Cyclo-Oxygenase (COX) Inhibitors and Cardiovascular Risk: Are Non-Steroidal Anti-Inflammatory Drugs Really Anti-Inflammatory?

Interplay Between Diabetes Mellitus and the Occurrence of Osteoarthritis and Associated Conditions in Women of Menopausal Age

Osteoarthritis (OA) and diabetes mellitus (DM) have long-term deleterious chronic effects and are among the most prevalent chronic disorders. DM and its associated factors, such as hyperglycemia, have a significant contribution to the pathophysiology of OA, particularly in post-menopausal women. Women who have uncontrolled diabetes (DM) are more prone to develop osteoarthritis (OA), which may be exacerbated by poor glycemic control. Furthermore, this category of female patients with DM has an increased risk of developing fractures, even in those with initially normal bone density scores, further illustrating the correlation between DM and bone health. Additionally, multiple risk factors, including obesity, metabolic syndrome, hypertension, estrogen-based hormone therapy, and hyperuricemia, in menopausal women can lead to the development and exacerbation of OA. It is discovered that these variables have a direct or indirect impact, frequently causing inflammation and hormonal changes, which contribute to the intricate interaction between DM and OA. The management of OA and DM in women thus calls for a multi-faceted management plan including glycemic control, weight control, exercise, and specialized pain management methods catering to the specific requirements of the patients. Regularly screening for OA should be implemented for menopausal women with DM and utmost care should be provided by healthcare professionals. Regular monitoring of joint health and early management, encouraging interdisciplinary cooperation, putting preventative measures into place, and creating individualized treatment programs are essential. A thorough understanding of the link between DM and OA will ultimately lead to improved health outcomes and a better future for these individuals.

Royal Jelly, A Super Food, Protects Against Celecoxib-Induced Renal Toxicity in Adult Male Albino Rats

Background

Celecoxib is a COX-2 nonsteroidal anti-inflammatory drug (NSAID). It is widely used for the treatment of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.

Objective

This study aimed to explore the effect of long-term administration of celecoxib on kidney of male albino rats, and to study the potential effect of treatment discontinuation on such tissues. The study also examined the alleged ameliorative effect of royal jelly (RJ).

Methods

Fifty, male albino rats were divided into 5 equal groups; 10 each. Group 1: rats received no drug (control group). Group 2: rats received celecoxib (50 mg/kg/day, orally for 30 successive days). Group 3: rats received celecoxib (50 mg/kg/day, orally) and royal jelly (300 mg/kg/day, orally) for 30 successive days. Group 4: rats received celecoxib for 30 successive days, then rats were left untreated for another 30 days. Group 5: rats received celecoxib and RJ for 30 successive days, then rats were left untreated for another 30 days.

Results

Long-term celecoxib administration caused significant elevation in kidney function tests, with ameliorative effects of RJ against celecoxib-induced renal toxicity.

Conclusion

Long-term celecoxib administration caused renal toxicity in male albino rats, with ameliorative effects of RJ.

Effect of miR-412-5p-loaded exosomes in H9c2 cardiomyocytes via the MAPK pathway

Objectives

MicroRNAs (miRNAs) are small non-coding RNAs that function in all biological processes. Recent findings suggest that exosomes, which are small vesicles abundantly secreted by various cell types, can transport miRNAs to target cells. Here, we elucidated the effect of miRNA-loaded exosomes on lipopolysaccharide (LPS)-induced inflammation in H9c2 cardiomyocytes.

Materials and Methods

Exosomes were isolated from mesenchymal stem cells (MSC) and loaded with miR-412-5p. Additionally, the effect of the miR-412-5p-loaded exosomes on LPS-induced inflammation in H9c2 cardiomyocytes was evaluated by assessing the levels of nitric oxide (NO), reactive oxygen species (ROS), and prostaglandin E2 (PGE2). The expression of cyclooxygenase-2 (COX-2), inducible nitric oxide synthase (iNOS), inflammatory cytokines, and mitogen-activated protein kinase (MAPK) signaling factors was evaluated using reverse transcription-quantitative PCR and western blotting.

Results

miR-412-5p-loaded exosomes inhibited LPS-induced secretion of inflammatory mediators (NO, PGE2, and ROS), pro-inflammatory cytokines (IL-1β and IL-6), and COX-2 and iNOS expression. Additionally, miR-412-5p-loaded exosomes significantly decreased the expression of MAPK signaling molecules, including p-extracellular signal-regulated kinase (ERK), p-p38, and p-Jun kinase (JNK), in H9c2 cardiomyocytes.

Conclusion

These findings showed that miR-412-5p-loaded exosomes ameliorated LPS-induced inflammation in H9c2 cardiomyocytes by inhibiting COX-2 and iNOS expression, inflammatory mediators, and pro-inflammatory cytokines via the MAPK pathway. The findings indicate that miR-412-5p-loaded exosomes may be effective for the prevention of myocardial injury.

Targeting endothelial cells with golden spice curcumin: A promising therapy for cardiometabolic multimorbidity

Cardiometabolic multimorbidity (CMM) is an increasingly significant global public health concern. It encompasses the coexistence of multiple cardiometabolic diseases, including hypertension, stroke, heart disease, atherosclerosis, and T2DM. A crucial component to the development of CMM is the disruption of endothelial homeostasis. Therefore, therapies targeting endothelial cells through multi-targeted and multi-pathway approaches hold promise for preventing and treatment of CMM. Curcumin, a widely used dietary supplement derived from the golden spice Carcuma longa, has demonstrated remarkable potential in treatment of CMM through its interaction with endothelial cells. Numerous studies have identified various molecular targets of curcumin (such as NF-κB/PI3K/AKT, MAPK/NF-κB/IL-1β, HO-1, NOs, VEGF, ICAM-1 and ROS). These findings highlight the efficacy of curcumin as a therapeutic agent against CMM through the regulation of endothelial function. It is worth noting that there is a close relationship between the progression of CMM and endothelial damage, characterized by oxidative stress, inflammation, abnormal NO bioavailability and cell adhesion. This paper provides a comprehensive review of curcumin, including its availability, pharmacokinetics, pharmaceutics, and therapeutic application in treatment of CMM, as well as the challenges and future prospects for its clinical translation. In summary, curcumin shows promise as a potential treatment option for CMM, particularly due to its ability to target endothelial cells. It represents a novel and natural lead compound that may offer significant therapeutic benefits in the management of CMM.

The Analgesic Effects of the Addition of Intravenous Ibuprofen to a Multimodal Analgesia Regimen for Pain Management After Pediatric Cardiac Surgery: A Randomized Controlled Study

OBJECTIVE

Intravenous ibuprofen is used to control fever and pain. This study aimed to assess the analgesic effects of the addition of intravenous ibuprofen to a multimodal analgesia regimen for pain management after pediatric cardiac surgery.

DESIGN

A randomized, controlled, double-blinded, superiority study.

SETTING

University hospital.

PARTICIPANTS

Seventy-eight pediatric patients who underwent open cardiac surgery using midline sternotomy incision were screened for eligibility; 10 patients were excluded, leaving 68 patients (34 patients in the ibuprofen group and 34 patients in the control group) for final data analysis.

INTERVENTIONS

Patients were randomly allocated to either the ibuprofen group, in which the patient received intravenous ibuprofen infusion of 10 mg/kg/6 hours for 24 hours, or the control group, in which the patient received a placebo 0.9% saline.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was the 24-hour postoperative fentanyl consumption, and the secondary endpoints were postoperative modified objective pain score and the incidence of ibuprofen-related side effects (eg, vomiting, epigastric pain, bleeding, and renal dysfunction). The mean total fentanyl consumption (μg/kg) during the first postoperative 24 hours after extubation was significantly lower (p<0.001) in the ibuprofen group (3.5 ± 1.3) than the control group (5.1 ± 1.4). The median postoperative modified objective pain score was significantly lower (p < 0.05) in the ibuprofen group than the control group at 0 hours, 2 hours, 12 hours, 16 hours, 20 hours, and 24 hours postoperatively. Ibuprofen did not cause significant increases in the incidences of bleeding, epigastric pain, and vomiting. Postoperative renal dysfunction was not reported in any patient.

CONCLUSIONS

The addition of intravenous ibuprofen to a multimodal analgesia regimen for pain management after pediatric cardiac surgery improved postoperative analgesia in terms of reduction of opioid consumption and pain scores.

Systemic complications of rheumatoid arthritis: Focus on pathogenesis and treatment

As a systemic autoimmune disease, rheumatoid arthritis (RA) usually causes damage not only to joints, but also to other tissues and organs including the heart, kidneys, lungs, digestive system, eyes, skin, and nervous system. Excessive complications are closely related to the prognosis of RA patients and even lead to increased mortality. This article summarizes the serious complications of RA, focusing on its incidence, pathogenesis, clinical features, and treatment methods, aiming to provide a reference for clinicians to better manage the complications of RA.

Celecoxib and Etoricoxib may reduce risk of ischemic stroke in patients with rheumatoid arthritis: A nationwide retrospective cohort study

Background and purpose

Previous studies reported conflicting results about the risk of ischemic stroke associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA). We aimed to investigate two specific COX-2 inhibitors, Celecoxib and Etoricoxib, and their corresponding effects on the risk of ischemic stroke in patients with RA.

Patients and methods

10,857 patients newly diagnosed with RA were identified and sampled from the Taiwanese National Health Insurance Research Database during the period from 2001 to 2009. The identification of RA was based on the criteria of ICD-9-CM diagnosis code 714.0. Patients diagnosed with cerebrovascular disease and those receiving RA treatment prior to the first diagnosis of RA were excluded. Study endpoint was ischemic stroke, defined by ICD-9-CM code. Cox proportional hazard models and Kaplan Meier curves were used to reveal covariates and differences by drugs in the risk of ischemic stroke. Dosages for Celecoxib were defined as ≤ 200 and >200 mg/day; those for Etoricoxib were 0 and >0 mg/day.

Results

Among 7,904 RA patients, 6,669 did not take Celecoxib and 564 (8.46%) of them experienced an ischemic stroke event. Of the 597 individuals who took ≤ 200 mg/day of Celecoxib, 58 (9.72%) had strokes. Of the 638 patients who took >200 mg/day of Celecoxib, 38 (5.96%) eventually experienced a stroke. Among the 7,681 patients who did not take Etoricoxib, 654 (8.51%) experienced an ischemic stroke, while 6 (2.69%) in 223 patients who consumed Etoricoxib had a stroke event. Consuming more than 200 mg of Celecoxib per day for <3.5 years lowered the incidence rate for strokes [hazard ratio (HR) 0.67, 95% Confidence Interval (CI) 0.48–0.93 for dosage and HR 0.22, 95% CI 0.10–0.46 for duration, both p < 0.001], while consuming any dosage of Etoricoxib significantly decreases the possibility (HR 0.35, 95% CI 0.16–0.80, p < 0.001). On the other hand, consuming Etoricoxib for 8 years might have a neutral or even a potentially protective effect compared to at 3.8 years.

Conclusion

This population-based retrospective cohort study has shown that Celecoxib and Etoricoxib reduce the risk of ischemic stroke in patients with RA in a dose- and time-dependent manner.

Comparison of intravenous ibuprofen versus ketorolac for postoperative analgesia in children undergoing lower abdominal surgery: A randomized, controlled, non-inferiority study

BACKGROUND

Non-steroidal anti-inflammatory drugs are often used as part of multimodal analgesia to control postoperative pain. This randomized, controlled, double-blinded, non-inferiority study aimed to compare the postoperative analgesic effects of intravenous ibuprofen versus ketorolac in children undergoing open unilateral lower abdominal surgery. The authors hypothesized that postoperative analgesia produced by intravenous ibuprofen would be non-inferior to that of intravenous ketorolac.

METHODS

Sixty-six children aged 2 to 8 years who were scheduled to undergo unilateral lower abdominal surgery, were recruited. Patients in the ibuprofen group received 10mg/kg/6h intravenous ibuprofen. Patients in the ketorolac group were given 0.5mg/kg/6h intravenous ketorolac. The primary outcome measure was 24-h postoperative morphine consumption. The secondary outcome measures were postoperative pain score, the incidence of early postoperative fever and the incidence of ibuprofen and ketorolac adverse effects including pain during drug infusion, vomiting, epigastric pain and allergic reaction.

RESULTS

Fifty-nine patients completed the study (30 ibuprofen, 29 ketorolac). There was no significant difference (P=0.305) in the mean (SD) 24-h postoperative morphine consumption (μ/kg) between intravenous ibuprofen, 16.00 (5.31), and ketorolac, 14.65 (4.61). The reported pain scores were similar in both groups. The incidence of postoperative fever was significantly lower (p=0.039) in the ibuprofen group (3%) than the ketorolac group (20%). The incidence of adverse effects was similar in both ibuprofen and ketorolac groups.

CONCLUSIONS

Intravenous ibuprofen can be used as an alternative to ketorolac for postoperative analgesia in children undergoing unilateral lower abdominal surgery because both drugs similarly provide safe and effective postoperative analgesia.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.

Targeting endothelial dysfunction and inflammation

Vascular endothelium maintains vascular homeostasis through liberating a spectrum of vasoactive molecules, both protective and harmful regulators of vascular tone, structural remodeling, inflammation and atherogenesis. An intricate balance between endothelium-derived relaxing factors (nitric oxide, prostacyclin and endothelium-derived hyperpolarizing factor) and endothelium-derived contracting factors (superoxide anion, endothelin-1 and constrictive prostaglandins) tightly regulates vascular function. Disruption of such balance signifies endothelial dysfunction, a critical contributor in aging and chronic cardiometabolic disorders, such as obesity, diabetes, hypertension, dyslipidemia and atherosclerotic vascular diseases. Among many proposed cellular and molecular mechanisms causing endothelial dysfunction, oxidative stress and inflammation are often the pivotal players and they are naturally considered as useful targets for intervention in patients with cardiovascular and metabolic diseases. In this article, we provide a recent update on the therapeutic values of pharmacological agents, such as cyclooxygenase-2 inhibitors, renin-angiotensin-system inhibitors, bone morphogenic protein 4 inhibitors, peroxisome proliferator-activated receptor δ agonists, and glucagon-like peptide 1-elevating drugs, and the physiological factors, particularly hemodynamic forces, that improve endothelial function by targeting endothelial oxidative stress and inflammation.

Roles of Hormone Replacement Therapy and Menopause on Osteoarthritis and Cardiovascular Disease Outcomes: A Narrative Review

Osteoarthritis (OA) is a highly prevalent condition characterized by degradation of the joints. OA and cardiovascular disease (CVD) are leading contributors to disease burden worldwide, with a high level of overlap between the risk factors and occurrence of both conditions. Chief among the risk factors that contribute to OA and CVD are sex and age, which are both independent and interacting traits. Specifically, the prevalence of both conditions is higher in older women, which may be mediated by the occurrence of menopause. Menopause represents a significant transition in a women's life, and the rapid decline in circulating sex hormones, estrogen and progesterone, leads to complex physiological changes. Declines in hormone levels may partially explain the increase in prevalence of OA and CVD in post-menopausal women. In theory, the use of hormone therapy (HT) may buffer adverse effects of menopause; however, it is unclear whether HT offers protective effects for the onset or progression of these diseases. Studies have shown mixed results when describing the influence of HT on disease risk among post-menopausal women, which warrants further exploration. The roles that increasing age, female sex, HT, and CVD play in OA risk demonstrate that OA is a multifaceted condition. This review provides a timely consolidation of current literature and suggests aims for future research directions to bridge gaps in the understanding of how OA, CVD, and HT interact in post-menopausal women.

Biological Evaluation and Molecular Docking Studies of Novel 1,3,4-Oxadiazole Derivatives of 4,6-Dimethyl-2-sulfanylpyridine-3-carboxamide

To date, chronic inflammation is involved in most main human pathologies such as cancer, and autoimmune, cardiovascular or neurodegenerative disorders. Studies suggest that different prostanoids, especially prostaglandin E₂, and their own synthase (cyclooxygenase enzyme-COX) can promote tumor growth by activating signaling pathways which control cell proliferation, migration, apoptosis, and angiogenesis. Non-steroidal anti-inflammatory drugs (NSAIDs) are used, alongside corticosteroids, to treat inflammatory symptoms particularly in all chronic diseases. However, their toxicity from COX inhibition and the suppression of physiologically important prostaglandins limits their use. Therefore, in continuation of our efforts in the development of potent, safe, non-toxic chemopreventive compounds, we report herein the design, synthesis, biological evaluation of new series of Schiff base-type hybrid compounds containing differently substituted N-acyl hydrazone moieties, 1,3,4-oxadiazole ring, and 4,6-dimethylpyridine core. The anti-COX-1/COX-2, antioxidant and anticancer activities were studied. Schiff base 13, containing 2-bromobenzylidene residue inhibited the activity of both isoenzymes, COX-1 and COX-2 at a lower concentration than standard drugs, and its COX-2/COX-1 selectivity ratio was similar to meloxicam. Furthermore, the results of cytotoxicity assay indicated that all of the tested compounds exhibited potent anti-cancer activity against A549, MCF-7, LoVo, and LoVo/Dx cell lines, compared with piroxicam and meloxicam. Moreover, our experimental study was supported by density functional theory (DFT) and molecular docking to describe the binding mode of new structures to cyclooxygenase.

Kidney damage from nonsteroidal anti-inflammatory drugs-Myth or truth? Review of selected literature

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely available drugs with anti-inflammatory and analgesic properties. Their mechanism of action is associated with the enzymes of the arachidonic acid cycle (cyclooxygenases: COX-1 and COX-2). The cyclooxygenase pathway results in the formation of prostanoids (prostaglandins [PGs], prostacyclins, and thromboxanes). It affects various structures of the human body, including the kidneys. Medical literature associates the usage of NSAIDs with acute kidney injury (AKI), tubulointerstitial nephritis (TIN), as well as nephrotic syndrome and chronic kidney disease (CKD). AKI associated with the chronic consumption of NSAIDs is mainly attributed to pharmacological polytherapy and the presence of cardiovascular or hepatic comorbidities. The pathomechanism of AKI and CKD is associated with inhibition of the biosynthesis of prostanoids involved in the maintenance of renal blood flow, especially PGE2 and PGI2. It is suggested that both COX isoforms play opposing roles in renal function, with natriuresis increased by COX-1 inhibition followed by a drop in a blood pressure, whereas COX-2 inhibition increases blood pressure and promotes sodium retention. TIN after NSAID use is potentially associated with glomerular basement membrane damage, reduction in pore size, and podocyte density. Therefore, nephrotic proteinuria and impairment of renal function may occur. The following article analyzes the association of NSAIDs with kidney disease based on available medical literature.

Vascular Inflammation in Hypertension: Targeting Lipid Mediators Unbalance and Nitrosative Stress

Arterial hypertension is a worldwide public health threat. High Blood Pressure (BP) is commonly associated with endothelial dysfunction, nitric oxide synthases (NOS) unbalance and high peripheral vascular resistance. In addition to those, inflammation has also been designated as one of the major components of BP increase and organ damage in hypertension. This minireview discusses vascular inflammatory triggers of high BP and aims to fill the existing gaps of antiinflammatory therapy of hypertension. Among the reasons discussed, enhanced prostaglandins rather than resolvins lipid mediators, immune cell infiltration and oxidative/nitrosative stress are pivotal players of BP increase within the inflammatory hypothesis. To address these inflammatory targets, this review also proposes new concepts in hypertension treatment with non-steroidal antiinflammatory drugs (NSAIDs), nitric oxide-releasing NSAIDs (NO-NSAIDs) and specialized proresolving mediators (SPM). In this context, the failure of NSAIDs in hypertension treatment seems to be associated with the reduction of endogenous NO bioavailability, which is not necessarily an effect of all drug members of this pharmacological class. For this reason, NO-releasing NSAIDs seem to be safer and more specific therapy to treat vascular inflammation in hypertension than regular NSAIDs.

The Effects of Anesthetics and Perioperative Medications on Immune Function: A Narrative Review

Preclinical and clinical studies have sought to better understand the effect of anesthetic agents, both volatile and intravenous, and perioperative adjuvant medications on immune function. The immune system has evolved to incorporate both innate and adaptive components, which are delicately interwoven and essential for host defense from pathogens and malignancy. This review summarizes the complex and nuanced relationship that exists between each anesthetic agent or perioperative adjuvant medication studied and innate and adaptive immune function with resultant clinical implications. The most commonly used anesthetic agents were chosen for review including volatile agents (sevoflurane, isoflurane, desflurane, and halothane), intravenous agents (propofol, ketamine, etomidate, and dexmedetomidine), and perioperative adjuvant medications (benzodiazepines, opioids, nonsteroidal anti-inflammatory drugs [NSAIDs], and local anesthetic agents). Patients who undergo surgery experience varying combinations of the aforementioned anesthetic agents and adjuncts, depending on the type of surgery and their comorbidities. Each has unique effects on immunity, which may be more or less ideal depending on the clinical situation. Further study is needed to better understand the clinical effects of these relationships so that patient-specific strategies can be developed to improve surgical outcomes.

Analgesic and anti-inflammatory articular effects of essential oil and camphor isolated from Ocimum kilimandscharicum Gürke leaves

ETHNOPHARMACOLOGICAL RELEVANCE

Leaves from Ocimum kilimandscharicum Gürke (Lamiaceae) are popularly used against articular pain.

AIM OF STUDY

The aim of this study was to test the anti-inflammatory and anti-hyperalgesic (analgesic) properties of the essential oil and camphor isolated from O. Kilimandscharicum leaves (EOOK) in 4 models including zymosan induced-articular inflammation model in mice.

MATERIAL AND METHODS

For in vivo models, EOOK was tested in carrageenan-induced paw edema model with oral doses of 30, 100, and 300 mg/kg (oral administration = p.o.) and in zymosan-induced articular inflammation (including knee edema, leukocyte infiltration, mechanical hyperalgesia and nitric oxide), EOOK (100 mg/kg, p. o.) and camphor (30 mg/kg, p. o.) were tested. EOOK (100 mg/kg, p. o.) was tested in the rolling and also in the adhesion of leukocytes to the mesenteric microcirculation in situ model of carrageenan induced inflammation and EOOK (1, 3, 10, 30, and 60 μg/mL) was tested in vitro against neutrophils chemotaxis induced by N-formyl methionyl leucyl phenylalanine (fMLP).

RESULTS

The treatment with EOOK significantly inhibited the carrageenan-induced edema, mechanical and cold hyperalgesia. Both, EOOK and camphor inhibited all articular parameters induced by zymosan. In situ intravitral microscopy analysis, EOOK significantly inhibited carrageenan-induced leukocyte rolling and adhesion. In vitro neutrophils chemotaxis, EOOK inhibited the leukocyte chemotaxis induced by fMLP.

CONCLUSIONS

The present study showed that EOOK inhibited pain and inflammatory parameters contributing, at least in part, to explain the popular use of this plant as analgesic natural agent. This study also demonstrates that camphor and some known anti-inflammatory compounds present in EOOK could contribute for analgesic and anti-inflammatory articular properties.

Deep sequencing of prostaglandin-endoperoxide synthase (PTGE) genes reveals genetic susceptibility for cross-reactive hypersensitivity to NSAID

BACKGROUND AND PURPOSE

Cross-reactive hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) is a relatively common adverse drug event caused by two or more chemically unrelated drugs and that is attributed to inhibition of the COX activity, particularly COX-1. Several studies investigated variations in the genes coding for COX enzymes as potential risk factors. However, these studies only interrogated a few single nucleotide variations (SNVs), leaving untested most of the gene sequence.

EXPERIMENTAL APPROACH

In this study, we analysed the whole sequence of the prostaglandin-endoperoxide synthase genes, PTGS1 and PTGS2, including all exons, exon-intron boundaries and both the 5' and 3' flanking regions in patients with cross-reactive hypersensitivity to NSAIDs and healthy controls. After sequencing analysis in 100 case-control pairs, we replicated the findings in 540 case-control pairs. Also, we analysed copy number variations for both PTGS genes.

KEY RESULTS

The most salient finding was the presence of two PTGS1 single nucleotide variations, which are significantly more frequent in patients than in control subjects. Patients carrying these single nucleotide variations displayed a significantly and markedly lower COX-1 activity as compared to non-carriers for both heterozygous and homozygous patients.

CONCLUSION AND IMPLICATIONS

Although the risk single nucleotide variations are present in a small proportion of patients, the strong association observed and the functional effect of these single nucleotide variations raise the hypothesis of genetic susceptibility to develop cross-reactive NSAID hypersensitivity in individuals with an impairment in COX-1 enzyme activity.

The Physiologic Activity and Mechanism of Quercetin-Like Natural Plant Flavonoids

The term "vitamin P" is an old but interesting concept. Most substances in this category belong to the family of flavonoids. "Vitamin P" has also been used to define the activity of some flavonoids, including quercetin, myricetin, and rutin. According to experimental studies, the "quercetin-like natural plant flavonoids" are beneficial to the body due to their various physiological and pharmacological activities in large doses (5 μM in vitro, 50 mg/kg in mice and 100 mg/kg in rats). The physiologically achievable concentration is 10 to 100 nM, which is quite high and hard to achieve from a normal diet. Thus, the physiologic activity and mechanism of "vitamin P" are still not clear. It should be noted that the quercetin-like natural plant flavonoids are physiological co-factors of cyclooxygenases (COXs), which are the rate-limiting key enzymes of prostaglandins. These quercetin-like natural plant flavonoids can strongly stimulate prostaglandin levels at lower doses (10 nM in vitro and in 0.1 mg/kg in vivo in rats). Although these "vitamin P" substances are not original substances in the body, their physiological functions affect the body. This review is focused on the most compelling evidence regarding the physiologic role and mechanism of quercetin-like natural plant flavonoids, which may be useful in understanding the physiological functions of "vitamin P", with the goal of focusing on the role of flavonoids in human physiological health.

Evaluation of the community pharmacists' performance in the screening of non-steroidal anti-inflmmatory drugs risks in Saudi Arabia

OBJECTIVES

To assess community pharmacists' knowledge and practices regarding screening risk factors and providing safety information about the use of non- steroidal anti-in ammatory drugs (NSAIDs) to patients.

METHODS

Cross-sectional and a self-administered questionnaire-based study was conducted over a 4-month period (May-August 2019) with selected community pharmacies in Jeddah, Saudi Arabia. The questionnaire composed of demographic data and the pharmacist's role in supplying NSAIDs.

RESULTS

The majority of participating community pharmacists dispense NSAIDs. However, many did not apply relevantly good communication skills such as seeking information about concomitant drugs (42.5%) or providing advice on managing any adverse side effects of taking NSAIDs (39.1%). Most of the community pharmacists also did not provide relevantly good communication about risk factors. The most common screening risk factors mentioned were a history of pregnancy and breastfeeding (84.2%) followed by being at an older age (74.5%) or a history of a gastrointestinal ulcer (71.5%).

CONCLUSION

Community pharmacists in Saudi Arabia need to appropriately screen their patients for adverse drug reactions and the ectively communicate the risks of using NSAIDs. The Saudi Regulatory Authority could endorse several approaches to apply a good strategy for improving the dispensing practices in community pharmacies, communication and awareness of risk factors especially in high-risk patients who are taking NSAIDs.

COVID-19: Pain Management in Patients with SARS-CoV-2 Infection-Molecular Mechanisms, Challenges, and Perspectives

Since the end of 2019, the whole world has been struggling with the pandemic of the new Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2). Available evidence suggests that pain is a common symptom during Coronavirus Disease 2019 (COVID-19). According to the World Health Organization, many patients suffer from muscle pain (myalgia) and/or joint pain (arthralgia), sore throat and headache. The exact mechanisms of headache and myalgia during viral infection are still unknown. Moreover, many patients with respiratory failure get admitted to the intensive care unit (ICU) for ventilatory support. Pain in ICU patients can be associated with viral disease itself (myalgia, arthralgia, peripheral neuropathies), may be caused by continuous pain and discomfort associated with ICU treatment, intermittent procedural pain and chronic pain present before admission to the ICU. Undertreatment of pain, especially when sedation and neuromuscular blocking agents are used, prone positioning during mechanical ventilation or extracorporeal membrane oxygenation (ECMO) may trigger delirium and cause peripheral neuropathies. This narrative review summarizes current knowledge regarding challenges associated with pain assessment and management in COVID-19 patients. A structured prospective evaluation should be undertaken to analyze the probability, severity, sources and adequate treatment of pain in patients with COVID-19 infection.

Astragalus membranaceus Injection Suppresses Production of Interleukin-6 by Activating Autophagy through the AMPK-mTOR Pathway in Lipopolysaccharide-Stimulated Macrophages

Astragalus membranaceus (AM), used in traditional Chinese medicine, has been shown to enhance immune functions, and recently, its anti-inflammatory effects were identified. However, the mechanisms of action remain unclear. Most studies have shown that autophagy might be involved in the immune response of the body, including inflammation. Here, we developed an inflammatory model by stimulating macrophages with lipopolysaccharides (LPS) to explore the anti-inflammatory effect and mechanisms of AM injection from the perspective of the regulation of autophagy. Immunoblot, immunofluorescence, and ELISA were used to determine the effects of AM injection on the production of interleukin-6 (IL-6) and alterations of autophagy markers. It was found that AM injection reduced the expression of IL-6 in LPS-stimulated macrophages and reversed the LPS-induced inhibition of cellular autophagy. After treatment with inhibitors of signaling pathways, it was shown that LPS downregulated autophagy and upregulated the production of IL-6 in macrophages via the protein kinase B (Akt)/mammalian target of rapamycin (mTOR) pathway. AM injection reversed the effects of LPS by activating the AMP-activated protein kinase (AMPK) instead of inhibiting Akt. These results were further confirmed by testing activators and siRNA silencing of AMPK. Hence, these 2 distinct signaling molecules appear to exert opposite effects on mTOR, which integrates information from multiple upstream signaling pathways, negatively regulating autophagy. In addition, we demonstrated that autophagy might play a key role in regulating the production of IL-6 by testing activators and inhibitors of autophagy and siRNA silencing of ATG5. These findings showed that AM injection might enhance autophagy by activating AMPK and might further play a repressive effect on the LPS-stimulated expression of IL-6. This study explored the relationship between autophagy, signaling pathways, and the production of inflammatory factors in a model of endotoxin infection and treatment with AM injection.

Structural investigation on the selective COX-2 inhibitors mediated cardiotoxicity: A review

Initially, the selective COX-2 inhibitors were developed as safer alternatives to the conventional NSAIDs, but later on, most of them were withdrawn from the market due to the risk of heart attack and stroke. Celecoxib, the first selective COX-2 inhibitor, was approved by the Food and Drug Administration (FDA) in December 1998 and was taken back from the market in 2004. Since then, many coxibs have been discontinued one by one due to adverse cardiovascular events. United States (US), Australian and European authorities related to Therapeutic Goods Administration (TGA) implemented the requirements to carry the "Black box" warning on the labels of COX-2 drugs highlighting the risks of serious cardiovascular events. These facts encouraged the researchers to explore them well and find out the biochemical basis behind the cardiotoxicity. From the last few decades, the molecular mechanisms behind the coxibs have regained the attention, especially the specific structural features of the selective COX-2 inhibitors that are associated with cardiotoxicity. This review discusses the key structural features of the selective COX-2 inhibitors and underlying mechanisms that are responsible for the cardiotoxicity. This report also unfolds different strategies that have been reported in the last 10 years to combat the problem of selective COX-2 inhibitors mediated cardiotoxicity.

Acupuncture for lumbar disc herniation: Protocol for a systematic review and meta-analysis

BACKGROUND

As development of society and change of modern life style, the prevalence of lumbar disc herniation (LDH) has been increasing. Being a major cause of low back pain, sciatica and radicular leg pain, LDH imposes a heavy burden on both individual and society. Because of high surgically intervene rate, non-invasive (non-surgical) treatments are recommended for most cases. Acupuncture has the advantages of low risk, good effect and low cost which has been proven that could alleviate pain while physical therapy plays a major role in the treatment of LDH in the vast majority of countries. The aim of this systematic review is to evaluate the effectiveness and safety of acupuncture for LDH.

METHODS

RCTs on ACU treating LDH will be searched from the following databases: PubMed, Web of science, EmBase, Cochrane Library, China National Knowledge Infrastructure, Wanfang data, from their inception to May 2020. The primary outcomes are verbal rating scale and functional disability. Two reviewers will independently exclude substandard articles and extract eligible data. The risk of bias will be assessed using the Cochrane Handbook 5.1.0 for Systematic Reviews of Interventions. Egger test will be used to assess the reporting bias. Heterogeneity will be evaluated by the I statistic and Q test. We will conduct the meta-analysis using Stata V12.0 to evaluate the effectiveness of ACU for LDH. In case of high heterogeneity, sensitivity analysis of different items and subgroup analysis will be performed. The Grading of Recommendations Assessment, Development, and Evaluation System will be used to assess the quality of evidence.

RESULTS

The results of this review will be submitted to a journal for publication.

CONCLUSION

This proposed systematic review will evaluate the effectiveness and safety of acupuncture for LDH.

REGISTRATION

PROSPERO (registration number CRD42019148272).