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

Risk of serious skin and subcutaneous tissue disorders for nimesulide among the pediatric population: a jeopardy identified through the analysis of global individual case safety reports

BACKGROUND

The safety reports arising currently on nimesulide are divulging the jeopardy of skin and subcutaneous tissue disorders (SSTDs).

RESEARCH DESIGN AND METHODS

The global individual case safety reports on nimesulide-induced SSTDs available at VigiBase® were analyzed up to 31 March 2023. Disproportionality analyses viz. Proportional Reporting Ratio (PRR), Reporting Odds Ratio (ROR), and Information Component (IC) were performed to identify the quantitative signals.

RESULTS

Out of 33,983,649 de-duplicated cases available in the VigiBase®, 1,664,134 (4.9%) were in pediatrics below 12 years of age. Among these, cases attributed to nimesulide were 251, of which 126 (50.2%) were on SSTDs. Among all the SSTDs reported for nimesulide, the serious reactions like urticaria [PRR = 2.3; lower bound (LB) ROR = 1.7; IC025 = 0.6], Stevens-Johnson syndrome (SJS) [PRR = 28.3; LB ROR = 18.2; IC025 = 3.2], angioedema [PRR = 7.5; LB ROR = 4.5; IC025 = 1.7], and toxic epidermal necrolysis (TEN) [PRR = 27.4; LB ROR = 11.5; IC025 = 1.5] were identified as potential signals. In comparison with non-SSTDs, SSTDs reported for nimesulide were significantly higher among children (2-11 years, 90.5%), from India (38.9%), and by the physician (60.3%).

CONCLUSIONS

Identifying the giant quantitate association between nimesulide and serious & life-threatening reactions like SJS and TEN, precautionary measures need to be taken by the regulatory authorities to prevent nimesulide-induced SSTDs among the pediatric population.

Human safety study of a selective neuronal adenylate cyclase 1 (AC1) inhibitor NB001 which relieves the neuropathic pain and blocks ACC in adult mice

Calcium-dependent, neuronal adenylyl cyclase subtype 1 (AC1) is critical for cortical potentiation and chronic pain. NB001 is a first-in-class drug acting as a selective inhibitor against AC1. The present study delineated the pharmacokinetic (PK) properties of human-used NB001 (hNB001) formulated as immediate-release tablet. This first-in-human study was designed as randomized, double-blind, placebo-controlled trial. hNB001 showed placebo-like safety and good tolerability in healthy volunteers. A linear dose-exposure relationship was demonstrated at doses between 20 mg and 400 mg. The relatively small systemic exposure of hNB001 in human showed low bioavailability of this compound through oral administration, which can be improved through future dosage research. Food intake had minimal impact on the absorption of hNB001 tablet. Animal experiments further confirmed that hNB001 had strong analgesic effect in animal models on neuropathic pain. In brain slice prepared from the anterior cingulate cortex (ACC), bath application of hNB001 blocked the induction of LTP. These results from both rodents and human strongly suggest that hNB001 can be safely used for the future treatment of different types of chronic pain in human patients.

[Nonsteroidal anti-inflammatory drugs in the treatment of anterior uveitis associated with spondyloarthritis]

Anterior uveitis (AU) is one of the common extraskeletal manifestations of spondyloarthritis (SpA). The course of AU in patients with SpA is characterized by frequent relapses. The article considers the question of local and systemic use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment and prevention of SpA-associated uveitis exacerbations.

[The use of nimesulide in the treatment of acute low back pain]

The objective is to study the efficacy and safety of nimesulide (nemulex) in the treatment of acute low back pain (LBP). The medical documentation of 54 patients with primary syndrome of LBP, which were treated in a polyclinic with nemulex at a dose of 200 mg per day had been studied. The assessment of patients' condition and efficacy and safety of the treatment was conducted based on the information after three visits (1-st, 5-th and 10-th day). The analysis took into account the data of clinical-neurological examination and the assessment of pain intensity at rest and at movement according to the visual analogue scale (VAS) and the severity of Lasegue symptom and limitation of movements in the lumbar spine. Safety of the therapy was evaluated on the basis of accounting of undesirable side reactions and data analysis and physical examination and laboratory testing. Cardiovascular safety was assessed by blood pressure and blood lipid profile on day 10. The use of nemulex at a dose of 200 mg per day resulted in relief of pain and increase of mobility in the lumbar spine on the 5th day of treatment that indicates the effectiveness of anti-inflammatory therapy to restore the previous functional status of patients with LBP. The use of nemulex was accompanied not only by statistically significant analgesic effect (0,78±0,14 points alone; 1,12±0,18 points when moving by VAS on the 10th day of the treatment) and high security (only 1 of the 54 patients was recorded to have elevation of hepatic transaminases; and 2 patients with dyspepsia without endoscopic changes of gastrointestinal tract).

Risk of gastrointestinal complications associated to NSAIDs, low-dose aspirin and their combinations: Results of a pharmacovigilance reporting system

Gastrointestinal (GI) complications are one of the most limiting cause of use of NSAIDs. Beyond others well defined factors, history of peptic ulcer, older age, Helicobacter pylori infection and use of gastrotoxic drugs may affect their GI safety profile. In particular, the risk of GI complications associated to the use of antiplatelet drugs, especially low-dose acetylsalicylic acid (LDA) should deserve much attention. However, only few studies have focused on the effect of combination LDA/NSAIDs on the GI tract compared with the monotherapy and much less studies assessed this effect with multiple NSAIDs use. We aimed to characterize the GI safety profile of NSAIDs and LDA as monotherapy or their combinations in real-life conditions by analysing spontaneous adverse drug reactions (ADRs) reporting system in a Southern Italy. We used the case/non-case method in the Italian Pharmacovigilance Network (RNF). Cases were reports of GI events in the RNF between January 2007 and December 2011. Non-cases were all other reports during the same period. The association between NSAID and suspected GI ADRs was calculated using the reporting odds ratio (ROR) with 95% confidence intervals as a measure of disproportionality while adjusting for age, and concomitant use of antineoplastic agents or drugs for cardiovascular diseases. Sub-analysis were performed within the NSAID class. Among the 2816 adverse drug reactions recorded, we identified 374 (13.3%) cases of GI complications. Upper GI complications were the most frequently reported type of events. The highest associations were found for the combined use of NSAIDs and/or LDA, whilst the lowest associations were for their respective monotherapy. Looking at individual NSAIDs the highest association with GI events was observed for ketorolac exposure followed by nimesulide, diclofenac, aspirin, ketoprofen, and ibuprofen. This study highlights the primary role of the national spontaneous reporting system to bring out potential signals, such as the inappropriate drug use pattern, which however, have to be furtherly studied in-depth with ad hoc population-based studies.

Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage?

Non-steroidal anti-inflammatory drugs (NSAIDs) constitute a family of drugs, which taken as a group, represents one of the most frequently prescribed around the world. Thus, not surprisingly NSAIDs, along with anti-infectious agents, list on the top for causes of Drug-Induced Liver Injury (DILI). The incidence of liver disease induced by NSAIDs reported in clinical studies is fairly uniform ranging from 0.29/100 000 [95% confidence interval (CI): 0.17-051] to 9/100 000 (95% CI: 6-15). However, compared with these results, a higher risk of liver-related hospitalizations was reported (3-23 per 100 000 patients). NSAIDs exhibit a broad spectrum of liver damage ranging from asymptomatic, transient, hyper-transaminasemia to fulminant hepatic failure. However, under-reporting of asymptomatic, mild cases, as well as of those with transient liver-tests alteration, in conjunction with reports non-compliant with pharmacovigilance criteria to ascertain DILI and flawed epidemiological studies, jeopardize the chance to ascertain the actual risk of NSAIDs hepatotoxicity. Several NSAIDs, namely bromfenac, ibufenac and benoxaprofen, have been withdrawn from the market due to hepatotoxicity; others like nimesulide were never marketed in some countries and withdrawn in others. Indeed, the controversy concerning the actual risk of severe liver disease persists within NSAIDs research. The present work intends (1) to provide a critical analysis of the dissimilar results currently available in the literature concerning the epidemiology of NSAIDS hepatotoxicity; and (2) to review the risk of hepatotoxicity for each one of the most commonly employed compounds of the NSAIDs family, based on past and recently published data.

Nimesulide-induced electrophile stress activates Nrf2 in human hepatocytes and mice but is not sufficient to induce hepatotoxicity in Nrf2-deficient mice

Nimesulide is a widely prescribed nitroaromatic sulfoanilide-type nonsteroidal anti-inflammatory drug that, despite its favorable safety profile, has been associated with rare cases of idiosyncratic drug-induced liver injury (DILI). Because reactive metabolites have been implicated in DILI, we aimed at investigating whether hepatic bioactivation of nimesulide produces a protein-reactive intermediate in hepatocytes. Also, we explored whether nimesulide can activate the transcription factor Nrf2 that would protect from drug-induced hepatocyte injury. We found that [(14)C]-nimesulide covalently bound to human liver microsomes (<50 pmol/mg under standard conditions) or immortalized human hepatocytes in a sulfaphenazole-sensitive, rifampicin-inducible manner; yet the overall extent of binding was modest. Although exposure of hepatocytes to nimesulide was not associated with increased net levels of superoxide anion, nimesulide (100 microM, 24 h) caused nuclear translocation of Nrf2 in a sulfaphenazole-sensitive manner, indicating a role of electrophilic metabolites. However, knockdown of Nrf2 with siRNA did not make the cells more sensitive to nimesulide-induced cell injury. Similarly, exposure of wild-type C57BL/6x129 Sv mice to nimesulide (100 mg/kg/day, po, for 5 days) was associated with nuclear translocation of immunoreactive Nrf2 in a small number of hepatocytes and induced >2-fold the expression levels of the Nrf2-target gene Nqo1 in wild-type but not Nrf2-null mice. Nimesulide administered to Nrf2(-/-) knockout mice did not cause increases in serum ALT activity or any apparent histopathological signs of liver injury. In conclusion, these data indicate that nimesulide is bioactivated by CYP2C to a protein-reactive electrophilic intermediate that activates the Nrf2 pathway even at nontoxic exposure levels.

Information about ADRs explored by pharmacovigilance approaches: a qualitative review of studies on antibiotics, SSRIs and NSAIDs

Background

Despite surveillance efforts, unexpected and serious adverse drug reactions (ADRs) repeatedly occur after marketing. The aim of this article is to analyse ADRs reported by available ADR signal detection approaches and to explore which information about new and unexpected ADRs these approaches have detected.

Methods

We selected three therapeutic cases for the review: antibiotics for systemic use, non-steroidal anti-inflammatory medicines (NSAID) and selective serotonin re-uptake inhibitors (SSRI). These groups are widely used and represent different therapeutic classes of medicines. The ADR studies were identified through literature search in Medline and Embase. The search was conducted in July 2007. For each therapeutic case, we analysed the time of publication, the strengths of the evidence of safety in the different approaches, reported ADRs and whether the studies have produced new information about ADRs compared to the information available at the time of marketing.

Results

79 studies were eligible for inclusion in the analysis: 23 antibiotics studies, 35 NSAID studies, 20 SSRI studies. Studies were mainly published from the end of the 1990s and onwards. Although the drugs were launched in different decades, both analytical and observational approaches to ADR studies were similar for all three therapeutic cases: antibiotics, NSAIDs and SSRIs. The studies primarily dealt with analyses of ADRs of the type A and B and to a lesser extent C and D, cf. Rawlins' classification system. The therapeutic cases provided similar results with regard to detecting information about new ADRs despite different time periods and organs attacked. Approaches ranging higher in the evidence hierarchy provided information about risks of already known or expected ADRs, while information about new and previously unknown ADRs was only detected by case reports, the lowest ranking approach in the evidence hierarchy.

Conclusion

Although the medicines were launched in different decades, approaches to the ADR studies were similar for all three therapeutic cases: antibiotics, NSAIDs and SSRIs. Both descriptive and analytical designs were applied. Despite the fact that analytical studies rank higher in the evidence hierarchy, only the lower ranking descriptive case reports/spontaneous reports provided information about new and previously undetected ADRs. This review underscores the importance of systems for spontaneous reporting of ADRs. Therefore, spontaneous reporting should be encouraged further and the information in ADR databases should continuously be subjected to systematic analysis.

Prescriptions of NSAIDs to patients undergoing third molar surgery : an observational, prospective, multicentre survey

BACKGROUND AND OBJECTIVES

Surgical extraction of an impacted third molar is generally followed by acute post-operative pain that has been shown to be primarily inflammatory. Thus, use of NSAIDs in this context is appropriate and has been shown to be effective. Several drugs are employed for this purpose, but no information exists on the reasons why preference is given to one rather than another. The principal objective of this study was to evaluate the pattern of administration of NSAIDs in patients undergoing surgery for impacted third molar extraction. The study also aimed to collect information on the efficacy, onset and duration of the analgesic effect of routinely prescribed NSAIDs and to assess the duration of treatment with these drugs and their tolerability.

METHODS

This was an observational, multicentre, prospective survey. A total of 616 patients (38% male and 62% female) from the Italian Stomatology Clinics of the Universities of Bologna, Brescia, Cagliari, Chieti, Pavia, Pisa, Siena and Varese and from the Department of Oral and Maxillo-Facial Surgery of Semmelweis University, Budapest, were eligible for the study. Patients were evaluated over the 7 days following surgical extraction. NSAIDs were prescribed according to the normal prescribing habits of the centre and physician involved. The main outcomes of interest in the survey were the efficacy, onset and duration of analgesic effect, duration of therapy, and tolerability of the NSAIDs prescribed.

RESULTS

Nimesulide was the most prescribed NSAID (68%), followed by diclofenac, ketoprofen and ibuprofen. Because of the low proportion of patients receiving other NSAIDs, these patients were considered a single treatment group for evaluation purposes. Nimesulide, especially when given before patients started experiencing pain after surgery, was more effective than other NSAIDs in reducing the severity of pain on the day of surgery, in delaying the time to maximum intensity of pain, in providing complete pain relief and in prolonging the duration of analgesic effect on the day of surgery. These results are consistent with the known anti-inflammatory and analgesic actions of nimesulide and with the important role of inflammation in the onset of pain after this type of surgery.

CONCLUSION

These results confirm nimesulide as an effective reference drug for the treatment of post-operative dental pain and show that it has a positive benefit/risk profile in this setting.

Pharmacovigilance of drug allergy and hypersensitivity using the ENDA-DAHD database and the GALEN platform. The Galenda project

Nonallergic hypersensitivity and allergic reactions are part of the many different types of adverse drug reactions (ADRs). Databases exist for the collection of ADRs. Spontaneous reporting makes up the core data-generating system of pharmacovigilance, but there is a large under-estimation of allergy/hypersensitivity drug reactions. A specific database is therefore required for drug allergy and hypersensitivity using standard operating procedures (SOPs), as the diagnosis of drug allergy/hypersensitivity is difficult and current pharmacovigilance algorithms are insufficient. Although difficult, the diagnosis of drug allergy/hypersensitivity has been standardized by the European Network for Drug Allergy (ENDA) under the aegis of the European Academy of Allergology and Clinical Immunology and SOPs have been published. Based on ENDA and Global Allergy and Asthma European Network (GA(2)LEN, EU Framework Programme 6) SOPs, a Drug Allergy and Hypersensitivity Database (DAHD((R))) has been established under FileMaker((R)) Pro 9. It is already available online in many different languages and can be accessed using a personal login. GA(2)LEN is a European network of 27 partners (16 countries) and 59 collaborating centres (26 countries), which can coordinate and implement the DAHD across Europe. The GA(2)LEN-ENDA-DAHD platform interacting with a pharmacovigilance network appears to be of great interest for the reporting of allergy/hypersensitivity ADRs in conjunction with other pharmacovigilance instruments.

Applying the evidence in osteoarthritis: strategies for pain management

Osteoarthritis is one of the most common joint diseases and is a major cause of chronic disability in the elderly, second only to cardiovascular disease. Although, in addition to important nonpharmacological measures, paracetamol is recommended as first-line therapy in osteoarthritis because of its analgesic efficacy and tolerability profile, its efficacy is often disappointing and the more recent guidelines from the European League Against Rheumatism (EULAR) highlight how NSAIDs may be a valid alternative in patients with an inadequate response to paracetamol. The American College of Rheumatology (ACR) 2000 guidelines state that NSAIDs may even be used as initial treatment in patients with osteoarthritis of the knee and moderate-to-severe pain and inflammation. Data from several clinical studies suggest that NSAIDs provide superior analgesia to paracetamol. Little evidence is available to distinguish one NSAID from another in terms of efficacy, whilst their gastrointestinal (GI) tolerability profile remains a main concern and a key discriminating factor in selecting a NSAID. Nimesulide is a NSAID with a multi-factorial mode of action which is particularly suitable in the symptomatic treatment of states characterised by acute pain, such as osteoarthritis flares. In particular, its proven efficacy, a fast onset of the analgesic action, its protective effect against the degradation of cartilage and a demonstrated low incidence of gastrointestinal adverse events compared with other NSAIDs make it a particularly valuable option in the symptomatic treatment of patients with joint osteoarthritis.

Non-steroidal anti-inflammatory drug-related hepatic damage in France and Spain: analysis from national spontaneous reporting systems

Several non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with liver damage. The aim of this study was to compare proportions of hepatic adverse drug reaction reports associated with NSAIDs in France and Spain. Information from the Spanish and French pharmacovigilance databases were used from 1982 to 2001. To assess the risk of liver injury, the case/non-case methodology was applied, 'cases' being reports of liver damage and 'non-cases' or controls, all other reports. Exposure was considered as the presence of at least one NSAID. Liver injury risk was estimated for each drug in the two databases by calculation of reporting odds ratio in cases and non-cases, with its 95% confidence interval. Out of 62 456 reports from the Spanish database, 2114 (3.38%) were identified as liver injuries, whereas there were 27 372 liver injuries out of 200 046 (13.68%) in the French database. In Spain, there was a significant association between liver injuries and droxicam, sulindac, and nimesulide. The risk was also slightly above 1 for aceclofenac. In France, the risk was very high with clometacin, followed by sulindac, and was slightly above 1 for naproxen, diclofenac, piroxicam, and tenoxicam. This study shows that some NSAIDs are associated with reports of hepatic injuries when compared with other drugs, and most of those have been withdrawn from the market for this reason. However, the frequency of drug-related hepatic injuries reported differed in the French and Spanish databases, and some drugs did not show the same risk level in the two countries. These discrepancies could be explained in part not only by reporting rates, but also by difference in drug use patterns and/or by genetic or environmental factors.

Medication use for pediatric upper respiratory tract infections

The present study monitored medication prescribing patterns to patients treated for upper respiratory tract infections (URTIs) in the pediatric outpatient department (OPD) at Central Referral Hospital (CRH), Gangtok, Sikkim. A total of 562 URTI prescriptions of children, aged 0-12 years attending pediatric OPD at CRH, Sikkim were collected by a random once-weekly survey between May 2002 and April 2003. Males numbered 284 (50.5%), and females 278 (49.5%). Most of the patients in our study were aged 2-5 years (preschool children) (44.8%). The average number of medications prescribed per encounter was 2.37; 59.2% (789) of medicines were fixed-dose combination (FDC) products and two-thirds of FDCs were respiratory medicines (521). The most commonly prescribed medicines were respiratory medicines (47% of the total medicines prescribed). Others were antimicrobials (30.7%) and analgesic-antipyretics (18.8%). Among respiratory medicines, cough and cold preparations (prescribed in 13 different FDC products in 25 brand names) were prescribed most frequently (62%) followed by nasal preparations (21%) and beta(2) adrenergic agonist inhalers (9.2%). Ninety-eight percent of nasal preparations were isotonic saline drops (129). Antihistaminics (41.8%), non-opioid antitussives (13.5%), alpha agonist oral decongestants (42.3%), expectorants (32.2%), mucolytics (18.7%), paracetamol (14.7%), and beta(2) agonists (17.2%) were common ingredients of respiratory medicine combinations. Antihistamines (2.5%) and beta(2) agonists (9.2%) were used alone. The most commonly prescribed antimicrobial was amoxicillin with clavulanate (28.4%) followed by cefadroxil (20%), cotrimoxazole (9.5%) and amoxicillin alone (9.3%). Average number of antimicrobials prescribed was 0.7 (409/562). The most commonly prescribed analgesic-antipyretic was paracetamol (81.3%) followed by combination of ibuprofen and paracetamol (12.4%) and nimesulide (5.6%). Medication selection was rational in few cases. Various anomalies were observed in various aspects of drug use in children for URTI's. The main aim of the initiative is the need for more rational medicine use in URTIs in children for improvement of clinical effectiveness, cost effectiveness and reduction of potential useless risk of side effects.

Nimesulide -- a multifactorial approach to inflammation and pain: scientific and clinical consensus

BACKGROUND

This paper summarises the outcome from a consensus meeting, held in Rome on 5 October 2005, that aimed to review the state of the art regarding the non-steroidal anti-inflammatory drug (NSAID) nimesulide, with reference to its chemical, pharmacokinetic, pharmacological and clinical characteristics.

SCOPE

The meeting aimed to provide a continuous and up-to-date evaluation of the clinical and safety profile of nimesulide, and of its role in the treatment of inflammatory pain, in light of existing therapeutic alternatives, through a revision and critical discussion on the information available on the drug among authoritative experts in different fields of medical science.

FINDINGS

The members of the Consensus Report Group on Nimesulide (CRGN) recognised that nimesulide is an NSAID which exerts its analgesic, anti-inflammatory and antipyretic activities thanks to unique chemical and pharmacokinetic characteristics, and to a multifactorial mechanism of action, which goes beyond its preferential inhibitory activity on the COX-2 enzyme. Nimesulide was found to be at least as effective, or superior, to placebo and other NSAIDs, with a particularly fast onset of analgesic action. The safety profile is in line with that expected from the class, with evidence of a better gastrointestinal safety profile.

CONCLUSIONS

Based on the available evidence, the CRGN concluded that nimesulide remains an effective and safe therapeutic choice for the treatment of various painful inflammatory conditions, with a rapid onset of analgesic activity and an overall positive benefit/risk profile.

Efficacy of rofecoxib and nimesulide in controlling postextraction pain in oral surgery: a randomised comparative study

Rofecoxib 50 mg/day for 6 days provided better postoperative analgesia than nimesulide 200 mg/day in a randomised trial in patients (n = 130) undergoing surgical extraction of third molars. The superiority of rofecoxib over nimesulide was especially marked during the first 2-3 postoperative days and in patients with fully impacted molars. The drugs had similar effects on clinical signs of local postoperative inflammation. The effectiveness of rofecoxib in this study, plus considerations of the toxicity profile of nimesulide, support the conclusion that rofecoxib is preferable to nimesulide for relief of post-operative pain in patients undergoing surgical extraction of molars.

[Cyclooxygenase 2 selective antirheumatic analgesics]

Because of Cyclooxygenase-2 selective non steroidal anti-inflammatory drugs (NSAIDs), the therapy of articular pain has become safer and more convenient. Currently, two highly Cyclooxygenase-2 selective drugs, celecoxib and rofecoxib, are available. Both are effective for patients with osteoarthritis (at daily dosages of 200 mg and 12.5 mg, respectively) and rheumatoid arthritis (RA) (at twice the above dosages). At higher daily dosages of 800 mg and 50 mg these substances still appear safe with regard to life-threatening gastrointestinal complications (perforation, obstruction, bleeding), if not given with concomitant aspirin. However, Cyclooxygenase-2 selective non steroidal anti-inflammatory drugs do not confer protection against platelet aggregation and aspirin must be given where required for cardiovascular prophylaxis. Most patients will then routinely need gastroprotective agents such as proton pump inhibitors or misoprostol; it is unclear whether coxibs confer any benefit under such circumstances. Although not a coxib, Meloxicam does not appear to cause serious gastrointestinal complications if the low daily dosage of 7.5 mg is sufficient for the control of less pronounced pain and thus not exceeded. The gastrointestinal safety of nimesulide can not be sufficiently evaluated based on the available clinical data.

Cohort study of hepatotoxicity associated with nimesulide and other non-steroidal anti-inflammatory drugs

OBJECTIVE

To estimate the risk of acute hepatotoxicity associated with nimesulide compared with other non-steroidal anti-inflammatory drugs.

DESIGN

Retrospective cohort and nested case-control study.

SETTING

Umbria region, Italy.

PARTICIPANTS

400 000 current, recent, and past users (almost 2 million prescriptions) of non-steroidal anti-inflammatory drugs between 1 January 1997 and 31 December 2001.

MAIN OUTCOME MEASURES

Admissions to hospital for acute non-viral hepatitis and incidence of all hepatopathies and liver injury among users of nimesulide and other non-steroidal anti-inflammatory drugs.

RESULTS

Current use of non-steroidal anti-inflammatory drugs was associated with a 1.4 (95% confidence interval 1.0 to 2.1) increased risk of hepatopathy compared with past use. In current users of nimesulide the rate ratio for all hepatopathies and more severe liver injury was 1.3 (0.7 to 2.3) and 1.9 (1.1 to 3.8), respectively.

CONCLUSION

The risk of liver injury in patients taking nimesulide and other non-steroidal anti-inflammatory drugs is small.

Adverse drug reactions related to the use of fluoroquinolone antimicrobials: an analysis of spontaneous reports and fluoroquinolone consumption data from three italian regions

OBJECTIVE

To analyse and compare with one another and with other antibacterial drugs the adverse drug reactions (ADRs) of the different fluoroquinolones currently used in Italy, spontaneously reported from doctors in three northern Italian regions.

METHODS

The data on fluoroquinolones and other antibacterials were obtained from the spontaneous reporting system database of Emilia Romagna, Lombardy and the Veneto, which are the principal contributors to the Italian spontaneous surveillance system. The fluoroquinolone ADRs with a causality assessment of certain, probable or possible (according to WHO criteria), reported between January 1999 and December 2001, were selected and toxicity profiles of individual drugs were described and compared with one another. The reports were also correlated with sex and age of patients and with regional prescription data to estimate individual fluoroquinolone reporting rate of adverse events.

RESULTS

During the study period, 10 011 reports were received by the system (a mean annual reporting rate of approximately 185 per million inhabitants): 1920 referred to systemic antimicrobials, of which 432 (22.5%) involved fluoroquinolones. Pefloxacin was associated with the highest reporting rate (982 reports/daily defined dose/1000 inhabitants/day), followed by moxifloxacin (356), rufloxacin (221) and lomefloxacin (196). The most frequently reported reactions to fluoroquinolones involved the skin, but their percentage (25%) was significantly lower (p < 0.01) than those of other systemic antimicrobials (58.5%), whereas the percentages of reactions involving the central nervous (12.2 vs 3.6%), musculoskeletal (14.7 vs 0.3%) and psychiatric systems (9.3 vs 1.8%) were significantly higher (p < 0.01). We found some significant differences in the safety profiles of individual fluoroquinolones: ciprofloxacin was more frequently associated with skin reactions (p < 0.01), levofloxacin and pefloxacin with musculoskeletal (p < 0.01), and rufloxacin with psychiatric disorders (p < 0.05). Levofloxacin was the fluoroquinolone associated with the highest rate of serious tendon disorders; phototoxic reactions were more frequent with lomefloxacin, and toxic epidermal necrolysis and Stevens-Johnson syndrome were seen only with ciprofloxacin.

CONCLUSIONS

The differences in the safety profiles should be taken into account when prescribing a fluoroquinolone to individual patients.

Mechanisms of NSAID-induced hepatotoxicity: focus on nimesulide

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with idiosyncratic hepatotoxicity in susceptible patients. The molecular mechanisms underlying this toxicity have not yet been fully elucidated. However, experimental evidence suggests that they include increased concentration of the drugs in the hepatobiliary compartment, formation of reactive metabolites that covalently modify proteins and produce oxidative stress, and mitochondrial injury. Genetic and/or acquired patient factors can either augment the pathways leading to hepatic toxicity or impede the protective and detoxifying pathways. An example is nimesulide, a selective cyclo-oxygenase-2 inhibitor widely used for the treatment of inflammatory and pain conditions, which has been recently associated with rare but serious and unpredictable adverse reactions in the liver (increases in serum aminotransferase activities, hepatocellular necrosis, and/or intrahepatic cholestasis). Similar to other drugs causing idiosyncratic hepatotoxicity, both the molecule and the patient contribute to the hazard. Here, the weakly acidic sulfonanilide drug undergoes bioreductive metabolism of the nitroarene group to reactive intermediates that have been implicated in oxidative stress, covalent binding, and mitochondrial injury. It is only in a small number of susceptible patients, however, that genetic or nongenetic factors will cause this potential toxicity to become clinically manifest. In view of the very large recipient population, the incidence of nimesulide-induced liver injury has been low (approximately 0.1 per 100,000 patients treated). Although this estimation is based on spontaneous reporting data versus sales units and needs correction due to the classical bias of this system, the type and incidence of these rare but severe hepatic adverse reactions are comparable to that of other NSAIDs.