A double-blind comparison of nimesulide and mefenamic acid in the treatment of acute upper respiratory tract infections in children

Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.

Non-steroidal anti-inflammatory drugs for the common cold

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used for the treatment of pain and fever associated with the common cold.

OBJECTIVES

To determine the effects of NSAIDs versus placebo (and other treatments) on signs and symptoms of the common cold, and to determine any adverse effects of NSAIDs in people with the common cold.

SEARCH METHODS

We searched CENTRAL (2015, Issue 4, April), (January 1966 to April week 3, 2015), EMBASE (January 1980 to April 2015), CINAHL (January 1982 to April 2015) and ProQuest Digital Dissertations (January 1938 to April 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of NSAIDS in adults or children with the common cold.

DATA COLLECTION AND ANALYSIS

Four review authors extracted data. We subdivided trials into placebo-controlled RCTs and head-to-head comparisons of NSAIDs. We extracted and summarised data on global analgesic effects (such as reduction of headache and myalgia), non-analgesic effects (such as reduction of nasal symptoms, cough, sputum and sneezing) and side effects. We expressed dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) or standardised mean differences (SMD). We pooled data using the fixed-effect and random-effects models.

MAIN RESULTS

We included nine RCTs with 1069 participants, describing 37 comparisons: six were NSAIDs versus placebo and three were NSAIDs versus NSAIDs. The overall risk of bias in the included studies was mixed. In a pooled analysis, NSAIDs did not significantly reduce the total symptom score (SMD -0.40, 95% CI -1.03 to 0.24, three studies, random-effects model), or duration of colds (MD -0.23, 95% CI -1.75 to 1.29, two studies, random-effects model). For respiratory symptoms, cough did not improve (SMD -0.05, 95% CI -0.66 to 0.56, two studies, random-effects model) but the sneezing score significantly improved (SMD -0.44, 95% CI -0.75 to -0.12, two studies, random-effects model). For outcomes related to the analgesic effects of NSAIDs (headache, ear pain, and muscle and joint pain) the treatment produced significant benefits. The risk of adverse effects was not high with NSAIDs (RR 2.94, 95% CI 0.51 to 17.03, two studies, random-effects model) but it is difficult to conclude that such drugs are no different from placebo. The quality of the evidence may be estimated as 'moderate' because of imprecision. The major limitations of this review are that the results of the studies are quite diverse and the number of studies for one result is quite small.

AUTHORS' CONCLUSIONS

NSAIDs are somewhat effective in relieving the discomfort caused by a cold but there is no clear evidence of their effect in easing respiratory symptoms. The balance of benefit and harms needs to be considered when using NSAIDs for colds.

Non-steroidal anti-inflammatory drugs for the common cold

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used for the treatment of pain and fever associated with the common cold. However, there is no systematic review to assess the effects of NSAIDs in treating the common cold.

OBJECTIVES

To determine the effects of NSAIDs versus placebo (and other treatments) on signs and symptoms of the common cold, and to determine any adverse effects of NSAIDs in people with the common cold.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2013, Issue 1), MEDLINE (January 1966 to April week 4, 2013), EMBASE (January 1980 to April 2013), CINAHL (January 1982 to April 2013) and ProQuest Digital Dissertations (January 1938 to April 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of NSAIDS in adults or children with the common cold.

DATA COLLECTION AND ANALYSIS

Four review authors extracted data. We subdivided trials into placebo-controlled RCTs and head-to-head comparisons of NSAIDs. We extracted and summarised data on global efficacies of analgesic effects (such as reduction of headache and myalgia), non-analgesic effects (such as reduction of nasal symptoms, cough, sputum and sneezing) and side effects. We expressed dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) or standardised mean differences (SMD). We pooled data using the fixed- and random-effects models.

MAIN RESULTS

We included nine RCTs with 1069 participants, describing 37 comparisons: six were NSAIDs versus placebo and three were NSAIDs versus NSAIDs. The overall risk of bias in the included studies was mixed. In a pooled analysis, NSAIDs did not significantly reduce the total symptom score (SMD -0.40, 95% CI -1.03 to 0.24, three studies, random-effects model), or duration of colds (MD -0.23, 95% CI -1.75 to 1.29, two studies, random-effects model). For respiratory symptoms, cough did not improve (SMD -0.05, 95% CI -0.66 to 0.56, two studies, random-effects model) but the sneezing score significantly improved (SMD -0.44, 95% CI -0.75 to -0.12, two studies, random-effects model). For outcomes related to the analgesic effects of NSAIDs (headache, ear pain, and muscle and joint pain) the treatment produced significant benefits. The risk of adverse effects was not high with NSAIDs (RR 2.94, 95% CI 0.51 to 17.03, two studies, random-effects model) and it is difficult to conclude that such drugs are not different from placebo.

AUTHORS' CONCLUSIONS

NSAIDs are somewhat effective in relieving discomfort caused by a cold but there is no clear evidence of their effect in easing respiratory symptoms. The balance of benefit and harms needs to be considered when using NSAIDs for colds.

Pediatric cough: children are not miniature adults

Pediatric cough-related issues, like most other conditions in particularly young children, share similarities but also have substantial important differences with adults. These can be understood from physiologically based domains simplified to (1) cough-specific, (2) general respiratory, (3) other direct systems such as the immune system, and (4) other general physiology. Among other reasons, these result in observed differences in etiology, management, and measurement of response between children and adults. For example, while empirical therapy for chronic cough is widely advocated for adults, it is not advocated for children. Indeed, there is some evidence that an empirical approach is potentially harmful; this is related to the use of medications and the delay in obtaining a correct diagnosis such as missed foreign body aspiration.

Non-steroidal anti-inflammatory drugs for the common cold

BACKGROUND

Although non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used for the treatment of pain and fever associated with the common cold, there is no systematic review to assess the effects of NSAIDs in patients with the common cold.

OBJECTIVES

To determine the effects of NSAIDs versus placebo and other treatments on the signs and symptoms of the common cold. To determine any adverse effects of NSAIDs in patients treated with NSAIDs for the common cold.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1) which includes the Acute Respiratory Infections (ARI) Group's Specialized Register; MEDLINE (January 1966 to March 2009); EMBASE (January 1980 to March 2009); CINAHL (January 1982 to March 2009); ProQuest Digital Dissertations (January 1938 to March 2009); KoreaMed (January 1958 to March 2009) and KMbase (January 1949 to March 2009).

SELECTION CRITERIA

Randomized controlled trials (RCTs) studying treatment of the common cold with NSAIDs in adults or children.

DATA COLLECTION AND ANALYSIS

Four review authors extracted data (SYK, YSM, YJC, YWH). We subdivided trials into placebo-controlled RCTs and NSAIDs versus NSAIDs RCTs. We extracted and summarized data on global efficacies: analgesic effects such as reduction of headache and myalgia; non-analgesic effects such as reduction of nasal symptoms, cough, sputum and sneezing; and side effects.

MAIN RESULTS

This review includes nine RCTs, describing 37 comparisons: six were NSAIDs versus placebo, and three were NSAIDs versus NSAIDs. A total of 1064 patients with the common cold were included. In a pooled analysis, NSAIDs did not significantly reduce the total symptom score, or duration of colds.However, for outcomes related to the analgesic effects of NSAIDs (headache, ear pain, and muscle and joint pain) NSAIDs produced significant benefits, and malaise showed a borderline benefit, although throat irritation was not improved. Chills showed mixed results. For respiratory symptoms, cough and nasal discharge scores were not improved, but the sneezing score significantly improved. We found no evidence of increased frequency of adverse effects in the NSAID treatment groups.

AUTHORS' CONCLUSIONS

The authors recommend NSAIDs for relieving discomfort or pain caused by the common cold. Further research is needed to investigate the effect of NSAIDs in relieving respiratory symptoms such as cough and nasal discharge.

Risks and benefits of nonsteroidal anti-inflammatory drugs in children: a comparison with paracetamol

Nonsteroidal anti-inflammatory drugs (NSAIDs) possess antipyretic, analgesic and anti-inflammatory effects. They are frequently used in children and have numerous therapeutic indications, the most common ones being fever, postoperative pain and inflammatory disorders, such as juvenile idiopathic arthritis (JIA) and Kawasaki disease. Their major mechanism of action is through inhibition of prostaglandin biosynthesis by blockade of cyclo-oxygenase (COX). The disposition of most NSAIDs has been mainly studied in infants > or = 2 years of age. Compared with adults, the volume of distribution and clearance of NSAIDs such as diclofenac, ibuprofen (infants aged between 3 months and 2.5 years), ketorolac and nimesulide were increased in children. The elimination half-life was similar in children to that in adults. These pharmacokinetic differences might be clinically significant with the need for higher loading and/or maintenance doses in children. Ibuprofen, acetylsalicylic acid (ASA) and acetaminophen are the most frequently used agents for fever reduction in children. Over the past 20 years, because of the association between ASA use and Reye's syndrome, most of the interest has been directed toward ibuprofen and acetaminophen. In view of its comparable antipyretic efficacy, but superior tolerability profile, acetaminophen, when used appropriately with age-adapted formulations, should remain the first-line therapy in the treatment of childhood fever. At the moment, there is no scientific evidence to recommend simultaneous use of these two antipyretic drugs. Most NSAIDs provide mild to moderate analgesia, with the exception of ketorolac which has a strong analgesic activity. The analgesic efficacy of ketorolac, ketoprofen, diclofenac and ibuprofen in the treatment of postoperative pain has been mainly studied following a single dose, in children of > or = 1 year of age undergoing minor surgeries. In this setting, when used either alone or in adjunct to caudal or epidural anaesthesia, they were associated with an opioid-sparing effect and were well tolerated. With the exception of ketorolac use in children undergoing tonsillectomy, where controversy exists regarding the risk of postoperative haemorrhage, NSAIDs have not been associated with an increased risk of perioperative bleeding. NSAIDs are the first-line therapy in JIA. They appear to be equally effective and tolerated, with the exception of ASA which is associated with more adverse effects. ASA has been used for many years in the treatment of Kawasaki disease and is part of the standard modality of treatment in combination with intravenous gammaglobulins. More recently, lung inflammation associated with cystic fibrosis (CF) has become a new target for NSAIDs. Despite promising preliminary results with ibuprofen, numerous questions need to be answered before this new strategy becomes part of the conventional treatment of patients with CF. In summary, NSAIDs are effective in reducing fever, alleviating pain and reducing inflammation in children, with a good tolerance profile. Pharmacokinetic studies are needed to characterise the disposition of NSAIDs in very young infants in order to use them rationally. To date, no studies have been published on the disposition, tolerability and efficacy of specific COX-2 inhibitors in children. Further clinical experience with these agents in adults is warranted before undergoing trials with specific COX-2 inhibitors in children.

Antipyretic effects of nimesulide, paracetamol and ibuprofen-paracetamol

The antipyretic effect of nimesulide has not been adequately compared with paracetamol and ibuprofen-paracetamol combination in children. Hence, a randomized, double blind, and parallel groups' design and multicenter study was conducted on children with respiratory tract infections. Eighty-nine patients with temperatures above 38.5 degrees C were randomly administered nimesulide (1.5 mg/kg/dose), paracetamol (10.0 mg/kg/dose), or ibuprofen-patients combination (10.0 mg/kg/dose), thrice daily for five days. The axillary temperature was recorded at the baseline and at different time intervals post administration of drugs. The hematological and biochemical investigations were performed at the basal level and at the end of the treatment period. The adverse drug reactions were monitored during the trial. All the drugs produced a significant fall in temperature as compared to their respective basal values (p < 0.001). However, on looking at the change in temperatures at different time intervals from the respective basal levels, no significant difference was found among all the drugs. Surprisingly, nimesulide had a tendency to raise serum glutamate pyruvate transaminase and serum glutamate oxaloacetate transaminase levels as compared to its baseline values. There was no marked adverse effect of the drugs on other hematological and biochemical parameters investigated. No other serious adverse reaction occurred in the study. Ibuprofen-paracetamol combination, nimesulide, and paracetamol had almost similar antipyretic effects in children.

Clinical and pharmacokinetic study of nimesulide in children

The pharmacokinetic profile and efficacy of nimesulide were assessed in 2 separate studies that recruited children with hypoglycaemia or upper respiratory tract infection and fever, respectively. A single dose of nimesulide 50mg (granules) administered orally to 14 hypoglycaemic children was rapidly absorbed. A mean maximum nimesulide plasma concentration of 3.5 mg/L was achieved within 2 hours of administration, which subsequently declined over the following 12 hours. Nimesulide was metabolised to its principal hydroxy metabolite, which was detectable in samples obtained 0.5 hours after giving the parent drug. Levels of this metabolite steadily increased, surpassing those of intact nimesulide at the 9-hour sampling point. In a randomised nonblind clinical investigation, 100 hospitalised children with acute upper respiratory infections and fever received nimesulide oral suspension (5 mg/kg/day) or paracetamol (26 mg/kg/day) for 3 to 9 days. The antipyretic and anti-inflammatory effects of nimesulide were superior to those observed with paracetamol (p < 0.01) and both drugs were equally well tolerated.