was distributed to all subjects. In particular, they were asked to clarify any reactive symptoms they had developed after ingestion of the drug. It was found that only 2.1% (4/192) of subjects who were given this drug experienced urticaria during treatment. We have identified three significant risk factors: a history of chronic urticaria, a history of antibiotic hypersensitivity and a history of hypersensitivity to more than one class of NSAIDs. In patients with the above risk factors, a prior tolerance test with a selective COX2 antagonist should be administered.

[Special features of NSAID intolerance in children]

Adverse reactions to acetylsalicylic acid (aspirin, ASA) and other non-steroidal anti-inflammatory drugs (NSAIDs) are the second most important cause of adverse drug reactions (ARDs) after beta-lactams. They produce various clinical manifestations and can affect different organs. Gastrointestinal reactions (pyrosis, vomiting, gastralgia), neurological reactions (tinnitus, deafness, vertigo), blood dyscrasias, and nephrotoxic and hepatotoxic reactions are well known.NSAIDs are the drugs of choice in the treatment of chronic arthropathies and other childhood connective-tissue diseases and are also commonly used in the treatment of febrile and acute inflammatory processes. Not all NAIDs are authorized for use in the pediatric population but their spectrum of use varies according to the entity for which they are indicated and the legislation of the country. Published studies on the prevalence of aspirin intolerance in patients with bronchial asthma show a fair amount of disagreement. This may be due to (i) the method of selecting asthmatic patients for the study, which differs according to whether all asthmatic patients are included or only those dependent on corticoids; (ii) the diagnostic method used, whether based on clinical criteria or oral provocation tests, which will affect the number of patients with a diagnosis of intolerance. In children aged less than 10 years, including children with asthma, the prevalence is low, while among children and young adults aged 10-20 years old, the prevalence is estimated at 10 %. Some hypotheses attempt to explain the mechanisms through which adverse reactions to NAIDs take place. One hypothesis attributes the reaction to a reaginic immunological mechanism but this hypothesis has only been confirmed in exceptional cases. The theory of the cyclooxygenase pathway, currently the most widely accepted, is based on the ability of NSAIDs to inhibit the cyclooxygenase pathway of arachidonic acid metabolism, leading to prostaglandin depletion and an increase in leukotrienes. The discovery of two isoforms of the cyclooxygenase enzymes, COX-1 and COX-2, has represented a great advance in our understanding of the mechanism of action of NSAIDs and has also elucidated the problem of cross-reactivities. According to the theory of viral infection, aspirin-induced asthma could be caused by chronic viral infection since, after initial exposure to the virus, cytotoxic lymphocytes are produced. Their activity is inhibited by prostaglandin E2 (PGE2); aspirin and other NSAIDs block PGE2 production and allow cytotoxic lymphocytes to attack and eliminate the respiratory tract cells infected by the virus. During this reaction lysosomal enzymes and mediators are released, which could precipitate an asthmatic crisis.Clinically, five types of reaction have been identified: 1. Respiratory illness with aspirin sensitivity. 2. Aspirin-induced urticarial disease. 3. Allergic reactions to NSAIDs and aspirin. 4 and 5. Aseptic meningitis and pneumonitis due to hypersensitivity. The latter are exceptional and are published as case reports. They have never been associated with aspirin or acetaminophen and usually occur in patients undergoing prolonged treatment. Diagnosis is based on a detailed history. Skin tests are not valid and in vitro tests are not widely used. Provocation tests with aspirin and NSAIDs definitively identify sensitized patients but their indications and limitations should be kept in mind. In children, certain features of adverse reactions to NSAIDs are observed in relation to their incidence and clinical manifestations. Acetaminophen is considered the drug of choice but further studies of other alternatives in children are required.

Double-blind, placebo-controlled study of the efficacy and tolerability of nimesulide administered orally in acute bronchial asthma

In this double-blind, placebo-controlled study, children with acute exacerbation of bronchial asthma between the ages of 1 and 12 years not responding to conventional therapy with bronchodilators and injectable steroids were enrolled. A total of 60 children (two groups of 30 each) was studied. The overall response to therapy was assessed based on the guidelines and recommendations of the National Heart, Lung and Blood Institute. The efficacy parameters included respiratory and heart rates, degree of dyspnea, accessory muscle usage, color, wheeze, and degree of oxygen saturation. Children with moderate to severe exacerbation received either nimesulide suspension 1.5 mg/kg per dose or identical placebo orally as per random protocol. To assess the clinical progress, all the efficacy parameters were reassessed after 30 minutes and 1, 2, and 6 hours. A significant difference was observed in the overall assessment of response at 1, 2, and 6 hours in the two treatment groups. A greater number of children showed a good overall response in the nimesulide group compared with the placebo group at 1, 2, and 6 hours (P <.01). No side effects were reported in any of the patients in either group. None of the patients was withdrawn prematurely from either group. It is evident from the current study that nimesulide showed good efficacy and tolerability. Therefore, nimesulide could be administered to asthmatic patients whenever there is a need for such therapy.

The use of analgesics in patients with asthma

Aspirin (acetylsalicylic acid) and other nonsteroidal anti-inflammatory drugs (NSAIDs) cause deterioration in respiratory function in approximately 10% of adults with asthma and a smaller proportion of children with asthma. We propose evidence-based guidelines for the safe use of NSAIDs in individuals with asthma following systematic review of data from the last 10 years relevant to the use of these drugs in such patients. We would currently recommend that patients with asthma who are known to be intolerant of NSAIDs or who exhibit any of the high risk clinical features for intolerance to these drugs (severe asthma, nasal polyps or chronic rhinosinusitis) should use NSAIDs only under close medical supervision. In those with high risk features formal aspirin provocation testing would be recommended prior to the therapeutic use of NSAIDs. Those individuals with asthma who regularly use NSAIDs can continue to do so but should be warned that intolerance to NSAIDs can develop late in life. Lack of relevant experimental evidence precludes the production of evidence-based guidelines for the group of patients with asthma who do not exhibit high risk clinical features and who have never before used NSAIDs. We would currently recommend that this group be treated as potentially intolerant to NSAIDs and use of these drugs can only be recommended under medical supervision but note that further studies and clinical experience could be expected to relax this restriction for many patients. Recent data have suggested that frequent use of paracetamol (acetaminophen) may contribute to a deterioration of respiratory function in asthma. A small proportion of patients with asthma who are NSAID-intolerant experience short-lived deterioration in respiratory function with the use of high doses of paracetamol but this is uncommon and has not been implicated in life-threatening reactions. Routine warnings about paracetamol use in asthma are, therefore, not warranted. Medical personnel, however, should be aware of the potential for worsening of symptoms in some individuals with asthma using paracetamol and institute formal investigation or withdrawal of the drug if they suspect such a reaction.

Adverse drug reactions related to the use of NSAIDs with a focus on nimesulide: results of spontaneous reporting from a Northern Italian area

OBJECTIVE

To analyse and compare the adverse drug reactions (ADRs) associated with the use of nimesulide with those associated with diclofenac, ketoprofen, and piroxicam, reported spontaneously in a northern Italian area (Veneto and Trentino).

METHODS

Data were obtained from the spontaneous reporting system database of Veneto-Trentino, the principal contributor to the Italian spontaneous surveillance system. All case reports that occurred in association with all formulations of the nonsteroidal anti-inflammatory drugs (NSAIDs) under investigation during the period from January 1988 to December 2000, were analysed in detail. Sales data from June 1996 to May 1999 and prescription data, from 1997 to 2000 from the Veneto region were utilised to select the most widely used NSAIDs to be included in the study. The prescription data were also used to look at the drug use in relation to age.

RESULTS

During the study period, 10 608 reports describing 16 571 adverse reactions were entered into the surveillance system. We found 207 case reports for nimesulide, 187 for diclofenac, 174 for ketoprofen, and 137 for piroxicam. Analysis of sales and prescription data revealed that in the Veneto region nimesulide was the most widely prescribed drug followed at a long distance by diclofenac, piroxicam and ketoprofen. No age-related difference in the use of the four drugs was found. Analysis of the case reports revealed significantly different toxicity profiles for the four drugs. In particular, nimesulide was associated with fewer and less severe gastrointestinal (GI) ADRs compared with the other NSAIDs. Nimesulide was associated with about half the number of GI reactions (10.4%) than the other three NSAIDs (21.2% for diclofenac, 21.7% for ketoprofen, 18.6% for piroxicam). Two previously unreported reactions were also found for piroxicam and ketoprofen.

CONCLUSIONS

Nimesulide is the most frequently used NSAID in Italy. Spontaneous reporting data suggest that nimesulide has the most favourable GI tolerability profile of the NSAIDs investigated, with few reports of severe GI reactions. A few reports of hepatic and renal impairment associated with nimesulide suggest caution in patients at risk. Age-related reporting analysis suggests a higher toxicity for diclofenac and piroxicam in the elderly compared with nimesulide and ketoprofen. This analysis of the Veneto-Trentino database on spontaneous reporting confirms that NSAIDs differ in their tolerability profile, and this fact should be taken into account in the choice of drugs in relation to patient characteristics.

Aspirin enhances the induction of type I allergic symptoms when combined with food and exercise in patients with food-dependent exercise-induced anaphylaxis

We examined the effect of aspirin as a substitute for exercise in inducing urticaria/anaphylaxis in three patients with food-dependent exercise-induced anaphylaxis (FDEIA). Two of the patients had specific IgE antibodies to wheat and the other had antibodies to shrimp. Administration of aspirin before ingestion of food allergens induced urticaria in one patient and urticaria and hypotension in another, while aspirin alone or food alone elicited no response. The third patient developed urticaria only when he took all three items, i.e. aspirin, food and additional exercise, whereas provocation with any one or or two of these did not induce any symptoms. These findings suggest that aspirin upregulates type I allergic responses to food in patients with FDEIA, and further shows that aspirin synergizes with exercise to provoke symptoms of FDEIA. This is the first report of a synergistic effect of aspirin in inducing urticaria/anaphylaxis, which was confirmed using challenge tests in patients with FDEIA.

Nimesulide: some pharmaceutical and pharmacological aspects--an update

Nimesulide, a non-steroidal anti-inflammatory drug (NSAID), is administered orally or rectally twice daily for a variety of inflammation and pain states. This is a unique NSAID, not only because of its chemical structure but also because of its specific affinity to inhibit cyclooxygenase-2 (COX-2), thus exerting milder effects on the gastrointestinal mucosa. Current data on selective COX-2 inhibitors suggest that they may have an efficacy similar to that of standard NSAIDs. Initial general clinical experience with selective COX-2 inhibitors appears to show that they are particularly promising in individuals at risk because of renal diseases, hypertension or congestive heart failure. Various experimental models and clinical studies have demonstrated the anti-inflammatory efficacy of nimesulide. Nimesulide is superior, or at least comparable in efficacy, to other NSAIDs, but is better tolerated and has less potential for adverse reactions. Thus, selective COX-2 inhibitors should have anti-inflammatory effects devoid of side effects on the kidney and stomach. They may also demonstrate new important therapeutic benefits as anticancer agents as well as help prevention of premature labour and even retard the progression of Alzheimer's disease. No clinically significant drug interactions have been reported for nimesulide. Not much has been reported about the pharmaceutical aspects of nimesulide. Its poor aqueous solubility poses bioavailability problems in-vivo. This could be overcome by the formation of inclusion complexes with beta-cyclodextrin, as has been reported by various researchers. However, absence of any in-vivo data regarding the relative absorption of nimesulide from beta-cyclodextrin complex compared with that from conventional formulations of the drug makes the use of such fast-releasing complexes rather questionable. Only a limited number of assay procedures (HPLC, spectrophotometric, spectrofluorimetric) for the determination of nimesulide and its metabolite in plasma/urine samples or in dosage forms have been reported in the literature. The purpose of this review is to provide a concise overview of the pharmacological and pharmaceutical profile of nimesulide. Various investigations carried out recently are reported, although older references to research performed on nimesulide have also been included, where appropriate.

[Aspirin: allergy or intolerance]

PURPOSE

The paper describes the clinical characteristics of patients with aspirin-induced asthma and/or urticaria, angioedema, shock, the results of the challenge tests and the evolution of this disease.

MAIN POINT

The authors present the different arguments supporting the physiopathological mechanisms from genetics to the inhibition of cyclooxugenase or the leukotriene hypothesis.

PROSPECTIVES

Finally, they recall the methodology to be used for a good clinical practice on this controversial field of research.

Occurrence of allergic conditions in asthmatics with analgesic intolerance

BACKGROUND

The study aimed to determine whether allergic conditions accompany analgesic intolerance.

METHODS

A total of 132 analgesic-intolerant patients with bronchial asthma admitted to the adult allergy unit from January 1991 to October 1997 and 103 patients with bronchial asthma randomly selected from among the asthmatics referred to our department between January and October 1997 were enrolled in the study. Those having analgesic intolerance and bronchial asthma were accepted as group I; patients having only asthma were accepted as group II. A standard questionnaire was completed for all the patients. Physical examination, routine skin prick tests, determination of total IgE levels and blood type, and oral analgesic provocation tests were also performed.

RESULTS

The results showed that some allergic conditions were significantly more common in group I (22.7% and 7.8% for food allergy/intolerance [P<0.05], 16.7% and 7.8% for antibiotic allergy, 16.7% and 2.9% for dermographism, 9.8% and 1.0% for metal allergy, and 9.1% and 1.0% for chronic urticaria for groups I and II, respectively [P<0.001]). In addition, the mean of the total IgE level in the serum was higher in group I than group II (77.6 and 53.7 IU/ml; P<0.05), and the cumulative analgesic consumption was more in group I (14.2+/-17.1 and 9.1+/-12.5 boxes; P<0.05).

CONCLUSIONS

Dermographism; chronic urticaria; antibiotic, metal, and food allergy; high levels of total IgE; and a high amount of cumulative analgesic consumption may be the conditions accompanying analgesic intolerance in asthmatics.

Aspirin and paracetamol tolerance in patients with nimesulide-induced urticaria

BACKGROUND

The administration of aspirin and other nonsteroidal anti-inflammatory drugs in patients sensitive to nimesulide might be hazardous.

OBJECTIVE

To assess the tolerance to both acetaminophen (paracetamol) and aspirin in patients with a history of urticaria induced by nimesulide.

METHODS

Nine patients with a history of nimesulide intolerance were submitted to single-blind, placebo-controlled peroral challenges with increasing doses of acetaminophen and aspirin.

RESULTS

Acetaminophen was tolerated by all patients, whereas two experienced immediate systemic urticaria after the administration of 125 mg of aspirin.

CONCLUSION

Acetaminophen and aspirin are well tolerated by most nimesulide-sensitive patients. Since a minority of patients show aspirin sensitivity, tolerance of this agent should always be ascertained by properly performed peroral challenges.

Localized unilateral periorbital edema induced by aspirin

BACKGROUND

Aspirin intolerance manifested as bronchospasm or urticaria/angioedema has been observed since the beginning of this century.

OBJECTIVE

To report a novel case of intolerance to aspirin ingestion.

METHODS

Case report; routine skin testing; pulmonary function testing; aspirin challenge.

RESULTS

A 30-year-old man with a history of left ocular trauma at the age of 10 noted a 3-year history of left periorbital angioedema after aspirin but not other nonsteroidal anti-inflammatory drugs. Incremental oral aspirin challenge resulted in this unilateral symptomatology at a dose of 673 mg.

CONCLUSION

To the best of our knowledge, this is the first reported case of unilateral periorbital edema following aspirin ingestion.