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Dietrich S, Ceulemans J, Hermans E, Argyropoulos T, Goumas K, Vertzoni M, Reppas C. Understanding the Conditions Under Which Drugs are Transferred from the Stomach Through the Upper Small Intestine After a High-Calorie, High-Fat Meal. J Pharm Sci 2024; 113:1546-1554. [PMID: 38218315 DOI: 10.1016/j.xphs.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
Information on the conditions under which drugs are transferred from the stomach through the upper small intestine after a high-calorie, high-fat meal is very limited. To simulate the drug presence after disintegration and arrival in the antral region, paracetamol solution and Sporanox® amorphous solid dispersion pellets at two dose levels were administered to the antrum of 8 healthy adults 30 min after administration of a high-calorie, high-fat meal on a crossover basis. The overall median buffer capacity of antral contents was estimated to be 18.0 and 24.0 mmol/ml/ΔpH when titrating with NaOH and HCl, respectively. The corresponding values for the contents of upper the small intestine were 14.0 and 16.8 mmol/ml/ΔpH, respectively. The drug transfer process from the antrum through the upper small intestine occurred with apparent first-order kinetics. The best estimate for the antral emptying half-life was 39min and 45min for paracetamol and itraconazole, respectively, the apparent volume of contents of the upper small intestine was more than double compared with previously reported values in the fasted state, the half-life of drug elimination from the upper small intestine was similar to recent estimates for highly permeable drugs in the fasted state, and the apparent volume of antral contents during the first couple of hours post drug administration was 303mL. Information collected in this study could increase the reliability of in silico and/or in vitro modelling approaches applied in clinical drug development.
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Affiliation(s)
- Shirin Dietrich
- Department of Pharmacy, National and Kapodistrian University of Athens, Zografou, Greece; Pharmaceutical and Material Sciences, Pharmaceutical Product Development and Supply, Janssen Pharmaceutica NV, Beerse, Belgium
| | - Jens Ceulemans
- Pharmaceutical and Material Sciences, Pharmaceutical Product Development and Supply, Janssen Pharmaceutica NV, Beerse, Belgium
| | - Eline Hermans
- Pharmaceutical and Material Sciences, Pharmaceutical Product Development and Supply, Janssen Pharmaceutica NV, Beerse, Belgium
| | | | - Konstantinos Goumas
- Department of Gastroenterology, Red Cross Hospital of Athens, Athens, Greece
| | - Maria Vertzoni
- Department of Pharmacy, National and Kapodistrian University of Athens, Zografou, Greece
| | - Christos Reppas
- Department of Pharmacy, National and Kapodistrian University of Athens, Zografou, Greece.
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Hu J, Wan J, Xi J, Shi W, Qian H. AI-driven design of customized 3D-printed multi-layer capsules with controlled drug release profiles for personalized medicine. Int J Pharm 2024; 656:124114. [PMID: 38615804 DOI: 10.1016/j.ijpharm.2024.124114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 04/16/2024]
Abstract
Personalized medicine aims to effectively and efficiently provide customized drugs that cater to diverse populations, which is a significant yet challenging task. Recently, the integration of artificial intelligence (AI) and three-dimensional (3D) printing technology has transformed the medical field, and was expected to facilitate the efficient design and development of customized drugs through the synergy of their respective advantages. In this study, we present an innovative method that combines AI and 3D printing technology to design and fabricate customized capsules. Initially, we discretized and encoded the geometry of the capsule, simulated the dissolution process of the capsule with classical drug dissolution model, and verified it by experiments. Subsequently, we employed a genetic algorithm to explore the capsule geometric structure space and generate a complex multi-layer structure that satisfies the target drug release profiles, including stepwise release and zero-order release. Finally, Two model drugs, isoniazid and acetaminophen, were selected and fused deposition modeling (FDM) 3D printing technology was utilized to precisely print the AI-designed capsule. The reliability of the method was verified by comparing the in vitro release curve of the printed capsules with the target curve, and the f2 value was more than 50. Notably, accurate and autonomous design of the drug release curve was achieved mainly by changing the geometry of the capsule. This approach is expected to be applied to different drug needs and facilitate the development of customized oral dosage forms.
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Affiliation(s)
- Jingzhi Hu
- School of Science, China Pharmaceutical University, Nanjing, PR China
| | - Jiale Wan
- School of Science, China Pharmaceutical University, Nanjing, PR China
| | - Junting Xi
- School of Science, China Pharmaceutical University, Nanjing, PR China
| | - Wei Shi
- Center of Drug Discovery, State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, China Pharmaceutical University, Nanjing, PR China
| | - Hai Qian
- Center of Drug Discovery, State Key Laboratory of Natural Medicines and Jiangsu Key Laboratory of Drug Discovery for Metabolic Disease, China Pharmaceutical University, Nanjing, PR China.
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Deslandes M, Deicke M, Grannemann JJ, Hinkelbein J, Hoyer A, Kalmbach M, Kobiella A, Strickmann B, Plappert T, Jansen G. Effectiveness and safety of prehospital analgesia with nalbuphine and paracetamol versus morphine by paramedics - an observational study. Scand J Trauma Resusc Emerg Med 2024; 32:41. [PMID: 38730453 PMCID: PMC11084095 DOI: 10.1186/s13049-024-01215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the development of various analgesic concepts, prehospital oligoanalgesia remains very common. The present work examines prehospital analgesia by paramedics using morphine vs. nalbuphine + paracetamol. METHODS Patients with out-of-hospital-analgesia performed by paramedics from the emergency medical services of the districts of Fulda (morphine) and Gütersloh (nalbuphine + paracetamol) were evaluated with regards to pain intensity at the beginning and the end of prehospital treatment using the Numeric-Rating-Scale for pain (NRS), sex, age, and complications. The primary endpoint was achievement of adequate analgesia, defined as NRS < 4 at hospital handover, depending on the analgesics administered (nalbuphine + paracetamol vs. morphine). Pain intensity before and after receiving analgesia using the NRS, sex, age and complications were also monitored. RESULTS A total of 1,808 patients who received out-of-hospital-analgesia were evaluated (nalbuphine + paracetamol: 1,635 (90.4%), NRS-initial: 8.0 ± 1.4, NRS-at-handover: 3.7 ± 2.0; morphine: 173(9.6%), NRS-initial: 8.5 ± 1.1, NRS-at-handover: 5.1 ± 2.0). Factors influencing the difference in NRS were: initial pain intensity on the NRS (regression coefficient (RK): 0.7276, 95%CI: 0.6602-0.7950, p < 0.001), therapy with morphine vs. nalbuphine + paracetamol (RK: -1.2594, 95%CI: -1.5770 - -0.9418, p < 0.001) and traumatic vs. non-traumatic causes of pain (RK: -0.2952, 95%CI: -0.4879 - -0.1024, p = 0.002). Therapy with morphine (n = 34 (19.6%)) compared to nalbuphine + paracetamol (n = 796 (48.7%)) (odds ratio (OR): 0.274, 95%CI: 0.185-0.405, p < 0.001) and the initial NRS score (OR:0.827, 95%CI: 0.771-0.887, p < 0.001) reduced the odds of having an NRS < 4 at hospital handover. Complications occurred with morphine in n = 10 (5.8%) and with nalbuphine + paracetamol in n = 35 (2.1%) cases. Risk factors for complications were analgesia with morphine (OR: 2.690, 95%CI: 1.287-5.621, p = 0.008), female sex (OR: 2.024, 95%CI: 1.040-3.937, p = 0.0379), as well as age (OR: 1.018, 95%CI: 1.003-1.034, p = 0.02). CONCLUSIONS Compared to morphine, prehospital analgesia with nalbuphine + paracetamol yields favourable effects in terms of analgesic effectiveness and a lower rate of complications and should therefore be considered in future recommendations for prehospital analgesia.
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Affiliation(s)
- Marvin Deslandes
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Martin Deicke
- Emergency Medical Service, County of Osnabrueck, Am Schölerberg 1, 49082, Osnabrueck, Germany
- Department of Anesthesiology and operative Intensive Care Medicine, Hospital of Osnabrueck, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Julia Johanna Grannemann
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Jochen Hinkelbein
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Matthias Kalmbach
- Emergency Medical Services, City and District of Fulda, Otfrid-von-Weißenburg-Str. 3, 36043, Fulda, Germany
- Emergency Department, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Germany
| | - André Kobiella
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Bernd Strickmann
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Thomas Plappert
- Emergency Medical Services, City and District of Fulda, Otfrid-von-Weißenburg-Str. 3, 36043, Fulda, Germany
- Emergency Medical Services of the Order of Malta, Region Hesse, Schmidtstrasse 67, 60326, Frankfurt/Main, Germany
| | - Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
- Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
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Zhou J, Pan H, Gong W, Yu DG, Sun Y. Electrosprayed Eudragit RL100 nanoparticles with Janus polyvinylpyrrolidone patches for multiphase release of paracetamol. Nanoscale 2024; 16:8573-8582. [PMID: 38602025 DOI: 10.1039/d4nr00893f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Advanced nanotechniques and the corresponding complex nanostructures they produce represent some of the most powerful tools for developing novel drug delivery systems (DDSs). In this study, a side-by-side electrospraying process was developed for creating double-chamber nanoparticles in which Janus soluble polyvinylpyrrolidone (PVP) patches were added to the sides of Eudragit RL100 (RL100) particles. Both sides were loaded with the poorly water-soluble drug paracetamol (PAR). Scanning electron microscope results demonstrated that the electrosprayed nanoparticles had an integrated Janus nanostructure. Combined with observations of the working processes, the microformation mechanism for creating the Janus PVP patches was proposed. XRD, DSC, and ATR-FTIR experiments verified that the PAR drug was present in the Janus particles in an amorphous state due to its fine compatibility with the polymeric matrices. In vitro dissolution tests verified that the Janus nanoparticles were able to provide a typical biphasic drug release profile, with the PVP patches providing 43.8 ± 5.4% drug release in the first phase in a pulsatile manner. In vivo animal experiments indicated that the Janus particles, on one hand, could provide a faster therapeutic effect than the electrosprayed sustained-release RL100 nanoparticles. On the other hand, they could maintain a therapeutic blood drug concentration for a longer period. The controlled release mechanism of the drug was proposed. The protocols reported here pioneer a new process-structure-performance relationship for developing Janus-structure-based advanced nano-DDSs.
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Affiliation(s)
- Jianfeng Zhou
- School of Materials Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China.
| | - Hao Pan
- School of Pharmacy, Liaoning University, 66 Chongshanzhong Road, Shenyang 110036, China.
| | - Wenjian Gong
- School of Materials Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China.
| | - Deng-Guang Yu
- School of Materials Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China.
| | - Yuhao Sun
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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Myers A, Bertoch T, Zhang P, Cooper SA. Clinical validation of a fast-acting acetaminophen: a randomized, active and placebo controlled dental pain study. Curr Med Res Opin 2024; 40:839-848. [PMID: 38505928 DOI: 10.1080/03007995.2024.2331159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/12/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To address the need for faster pain relief of over-the-counter (OTC) analgesic users, a novel drug delivery technology was developed to achieve faster absorption of orally administered acetaminophen with the goal of delivering earlier onset of pain relief. Previous development studies suggested that a 1000 mg dose of this fast-acting acetaminophen (FA-acetaminophen) formulation provided faster absorption and onset of action versus, commercially available OTC fast-acting analgesics, 1000 mg of extra-strength acetaminophen (ES-acetaminophen) or 400 mg of liquid-filled ibuprofen capsules (LG-ibuprofen). This study was designed as the definitive trial evaluating the onset of pain relief of FA-acetaminophen versus these same OTC comparators. METHODS This single-dose, randomized, double-blind, placebo- and active-controlled clinical trial compared analgesic onset, overall efficacy, and safety of FA-acetaminophen 1000 mg, ES-acetaminophen 1000 mg, LG-ibuprofen 400 mg, and placebo over 4 h in a postsurgical dental pain model. Following removal of 3 to 4 impacted third molars, 664 subjects with moderate-to-severe pain were randomized in a 4:4:2:1 ratio to FA-acetaminophen (249), ES-acetaminophen (232), LG-ibuprofen (124), or placebo (59). Mean age was 18.9 years; 45.5% were male; 57.5% had severe baseline pain intensity. Subjects stopped a first stopwatch if/when they had perceptible pain relief and a second stopwatch if/when their pain relief became meaningful to them. Pain intensity difference (PID) and pain relief (PAR) were obtained using an 11-point numerical rating scale. FINDINGS FA-acetaminophen 1000 mg had faster median time to onset of pain relief (15.7 min) compared to ES-acetaminophen 1000 mg (20.2 min, p = 0.035), LG-ibuprofen 400 mg (23.2 min, p < 0.001), and placebo (non-estimable), statistically greater mean PAR and PID scores than other treatment groups at 15 and 30 min, and a statistically greater percentage of subjects with confirmed perceptible pain relief at 15 and 20 min. At 25 min, FA-acetaminophen 1000 mg had a statistically significantly greater percentage of subjects with confirmed perceptible pain relief than LG-ibuprofen 400 mg and placebo. No clinically significant adverse events were reported. CONCLUSIONS This study supports previous studies, demonstrating faster onset of analgesia with FA-acetaminophen 1000 mg compared to OTC ES-acetaminophen 1000 mg and OTC LG-ibuprofen 400 mg. CLINICALTRIALS.GOV IDENTIFIER NCT03224403 https://clinicaltrials.gov/ct2/show/NCT03224403.
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Affiliation(s)
- Andrew Myers
- Johnson and Johnson Consumer, Inc, McNeil Healthcare Division, Downingtown, PA, USA
| | | | - Paul Zhang
- Johnson and Johnson Consumer, Inc, McNeil Healthcare Division, Downingtown, PA, USA
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Moshiri M, Chaeideh B, Ebrahimi M, Dadpour B, Ghodsi A, Haghighizadeh A, Etemad L. Buprenorphine induced opioid withdrawal syndrome relieved by adjunctive Magnesium: A clinical trial. J Subst Use Addict Treat 2024; 160:209307. [PMID: 38309436 DOI: 10.1016/j.josat.2024.209307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Precipitated opioid withdrawal syndrome (OWS) is a severe and intolerable situation that may occur by a pharmaceutical agent. Reactivation of inhibited N-methyl-d-aspartate (NMDA) receptor in person with prolonged opioid use can led to severe OWS. We conducted a double-blind, randomized clinical trial to assess the effect of magnesium sulfate (MGSO4) as an NMDA receptor antagonist on OWS. MATERIALS AND METHODS The study randomly divided forty patients with precipitated OWS due to partial agonist (buprenorphine) use referred to the emergency unit of Toxicology Department of Mashhad University of Medical Sciences, Iran; into two groups. The control group received conventional therapies, including clonidine 0.1 mg tablet each hour, intravenous infusion of 10 mg diazepam every 30 min, and IV paracetamol (Acetaminophen) 1 g, while the intervention group received 3 g of MGSO4 in 20 min and then 10 mg/kg/h up to 2 h, in addition to the conventional treatment. The clinical opiate withdrawal scale (COWS) evaluated OWS at the start of the treatment, 30 min, and 2 h later. RESULTS Both groups had similar demographic, opiate types, and COWS severity at the start of the intervention. COWS was lower in the intervention than the control group at 30 min (11.20 ± 2.86 and 14.65 ± 2.36, respectively, P = 0.002) and at 2 h (3.2 ± 1.61 and 11.25 ± 3.27, respectively, P < 0.001) after treatment. The intervention group received lesser doses of clonidine (0.12 ± 0.51 and 0.17 ± 0.45 mg, P = 0.003) and Diazepam (13.50 ± 5.87, 24.0 ± 6.80 mg, P = 0.001) than the control group. Serum magnesium levels raised from 1.71 ± 0.13 mmol/L to 2.73 ± 0.13 mmol/L in the intervention group. CONCLUSION Magnesium can significantly reduce the severity of OWS. Additional studies are required to confirm these results.
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Affiliation(s)
- Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Clinical Toxicology and Poisoning, Imam Reza (p) Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohsen Ebrahimi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Dadpour
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Clinical Toxicology and Poisoning, Imam Reza (p) Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Ghodsi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atoosa Haghighizadeh
- Department of Pharmaceutical and Food Control, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Etemad
- Medical Toxicology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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Macheras GA, Tzefronis D, Argyrou C, Nikolakopoulou E, Gálvez Miravete A, Karachalios TS. Pain management after total hip arthroplasty: comparative study of analgesic efficacy and tolerability between oral tramadol/dexketoprofen and injectable paracetamol + tramadol. Hip Int 2024; 34:304-310. [PMID: 38204364 DOI: 10.1177/11207000231219797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Multimodal analgesia for total hip arthroplasty (THA) is increasingly employed to reduce early postoperative pain and promote fast patient discharge. The aim of this study was to compare the efficacy and tolerability of tramadol/dexketoprofen (TRAM/DKP, Group A) versus paracetamol + tramadol (PARA+TRAM, Group B) in patients undergoing THA using minimally invasive direct anterior approach (DAA). METHODS A single-centre, randomised, single-blind, parallel, interventional study conducted in 323 patients undergoing primary THA with DAA was performed. Group A consisted of 188 patients and Group B of 135. The primary endpoints were the change from baseline (measured 2 hours postoperatively) in pain intensity (PI) during the treatment period (48 hours), assessed by visual analogue scale (VAS) at pre-specified postoperative time-points (2, 8, 24, 48 hours) and the total rescue medication (RM) use during the first 24 hours postoperatively. RESULTS As early as 2 hours after baseline, Group A showed a greater PI reduction from baseline compared to Group B (-26.24% vs. -6.87%; p < 0.001). A lower mean PI (VAS) score was consistently found over the entire observation period following treatment with TRAM/DKP than with PARA+TRAM as well as more than 2-fold higher proportion of responders at the end of treatment period. More patients in Group B required RM in comparison to those in Group A (15.6% vs. 3.7%, p < 0.001). Both treatments were well tolerated. CONCLUSIONS After THA, oral TRAM/DKP provides faster and greater pain relief when compared to intravenous PARA+TRAM with limited consumption of RM and favourable tolerability profile. Our study expands the use of TRAM/DKP in the setting of major orthopaedic surgeries. CLINICAL TRIAL REGISTRATION clinicaltrials.gov (NCT04178109).
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MESH Headings
- Humans
- Pain, Postoperative/drug therapy
- Pain, Postoperative/diagnosis
- Arthroplasty, Replacement, Hip
- Male
- Female
- Tramadol/administration & dosage
- Tramadol/therapeutic use
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Middle Aged
- Ketoprofen/administration & dosage
- Ketoprofen/analogs & derivatives
- Ketoprofen/therapeutic use
- Single-Blind Method
- Aged
- Administration, Oral
- Pain Measurement
- Tromethamine/administration & dosage
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Treatment Outcome
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Drug Therapy, Combination
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Adult
- Pain Management/methods
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Affiliation(s)
- George A Macheras
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | - Dimitrios Tzefronis
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | - Chrysoula Argyrou
- 4th Department of Trauma and Orthopaedics, KAT Hospital, Athens, Attica, Greece
| | - Elena Nikolakopoulou
- 7th Department of Orthopaedic Surgery, Henry Dunant Hospital Centre, Athens, Attica, Greece
| | | | - Thefilos S Karachalios
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University General Hospital of Larissa, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Thessalia Sterea Ellada, Greece
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Bochi-Kurimoto M, Sakai T, Goto H, Miyazaki S, Hatano Y. Management of severe allergy, reacting to acetaminophen and small doses of cyclooxygenase-2 inhibitor. J Dermatol 2024; 51:e158-e159. [PMID: 38009834 DOI: 10.1111/1346-8138.17050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/06/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Minori Bochi-Kurimoto
- Department of Dermatology, Faculty of Medicine, Oita University, Yufu-shi, Oita, Japan
| | - Takashi Sakai
- Department of Dermatology, Faculty of Medicine, Oita University, Yufu-shi, Oita, Japan
| | - Hinako Goto
- Department of Dermatology, Faculty of Medicine, Oita University, Yufu-shi, Oita, Japan
| | - Sayuri Miyazaki
- Department of Dermatology, Faculty of Medicine, Oita University, Yufu-shi, Oita, Japan
| | - Yutaka Hatano
- Department of Dermatology, Faculty of Medicine, Oita University, Yufu-shi, Oita, Japan
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Bachar G, Alter A, Justman N, Buchnik Fater G, Farago N, Ben-David C, Abu-Rass H, Siegler Y, Hajaj A, Landau-Levin M, Zipori Y, Khatib N, Weiner Z, Vitner D. Fixed-time interval vs on-demand oral analgesia after vaginal delivery: a randomized controlled trial. Am J Obstet Gynecol MFM 2024; 6:101372. [PMID: 38583715 DOI: 10.1016/j.ajogmf.2024.101372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Scheduled administration of analgesics was proven superior to on-demand dosing following cesarean deliveries. However, this protocol was not compared after vaginal delivery. OBJECTIVE To compare the efficacy of a fixed- vs on-demand analgesic protocol for the management of pain in the first 24 hours after a vaginal delivery. STUDY DESIGN This randomized, prospective, controlled trial was conducted at a single tertiary medical center between June 1, 2020 and June 30, 2022. Vaginally delivered patients were randomly assigned to receive oral analgesics (paracetamol 1 g + ibuprofen 400 mg) either every 6 hours for the first 24 hours postpartum (scheduled analgesia group) or as needed (on-demand group). Pain level during the first 24 hours postdelivery was measured using a 10-point visual analog scale. RESULTS A total of 200 patients were randomized 1:1 to the 2 cohorts. Baseline and delivery characteristics, including oxytocin augmentation, epidural anesthesia, episiotomy rate, and neonatal birthweight, were comparable between groups. Patients in the scheduled group received more paracetamol and ibuprofen doses in the first 24 hours (2.9±1.3 and 2.9±1.2 doses vs 0.8±1.1 and 0.7±1.1 doses, respectively; P<.001). Pain score was comparable between study groups (5.31±1.92 vs 5.29±1.67; P=.626) even after subanalysis for primiparity, episiotomy, and vacuum-assisted delivery (P>.05). However, patients on a fixed treatment schedule were more likely to breastfeed their baby (98% vs 88%; P=.006) as than those receiving treatment on demand. In addition, they were more satisfied with their labor and delivery experience, as evaluated by Birth Satisfaction Scale questionnaires quality control (37.9±4.7 vs 31.1±5.2; P=.0324), patient attributes (35.0±5.1 vs 30.3±6.3; P=.0453), and stress experienced (58.1±8.5 vs 50.1±8.3; P=.0398). No side effects or adverse outcomes were reported in either group. CONCLUSION A scheduled analgesic protocol for postpartum pain management following vaginal delivery revealed similar pain scores compared with an on-demand protocol, although it was associated with higher breastfeeding rates and higher maternal satisfaction.
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Affiliation(s)
- Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner).
| | - Adi Alter
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Gili Buchnik Fater
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Naama Farago
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Chen Ben-David
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Hiba Abu-Rass
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Yoav Siegler
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Areen Hajaj
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Maya Landau-Levin
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner)
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Zipori, Khatib, Weiner, and Vitner)
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Zipori, Khatib, Weiner, and Vitner)
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Zipori, Khatib, Weiner, and Vitner)
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Bachar, Alter, Justman, Buchnik Fater, Farago, Ben-David, Abu-Rass, Siegler, Hajaj, Landau-Levin, Zipori, Khatib, Weiner, and Vitner); Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (Drs Zipori, Khatib, Weiner, and Vitner)
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10
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Leavitt VM, Tozlu C, Nelson KE, Boehme AK, Donnelly JE, Aguerre I, Spinner M, Riley CS, Stein J, Onomichi K. A randomized controlled trial of oral antipyretic treatment to reduce overheating during exercise in adults with multiple sclerosis. J Neurol 2024; 271:2207-2215. [PMID: 38413464 DOI: 10.1007/s00415-023-12147-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 02/29/2024]
Abstract
BACKGROUND Some people with multiple sclerosis (pwMS) avoid exercise due to overheating. Evidence from a variety of cooling treatments shows benefits for pwMS. OBJECTIVE Conduct a randomized controlled trial of antipyretic treatment before exercise in pwMS. METHODS Adults over age 18 diagnosed with relapsing-remitting MS reporting heat sensitivity during exercise were randomly assigned to one of six sequences counterbalancing aspirin, acetaminophen, placebo. At each of three study visits separated by ≥ one week, participants received 650-millograms of aspirin, acetaminophen, or placebo before completing a maximal exercise test. Primary outcomes were body temperature change and total time-to-exhaustion (TTE), secondary outcomes were physiological and patient-reported outcomes (PROs). RESULTS Sixty participants were enrolled and assigned to treatment sequence; 37 completed ≥ one study visit. After controlling for order effects, we found that body temperature increase was reduced after aspirin (+ 0.006 ± 0.32 degrees Fahrenheit, p < 0.001) and after acetaminophen (+ 0.31 ± 0.35; p = 0.004) compared to placebo (+ 0.68 ± 0.35). TTE after aspirin (331.6 ± 76.6 s) and acetaminophen (578.2 ± 82.1) did not differ significantly from placebo (551.0 ± 78.4; p's > 0.05). Aspirin benefited all secondary outcomes compared to placebo (all p's < 0.001); acetaminophen showed broadly consistent benefits. CONCLUSION These results support antipyretic treatment as effective for reducing overheating during exercise in pwMS and failed to support antipyretics for increasing TTE in the context of a maximal exercise test. Benefits were shown for physiological markers of exercise productivity and PROs of fatigue, pain, and perceived exertion.
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Affiliation(s)
- Victoria M Leavitt
- Cognitive Neuroscience Division, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
| | - Ceren Tozlu
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Katherine E Nelson
- Multiple Sclerosis Center, Department of Neurology, Columbia University Irving Medical Center, New York, USA
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Irving Medical Center, New York, USA
| | - Amelia K Boehme
- Department of Neurology and Epidemiology, Columbia University Irving Medical Center, New York, USA
| | - Jaime E Donnelly
- Multiple Sclerosis Center, Department of Neurology, Columbia University Irving Medical Center, New York, USA
| | - Ines Aguerre
- Multiple Sclerosis Center, Department of Neurology, Columbia University Irving Medical Center, New York, USA
| | - Michael Spinner
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Claire S Riley
- Multiple Sclerosis Center, Department of Neurology, Columbia University Irving Medical Center, New York, USA
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Irving Medical Center, New York, USA
| | - Joel Stein
- Department of Rehabilitation and Regenerative Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Kaho Onomichi
- Multiple Sclerosis Center, Department of Neurology, Columbia University Irving Medical Center, New York, USA
- Center for Translational and Computational Neuroimmunology, Department of Neurology, Columbia University Irving Medical Center, New York, USA
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11
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Zeilmaker-Roest G, de Vries-Rink C, van Rosmalen J, van Dijk M, de Wildt SN, Knibbe CAJ, Koomen E, Jansen NJG, Kneyber MCJ, Maebe S, Van den Berghe G, Haghedooren R, Vlasselaers D, Bogers AJJC, Tibboel D, Wildschut ED. Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial. Crit Care 2024; 28:143. [PMID: 38689310 PMCID: PMC11061924 DOI: 10.1186/s13054-024-04905-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/07/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0-3 years after cardiac surgery with cardiopulmonary bypass. METHODS Multi-center, randomized, double-blinded, controlled trial in four level-3 Pediatric Intensive Care Units (PICU) in the Netherlands and Belgium. Inclusion period; March 2016-July 2020. Children aged 0-3 years, undergoing cardiac surgery with cardiopulmonary bypass were eligible. Patients were randomized to continuous morphine or intermittent IV paracetamol as primary analgesic after a loading dose of 100 mcg/kg morphine was administered at the end of surgery. Rescue morphine was given if numeric rating scale (NRS) pain scores exceeded predetermined cutoff values. Primary outcome was median weight-adjusted cumulative morphine dose in mcg/kg in the first 48 h postoperative. For the comparison of the primary outcome between groups, the nonparametric Van Elteren test with stratification by center was used. For comparison of the proportion of patients with one or more NRS pain scores of 4 and higher between the two groups, a non-inferiority analysis was performed using a non-inferiority margin of 20%. RESULTS In total, 828 were screened and finally 208 patients were included; parents of 315 patients did not give consent and 305 were excluded for various reasons. Fourteen of the enrolled 208 children were withdrawn from the study before start of study medication leaving 194 patients for final analysis. One hundred and two patients received intermittent IV paracetamol, 106 received continuous morphine. The median weight-adjusted cumulative morphine consumption in the first 48 h postoperative in the IV paracetamol group was 5 times lower (79%) than that in the morphine group (median, 145.0 (IQR, 115.0-432.5) mcg/kg vs 692.6 (IQR, 532.7-856.1) mcg/kg; P < 0.001). The rescue morphine consumption was similar between the groups (p = 0.38). Non-inferiority of IV paracetamol administration in terms of NRS pain scores was proven; difference in proportion - 3.1% (95% CI - 16.6-10.3%). CONCLUSIONS In children aged 0-3 years undergoing cardiac surgery, use of intermittent IV paracetamol reduces the median weight-adjusted cumulative morphine consumption in the first 48 h after surgery by 79% with equal pain relief showing equipoise for IV paracetamol as primary analgesic. Trial Registration Clinicaltrials.gov, Identifier: NCT05853263; EudraCT Number: 2015-001835-20.
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MESH Headings
- Humans
- Morphine/therapeutic use
- Morphine/administration & dosage
- Acetaminophen/therapeutic use
- Acetaminophen/administration & dosage
- Male
- Female
- Infant
- Double-Blind Method
- Pain, Postoperative/drug therapy
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Belgium
- Netherlands
- Infant, Newborn
- Administration, Intravenous
- Cardiac Surgical Procedures/methods
- Child, Preschool
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Intensive Care Units, Pediatric/organization & administration
- Intensive Care Units, Pediatric/statistics & numerical data
- Pain Measurement/methods
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Affiliation(s)
- Gerdien Zeilmaker-Roest
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands.
| | - Christine de Vries-Rink
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Monique van Dijk
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein/Utrecht, Utrecht, The Netherlands
| | - Erik Koomen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Sofie Maebe
- Department of Pediatrics, Maastricht University Medical Center+, MosaKids Children's Hospital, Maastricht, The Netherlands
| | | | | | - Dirk Vlasselaers
- Department of Intensive Care Medicine, UZ Leuven, Louvain, Belgium
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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12
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Intravenous acetaminophen/ibuprofen (Combogesic IV). Med Lett Drugs Ther 2024; 66:68-9. [PMID: 38691646 DOI: 10.58347/tml.2024.1701c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
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13
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Bouazza N, Cambonie G, Flamant C, Rideau A, Tauzin M, Patkai J, Gascoin G, Lumia M, Aikio O, Lui G, Bournaud LF, Walsh-Papageorgiou A, Tortigue M, Baruteau AE, Kallio J, Hallman M, Diallo A, Levoyer L, Treluyer JM, Roze JC. Prophylactic Intravenous Acetaminophen in Extremely Premature Infants: Minimum Effective Dose Research by Bayesian Approach. Paediatr Drugs 2024; 26:83-93. [PMID: 37978159 PMCID: PMC10770203 DOI: 10.1007/s40272-023-00602-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) in preterm infants is associated with increased morbidities and mortality. Prophylactic treatment with cyclooxygenase inhibitors, as indomethacin or ibuprofen, failed to demonstrate significant clinical benefits. Acetaminophen may represent an alternative treatment option. OBJECTIVE This study evaluated the minimum effective dose of prophylactic acetaminophen to close the ductus and assessed the safety and tolerability profile in extremely preterm infants at 23-26 weeks of gestation. METHODS A dose finding trial with Bayesian continual reassessment method was performed in a multicenter study with premature infants hospitalized in neonatal intensive care unit. Infants of 23-26 weeks of gestation and post-natal age ≤ 12 h were enrolled. Four intravenous acetaminophen dose levels were predefined. The primary outcome was the ductus arteriosus closing at two consecutive echocardiographies or at day 7. The main secondary objectives included the safety of acetaminophen on hemodynamics and biological hepatic function. RESULTS A total of 29 patients were analyzed sequentially for the primary analysis with 20 infants assigned to the first dose level followed by 9 infants to the second dose level. No further dose level increase was necessary. The posterior probabilities of success, estimated from the Bayesian logistic model, were 46.1% [95% probability interval (PI), 24.9-63.9] and 67.6% (95% PI, 51.5-77.9) for dose level 1 and 2, respectively. A closing or closed pattern was observed among 19 patients at the end of treatment [65.5% (95% confidence interval (CI), 45.7-82.0)]. No change in alanine aminotransferase values was observed during treatment. A significant decrease in aspartate aminotransferase values was observed with postnatal age. No change in systolic and diastolic blood pressures was observed during treatment. CONCLUSIONS Minimum effective dose to close the ductus was 25 mg/kg loading dose then 10 mg/kg/6 h for 5 days in extremely preterm infants. Acetaminophen was well tolerated in this study following these doses. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04459117.
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Affiliation(s)
- Naïm Bouazza
- EA 7323, Université Paris Cité, Pharmacologie et évaluations thérapeutiques chez l'enfant et la femme enceinte, Paris, France.
- Unité de Recherche Clinique, Université Paris Cité Necker/Cochin, Hôpital Tarnier, Paris, France.
- CIC-1419 Inserm, Cochin-Necker, Paris, France.
| | - Gilles Cambonie
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 371 Avenue du Doyen Giraud, 34295, Montpellier, France
- Pathogenesis and Control of Chronic Infection, INSERM, UMR 1058, University of Montpellier, Montpellier, France
| | - Cyril Flamant
- Department of Neonatology, CHU Nantes, Nantes, France
| | - Aline Rideau
- Department of Pediatrics, Robert Debré Hospital, APHP, Paris, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Juliana Patkai
- Neonatology Department, Port-Royal Hospital, 75014, Paris, France
| | - Géraldine Gascoin
- Department of Neonatology, Angers University Hospital, Angers, France
| | - Mirka Lumia
- Department of Children and Adolescents, New Children's Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Outi Aikio
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, and Research Unit of Clinical Medicine and MRC Oulu, University of Oulu, Oulu, Finland
| | - Gabrielle Lui
- Service de Pharmacologie Clinique, Hôpital Cochin, AP-HP, Groupe Hospitalier Paris Centre, Paris, France
| | - Léo Froelicher Bournaud
- Service de Pharmacologie Clinique, Hôpital Cochin, AP-HP, Groupe Hospitalier Paris Centre, Paris, France
| | | | - Marine Tortigue
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
- Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, CHU Nantes, Nantes, France
- Nantes Université, CHU Nantes, INSERM, CIC FEA 1413, Nantes, France
| | - Alban-Elouen Baruteau
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
- Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, CHU Nantes, Nantes, France
- Nantes Université, CHU Nantes, INSERM, CIC FEA 1413, Nantes, France
- Nantes Université, INRAE, UMR 1280, PhAN, Nantes, France
| | - Jaana Kallio
- Department of Children and Adolescents, New Children's Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Hallman
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, and Research Unit of Clinical Medicine and MRC Oulu, University of Oulu, Oulu, Finland
| | - Alpha Diallo
- Clinical Trial Safety and Public Health, ANRS|Emerging Infectious Diseases, Paris, France
- Clinical Research Safety Department, INSERM, Paris, France
| | - Léa Levoyer
- Clinical Trial Safety and Public Health, ANRS|Emerging Infectious Diseases, Paris, France
- Clinical Research Safety Department, INSERM, Paris, France
| | - Jean-Marc Treluyer
- EA 7323, Université Paris Cité, Pharmacologie et évaluations thérapeutiques chez l'enfant et la femme enceinte, Paris, France
- Unité de Recherche Clinique, Université Paris Cité Necker/Cochin, Hôpital Tarnier, Paris, France
- CIC-1419 Inserm, Cochin-Necker, Paris, France
- Service de Pharmacologie Clinique, Hôpital Cochin, AP-HP, Groupe Hospitalier Paris Centre, Paris, France
| | - Jean-Christophe Roze
- Nantes Université, CHU Nantes, INSERM, CIC FEA 1413, Nantes, France
- Nantes Université, INRAE, UMR 1280, PhAN, Nantes, France
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14
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Lappalainen E, Huttunen J, Kokki H, Toroi P, Kokki M. Tramadol-paracetamol for postoperative pain after spine surgery - A randomized, double-blind, placebo-controlled study. Scand J Pain 2024; 24:sjpain-2023-0105. [PMID: 38708610 DOI: 10.1515/sjpain-2023-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 04/05/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Multimodal pain management is one component in enhanced recovery after surgery protocol. Here we evaluate the efficacy of tramadol-paracetamol in acute postoperative pain and pain outcome at 12 months after spine surgery in randomized, double-blind, placebo-controlled trial. METHODS We randomized 120 patients undergoing spine surgery to receive, for add-on pain management, two tramadol-paracetamol 37.5 mg/325 mg (n = 61) or placebo tablets (n = 59) twice a day for 5 postoperative days. In the hospital, multimodal pain management consisted of dexketoprofen and oxycodone. After discharge, patients were prescribed ibuprofen 200 mg, maximum 1,200 mg/day. Pain, analgesic use, and satisfaction with pain medication were followed up with the Brief Pain Inventory questionnaire before surgery and at 1 and 52 weeks after surgery. The primary outcome was patients' satisfaction with pain medication 1 week after surgery. RESULTS At 1 week after surgery, patients' satisfaction with pain medication was similarly high in the two groups, 75% [interquartile range, 30%] in the placebo group and 70% [40%] in the tramadol-paracetamol group (p = 0.949) on a scale: 0% = not satisfied, 100% = totally satisfied. At 1 week, ibuprofen dose was lower in the placebo group 200 mg [1,000] compared to the tramadol-paracetamol group, 800 mg [1,600] (p = 0.016). There was no difference in the need for rescue oxycodone. Patients in the tramadol-paracetamol group had more adverse events associated with analgesics during the first postoperative week (relative risk = 1.8, 95% confidence interval, 1.2-2.6). CONCLUSION Add-on pain treatment with tramadol-paracetamol did not enhance patients' satisfaction with early pain management after back surgery.
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Affiliation(s)
- Emma Lappalainen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Department of Neurosurgery, Neuro Centre, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Kokki
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Petri Toroi
- Department of Anaesthesiology and Intensive care, Kuopio University Hospital, PO Box 100, FI-70029 KYS, Kuopio, Finland
| | - Merja Kokki
- Department of Anaesthesiology and Intensive care, Kuopio University Hospital, PO Box 100, FI-70029 KYS, Kuopio, Finland
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15
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Qureshi I, Abdulrashid K, Thomas SH, Abdel-Rahman ME, Pathan SA, Harris T. Comparison of intravenous paracetamol (acetaminophen) to intravenously or intramuscularly administered non-steroidal anti-inflammatory drugs (NSAIDs) or opioids for patients presenting with moderate to severe acute pain conditions to the ED: systematic review and meta-analysis. Emerg Med J 2023; 40:499-508. [PMID: 37173122 DOI: 10.1136/emermed-2022-212869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opiates/opioids, administered parenterally via intravenous or intramuscular route, are widely used to provide analgesia for patients with moderate to severe pain. This systematic review and meta-analysis evaluated the level of analgesia provided by intravenous paracetamol (IVP) alone compared with NSAIDs (intravenous or intramuscular), or opioids (intravenous) alone in adults attending the ED with acute pain. METHODS Two authors independently searched PubMed (MEDLINE), Web of Science, Embase (OVID), Cochrane Library, SCOPUS and Google Scholar (3 March 2021-20 May 2022) for randomised trials without any language or date restriction. Clinical trials were evaluated using the Risk of Bias V.2 tool. The primary outcome was mean difference (MD) for pain reduction at 30 min (T30) post analgesia delivery. The secondary outcomes were MD in pain reduction at 60, 90 and 120 min; the need for rescue analgesia; and the occurrence of adverse events (AEs). RESULTS Twenty-seven trials (5427 patients) were included in the systematic review and 25 trials (5006 patients) in the meta-analysis. There was no significant difference in pain reduction at T30 between the IVP group and opioids (MD -0.13, 95% CI -1.49 to 1.22) or IVP and NSAIDs (MD -0.27, 95% CI -1.0 to 1.54. There was also no difference at 60 min, IVP group versus opioid group (MD -0.09, 95% CI -2.69 to 2.52) or IVP versus NSAIDs (MD 0.51, 95% CI 0.11 to 0.91). The quality of the evidence using Grading of Recommendations, Assessments, Development and Evaluations methodology was low for MD in pain scores.The need for rescue analgesia at T30 was significantly higher in the IVP group compared with the NSAID group (risk ratio (RR): 1.50, 95% CI 1.23 to 1.83), with no difference found between the IVP group and the opioid group (RR: 1.07, 95% CI 0.67 to 1.70). AEs were 50% lower in the IVP group compared with the opioid group (RR: 0.50, 95% CI 0.40 to 0.62), whereas no difference was observed in the IVP group compared with the NSAID group (RR: 1.30, 95% CI 0.78 to 2.15). CONCLUSION In patients presenting to the ED with a diverse range of pain conditions, IVP provides similar levels of pain relief compared with opiates/opioids or NSAIDs at T30 post administration. Patients treated with NSAIDs had lower risk of rescue analgesia, and opioids cause more AEs, suggesting NSAIDs as the first-choice analgesia and IVP as a suitable alternative. PROSPERO REGISTRATION NUMBER CRD42021240099.
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Affiliation(s)
- Isma Qureshi
- Emergency Medicine, Hamad General Hospital, Doha, Qatar
| | - Khadiga Abdulrashid
- Public Health, Qatar University College of Health Sciences, Doha, Qatar
- Primary Health Care Corporation, Doha, Qatar
| | - Stephen H Thomas
- Emergency Medicine, Hamad General Hospital, Doha, Qatar
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Sameer A Pathan
- Emergency Medicine, Hamad General Hospital, Doha, Qatar
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
- School of Public health and Preventive medicine, Monash University, Melbourne, Victoria, Australia
| | - Tim Harris
- Emergency Medicine, Hamad General Hospital, Doha, Qatar
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
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16
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Macedo J, Vanhoorne V, Vervaet C, Pinto JF. Influence of formulation variables on the processability and properties of tablets manufactured by fused deposition modelling. Int J Pharm 2023; 637:122854. [PMID: 36948473 DOI: 10.1016/j.ijpharm.2023.122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/24/2023]
Abstract
The present work studied the influence of different formulation variables (defined also as factors), namely, different polymers (HPC EF, PVA and HPMC-AS LG), drugs with different water solubilities (paracetamol, hydrochlorothiazide and celecoxib) and drug loads (10 or 30 %) on their processability by HME and FDM. Both filaments and tablets were characterized for physic and chemical properties (DSC, XRPD, FTIR) and performance properties (drug content, in vitro drug release). Experiments were designed to highlight relationships between the 3 factors selected and the mechanical properties of filaments, tablet mass and dissolution profiles of the model drugs from printed tablets. While the combination of hydrochlorothiazide and HPMC-AS LG could not be extruded, the combination of paracetamol with HPC EF turned the filaments too ductile and not stiff enough hampering the process of printing. All other polymer and drug combinations could be successfully extruded and printed. Models reflected the influence of the solubility of the drug considered but not the drug load in formulations. The ranking of the drug release rates was in good agreement with their solubilities. Furthermore, PVA presenting the fastest swelling rate, promoted the fastest drugs' releases in comparison with the other polymers studied. Overall, the study enabled the identification of the key factors affecting the properties of printed tablets, with the proposal of a model that has valued the relative contribution of each factor to the overall performance of tablets.
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Affiliation(s)
- Joana Macedo
- iMed.ULisboa, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Valérie Vanhoorne
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - Chris Vervaet
- Laboratory of Pharmaceutical Technology, Ghent University, Ghent, Belgium
| | - João F Pinto
- iMed.ULisboa, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal.
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Orandi BJ, McLeod MC, MacLennan PA, Lee WM, Fontana RJ, Karvellas CJ, McGuire BM, Lewis CE, Terrault NM, Locke JE. Association of FDA Mandate Limiting Acetaminophen (Paracetamol) in Prescription Combination Opioid Products and Subsequent Hospitalizations and Acute Liver Failure. JAMA 2023; 329:735-744. [PMID: 36881033 PMCID: PMC9993184 DOI: 10.1001/jama.2023.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/08/2023]
Abstract
Importance In January 2011, the US Food and Drug Administration (FDA) announced a mandate to limit acetaminophen (paracetamol) to 325 mg/tablet in combination acetaminophen and opioid medications, with manufacturer compliance required by March 2014. Objective To assess the odds of hospitalization and the proportion of acute liver failure (ALF) cases with acetaminophen and opioid toxicity prior to and after the mandate. Design, Setting, and Participants This interrupted time-series analysis used hospitalization data from 2007-2019 involving ICD-9/ICD-10 codes consistent with both acetaminophen and opioid toxicity from the National Inpatient Sample (NIS), a large US hospitalization database, and ALF cases from 1998-2019 involving acetaminophen and opioid products from the Acute Liver Failure Study Group (ALFSG), a cohort of 32 US medical centers. For comparison, hospitalizations and ALF cases consistent with acetaminophen toxicity alone were extracted from the NIS and ALFSG. Exposures Time prior to and after the FDA mandate limiting acetaminophen to 325 mg in combination acetaminophen and opioid products. Main Outcomes and Measures Odds of hospitalization involving acetaminophen and opioid toxicity and percentage of ALF cases from acetaminophen and opioid products prior to and after the mandate. Results In the NIS, among 474 047 585 hospitalizations from Q1 2007 through Q4 2019, there were 39 606 hospitalizations involving acetaminophen and opioid toxicity; 66.8% of cases were among women; median age, 42.2 (IQR, 28.4-54.1). In the ALFSG, from Q1 1998 through Q3 2019, there were a total of 2631 ALF cases, of which 465 involved acetaminophen and opioid toxicity; 85.4% women; median age, 39.0 (IQR, 32.0-47.0). The predicted incidence of hospitalizations 1 day prior to the FDA announcement was 12.2 cases/100 000 hospitalizations (95% CI, 11.0-13.4); by Q4 2019, it was 4.4/100 000 hospitalizations (95% CI, 4.1-4.7) (absolute difference, 7.8/100 000 [95% CI, 6.6-9.0]; P < .001). The odds of hospitalizations with acetaminophen and opioid toxicity increased 11%/y prior to the announcement (odds ratio [OR], 1.11 [95% CI, 1.06-1.15]) and decreased 11%/y after the announcement (OR, 0.89 [95% CI, 0.88-0.90]). The predicted percentage of ALF cases involving acetaminophen and opioid toxicity 1 day prior to the FDA announcement was 27.4% (95% CI, 23.3%-31.9%); by Q3 2019, it was 5.3% (95% CI, 3.1%-8.8%) (absolute difference, 21.8% [95% CI, 15.5%-32.4%]; P < .001). The percentage of ALF cases involving acetaminophen and opioid toxicity increased 7% per year prior to the announcement (OR, 1.07 [95% CI, 1.03-1.1]; P < .001) and decreased 16% per year after the announcement (OR, 0.84 [95% CI, 0.77-0.92]; P < .001). Sensitivity analyses confirmed these findings. Conclusions and Relevance The FDA mandate limiting acetaminophen dosage to 325 mg/tablet in prescription acetaminophen and opioid products was associated with a statistically significant decrease in the yearly rate of hospitalizations and proportion per year of ALF cases involving acetaminophen and opioid toxicity.
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Affiliation(s)
- Babak J. Orandi
- University of Alabama at Birmingham Heersink School of Medicine
- Joan & Sanford Weill Medical College of Cornell University, New York, New York
| | | | | | - William M. Lee
- University of Texas Southwestern Medical Center at Dallas
| | | | | | | | - Cora E. Lewis
- University of Alabama at Birmingham School of Public Health
| | - Norah M. Terrault
- University of Southern California Keck School of Medicine, Los Angeles
| | - Jayme E. Locke
- University of Alabama at Birmingham Heersink School of Medicine
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18
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Arnold CG, Dylla L, Monte AA, Heard K, Heard S, D'Alessandro A, Reynolds K, Dart R, Rumack B, Sonn B. Metabolomic Evaluation of N-Acetyl-p-Benzoquinone Imine Protein Adduct Formation with Therapeutic Acetaminophen Administration: Sex-based Physiologic Differences. J Med Toxicol 2022; 18:297-310. [PMID: 35751009 PMCID: PMC9492831 DOI: 10.1007/s13181-022-00903-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Acetaminophen (APAP)-associated transaminase elevation, induced by N-acetyl-p-benzoquinone imine (NAPQI) protein adduction, remains an area of research interest. Distinct from known genetic, physiologic, and dosage associations dictating severity of hepatic injury, no known factors predict an absence of protein adduct formation at therapeutic APAP dosing. HYPOTHESIS Sex-based physiology is predictive of APAP-induced protein adduct formation and differential metabolite expression at therapeutic doses. METHODS This retrospective study interrogated serum samples collected for a prior study investigating fluctuations of alanine aminotransferase (ALT) over time with 4G daily APAP dosing for ≥ 16 days in subjects from Denver, Colorado. Subjects were grouped by adduct formation (n = 184) vs no adducts (n = 20). Samples were run on ultra-high-performance liquid chromatography mass spectrometry from study days 0, 7, 16, and 31. Significant metabolite expressions were identified using t-tests with false discovery rate correction (FDR), partial least squares discriminant, and ANOVA simultaneous comparison analyses. Demographic and clinical data were explored using t-tests with FDR (age, weight, BMI, ALT) and Chi-square (sex, ethnicity, race) analyses. RESULTS In pre-treatment samples, relative quantitation caprylic acid was expressed ninefold higher and 6-carboxyhexanoate was expressed threefold lower in subjects who did not develop adducts. Lactate had greater expression in the no adducts group (p = 0.001). Using absolute quantitation, glutathione was expressed 2.6-fold greater among no adduct subjects. Odds of males developing NAPQI protein adducts at therapeutic APAP dosing were 5.91 times lower than females (95% CI = 2.3-14.9; p = 0.0001). CONCLUSION Multiple metabolites were differentially expressed based on adduct group and sex. Metabolites were identified unique to adduct development independent of sex. At therapeutic APAP dosing, males were less likely to develop APAP protein adducts. Further research into lipid biosynthesis and metabolism may provide further insight into physiology associated with adduct production.
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Affiliation(s)
- Cosby G Arnold
- Department of Emergency Medicine, University of Colorado School of Medicine, University of Colorado Denver-Anschutz Medical Center, Mail Stop B-215, 12401 East 17thAvenue, Aurora, CO, 80045, USA.
| | - Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, University of Colorado Denver-Anschutz Medical Center, Mail Stop B-215, 12401 East 17thAvenue, Aurora, CO, 80045, USA
| | - Andrew A Monte
- Department of Emergency Medicine, University of Colorado School of Medicine, University of Colorado Denver-Anschutz Medical Center, Mail Stop B-215, 12401 East 17thAvenue, Aurora, CO, 80045, USA
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd Unit 600, Denver, CO, 80204, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, University of Colorado Denver-Anschutz Medical Center, Mail Stop B-215, 12401 East 17thAvenue, Aurora, CO, 80045, USA
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd Unit 600, Denver, CO, 80204, USA
| | - Susan Heard
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd Unit 600, Denver, CO, 80204, USA
| | - Angelo D'Alessandro
- Division of Bioinformatics & Personalized Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Fitzimons Building, 5th floor, #563, Aurora, CO, 80045, USA
| | - Kate Reynolds
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd Unit 600, Denver, CO, 80204, USA
| | - Richard Dart
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd Unit 600, Denver, CO, 80204, USA
| | - Barry Rumack
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd Unit 600, Denver, CO, 80204, USA
- Department of Pediatrics, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA
| | - Brandon Sonn
- Department of Emergency Medicine, University of Colorado School of Medicine, University of Colorado Denver-Anschutz Medical Center, Mail Stop B-215, 12401 East 17thAvenue, Aurora, CO, 80045, USA
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Gasbjerg KS, Hägi-Pedersen D, Lunn TH, Laursen CC, Holmqvist M, Vinstrup LØ, Ammitzboell M, Jakobsen K, Jensen MS, Pallesen MJ, Bagger J, Lindholm P, Pedersen NA, Schrøder HM, Lindberg-Larsen M, Nørskov AK, Thybo KH, Brorson S, Overgaard S, Jakobsen JC, Mathiesen O. Effect of dexamethasone as an analgesic adjuvant to multimodal pain treatment after total knee arthroplasty: randomised clinical trial. BMJ 2022; 376:e067325. [PMID: 34983775 PMCID: PMC8724786 DOI: 10.1136/bmj-2021-067325] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the effects of one and two doses of intravenous dexamethasone in patients after total knee arthroplasty. DESIGN Randomised, blinded, placebo controlled trial with follow-up at 90 days. SETTING Five Danish hospitals, September 2018 to March 2020. PARTICIPANTS 485 adult participants undergoing total knee arthroplasty. INTERVENTION A computer generated randomised sequence stratified for site was used to allocate participants to one of three groups: DX1 (dexamethasone (24 mg)+placebo); DX2 (dexamethasone (24 mg)+dexamethasone (24 mg)); or placebo (placebo+placebo). The intervention was given preoperatively and after 24 hours. Participants, investigators, and outcome assessors were blinded. All participants received paracetamol, ibuprofen, and local infiltration analgesia. MAIN OUTCOME MEASURES The primary outcome was total intravenous morphine consumption 0 to 48 hours postoperatively. Multiplicity adjusted threshold for statistical significance was P<0.017 and minimal important difference was 10 mg morphine. Secondary outcomes included postoperative pain. RESULTS 485 participants were randomised: 161 to DX1, 162 to DX2, and 162 to placebo. Data from 472 participants (97.3%) were included in the primary outcome analysis. The median (interquartile range) morphine consumptions at 0-48 hours were: DX1 37.9 mg (20.7 to 56.7); DX2 35.0 mg (20.6 to 52.0); and placebo 43.0 mg (28.7 to 64.0). Hodges-Lehmann median differences between groups were: -2.7 mg (98.3% confidence interval -9.3 to 3.7), P=0.30 between DX1 and DX2; 7.8 mg (0.7 to 14.7), P=0.008 between DX1 and placebo; and 10.7 mg (4.0 to 17.3), P<0.001 between DX2 and placebo. Postoperative pain was reduced at 24 hours with one dose, and at 48 hours with two doses, of dexamethasone. CONCLUSION Two doses of dexamethasone reduced morphine consumption during 48 hours after total knee arthroplasty and reduced postoperative pain. TRIAL REGISTRATION Clinicaltrials.gov NCT03506789.
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Affiliation(s)
- Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Cleveland Laursen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Majken Holmqvist
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Louise Ørts Vinstrup
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Centre for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Ammitzboell
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Karina Jakobsen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Mette Skov Jensen
- Department of Anaesthesiology, Næstved, Slagelse and Ringsted Hospitals, Næstved, Denmark
| | - Marie Jøhnk Pallesen
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens Bagger
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Nordsjællands University Hospital, Hillerød, Denmark Anders
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Søren Overgaard
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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20
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Bergman JE, Casiano RR, Perez AB, Mantero AM, Levine CG. Opiate vs non-opiate prescription medication for pain control after endoscopic sinus surgery for chronic rhinosinusitis. Am J Otolaryngol 2022; 43:103214. [PMID: 34607277 DOI: 10.1016/j.amjoto.2021.103214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/05/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Research indicates that most providers give opiates after endoscopic sinonasal surgery. The effectiveness of non-opiate medications after sinonasal surgery is poorly understood and most studies do not assess medication failure. This study compares oral opiate, oral opiate and topical steroid, and oral non-opiate pain control. Patient call-backs are used as a proxy for pain medication failure. MATERIALS AND METHODS This study compares three medication regiments after sinonasal surgery for 180 adults with chronic rhinosinusitis. Patients were instructed to take acetaminophen for mild pain. For moderate/severe pain, patients used: 1) oxycodone-acetaminophen, 2) oxycodone-acetaminophen + budesonide nasal rinses, or 3) meloxicam + acetaminophen. Patients were instructed to call clinic if pain was not controlled. Descriptive statistics compared cohorts. Chi-square tests compared call-backs between cohorts. Logistic regression adjusted for baseline differences in covariates, comorbidities, and operative sites. RESULTS Cohorts had similar age, sex distribution, disease features, and extent of surgery. The meloxicam cohort had less subjects with pain disorders. The oxycodone cohort had less subjects with diabetes, septoplasty, and turbinate reduction. After adjusting for baseline differences and using oxycodone as the reference group (n = 50), the odds of calling clinic for poorly controlled pain was 0.18 (95% Confidence Interval (CI): 0.05-0.6) in the meloxicam cohort (n = 45) and 0.19 (95% CI:0.07-0.5) in the oxycodone + budesonide rinses cohort (n = 85). CONCLUSION In this study, both meloxicam and oxycodone + budesonide rinses were more effective at controlling pain after sinonasal surgery than oxycodone alone.
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Affiliation(s)
- Jenna E Bergman
- Department of Otolaryngology- Head and Neck Surgery, University of South Florida, Tampa, FL, United States of America
| | - Roy R Casiano
- Rhinology and Endoscopic Skull Base Program, Department of Otolaryngology- Head and Neck Surgery, University of Miami Miller School of Medicine, FL, United States of America
| | - Ana B Perez
- Rhinology and Endoscopic Skull Base Program, Department of Otolaryngology- Head and Neck Surgery, University of Miami Miller School of Medicine, FL, United States of America
| | - Alejandro M Mantero
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, FL, United States of America
| | - Corinna G Levine
- Rhinology and Endoscopic Skull Base Program, Department of Otolaryngology- Head and Neck Surgery, University of Miami Miller School of Medicine, FL, United States of America.
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21
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Hickey T, Abelleira A, Acampora G, Becker WC, Falker CG, Nazario M, Weimer MB. Perioperative Buprenorphine Management: A Multidisciplinary Approach. Med Clin North Am 2022; 106:169-185. [PMID: 34823729 DOI: 10.1016/j.mcna.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Buprenorphine formulations (including buprenorphine/naloxone) are effective treatments of pain and opioid use disorder (OUD). Historically, perioperative management of patients prescribed buprenorphine involved abstinence from buprenorphine sufficient to allow for unrestricted mu-opioid receptor availability to full agonist opioid (FAO) treatment. Evidence is mounting that a multimodal analgesic strategy, including simultaneous administration of buprenorphine and FAO, nonopioid adjuncts such as acetaminophen and nonsteroidal anti-inflammatory drugs, and regional anesthesia, is a safe and effective perioperative strategy for the patient prescribed long-term buprenorphine treatment of OUD. This strategy will likely simplify management and more seamlessly provide continuous buprenorphine treatment of OUD after hospital discharge.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Aged
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/pharmacology
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Buprenorphine/administration & dosage
- Buprenorphine/pharmacology
- Buprenorphine/therapeutic use
- Combined Modality Therapy/methods
- Drug Compounding/methods
- Female
- Humans
- Interdisciplinary Communication
- Male
- Opiate Substitution Treatment/methods
- Opioid-Related Disorders/drug therapy
- Pain/drug therapy
- Pain Management/methods
- Pain, Postoperative/prevention & control
- Perioperative Care/methods
- Receptors, Opioid, mu/drug effects
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Affiliation(s)
- Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Anesthesiology, Yale School of Medicine, 950 Campbell Avenue, West Haven, CT 06516, USA.
| | - Audrey Abelleira
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System; Program in Addiction Medicine, Yale School of Medicine
| | - Caroline G Falker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Mitchell Nazario
- National PBM Clinical Program Manager, VHA Pharmacy Benefits Management (12PBM), 1st Avenue - 1 Block North of Cermak (Building 37), Hines, IL 60141, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Yale School of Medicine; Yale School of Public Health
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22
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Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. Association of Intravenous Acetaminophen Administration With the Duration of Intravenous Opioid Use Among Hospitalized Pediatric Patients. JAMA Netw Open 2021; 4:e2138420. [PMID: 34932106 PMCID: PMC8693214 DOI: 10.1001/jamanetworkopen.2021.38420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/17/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Adoption of multimodal pain regimens that incorporate nonopioid analgesic medications to reduce inpatient opioid administration can prevent serious opioid-related adverse effects in children, including tolerance, withdrawal, delirium, and respiratory depression. Intravenous (IV) acetaminophen is in widespread pediatric use; however, its effectiveness as an opioid-sparing agent has not been evaluated in general pediatric inpatients. Objective To determine if IV acetaminophen administered prior to IV opioids is associated with a reduction in the total duration of IV opioids administered compared with IV opioids administered without IV acetaminophen in general pediatric inpatients. Design, Setting, and Participants This comparative effectiveness research study included data on pediatric inpatients from 274 US hospitals between January 2011 and June 2016 collected from a national database. Outcomes were compared with a propensity score-matched analysis of pediatric inpatients administered IV opioids without IV acetaminophen (control) and those administered IV acetaminophen prior to IV opioids (intervention). Data were analyzed from January 2020 through October 2021. Exposures Patients in the intervention group received IV acetaminophen prior to IV opioids. Patients in the control group received IV opioids without IV acetaminophen. Main Outcomes and Measures Total duration of all IV opioids administered during a patient's hospitalization. Results Of 893 293 pediatric inpatients, a total of 104 579 were included in analysis (median [IQR] age, 1.3 [0-14.7] years; 59 806 [57.2%] female; 21 485 [21.5%] African American, 56 309 [53.8%] White), of whom 18 197 (2.0%) received IV acetaminophen, and 287 504 (34.0%) received IV opioids. After applying exclusion criteria, among patients who received IV acetaminophen, 1739 (10.8%) received IV acetaminophen prior to IV opioids within a median (IQR) treatment time of 1.5 (0.02-7.3) hours. After propensity score matching produced comparable groups in the control and intervention groups (with 839 patients in each group), the multivariable model estimated a 15.5% shorter duration of IV opioid use in the intervention group, with an absolute IV opioid reduction of 7.5 hours (95% CI, 0.7-15.8 hours). Conclusions and Relevance In this comparative effectiveness study, IV acetaminophen administered prior to IV opioids was associated with a reduction in IV opioid duration by 15.5%. Multimodal pain regimens that use IV acetaminophen prior to IV opioids could reduce IV opioid duration.
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Affiliation(s)
- Anita K. Patel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jiaxiang Gai
- Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | - Dongkyu Kim
- Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E. Bost
- Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
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Lyngstad G, Skjelbred P, Swanson DM, Skoglund LA. Analgesic effect of oral ibuprofen 400, 600, and 800 mg; paracetamol 500 and 1000 mg; and paracetamol 1000 mg plus 60 mg codeine in acute postoperative pain: a single-dose, randomized, placebo-controlled, and double-blind study. Eur J Clin Pharmacol 2021; 77:1843-1852. [PMID: 34655316 PMCID: PMC8585829 DOI: 10.1007/s00228-021-03231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Effect size estimates of analgesic drugs can be misleading. Ibuprofen (400 mg, 600 mg, 800 mg), paracetamol (1000 mg, 500 mg), paracetamol 1000 mg/codeine 60 mg, and placebo were investigated to establish the multidimensional pharmacodynamic profiles of each drug on acute pain with calculated effect size estimates. METHODS A randomized, double-blind, single-dose, placebo-controlled, parallel-group, single-centre, outpatient, and single-dose study used 350 patients (mean age 25 year, range 18 to 30 years) of homogenous ethnicity after third molar surgery. Primary outcome was sum pain intensity over 6 h. Secondary outcomes were time to analgesic onset, duration of analgesia, time to rescue drug intake, number of patients taking rescue drug, sum pain intensity difference, maximum pain intensity difference, time to maximum pain intensity difference, number needed to treat values, adverse effects, overall drug assessment as patient-reported outcome measure (PROM), and the effect size estimates NNT and NNTp. RESULTS Ibuprofen doses above 400 mg do not significantly increase analgesic effect. Paracetamol has a very flat analgesic dose-response profile. Paracetamol 1000/codeine 60 mg gives similar analgesia as ibuprofen from 400 mg, but has a shorter time to analgesic onset. Active drugs show no significant difference in maximal analgesic effect. Other secondary outcomes support these findings. The frequencies of adverse effects were low, mild to moderate in all active groups. NNT and NTTp values did not coincide well with PROMs. CONCLUSION Ibuprofen doses above 400 mg for acute pain offer limited analgesic gain. Paracetamol 1000 mg/codeine 60 mg is comparable to ibuprofen doses from 400 mg. Calculated effect size estimates and PROM in our study seem not to relate well as clinical analgesic efficacy estimators. TRIAL REGISTRATION NCT00699114.
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Affiliation(s)
- Gaute Lyngstad
- Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Blindern, P. O. Box 1119, N-0317 Nydalen Oslo, Norway
| | - Per Skjelbred
- Department of Maxillofacial Surgery, Oslo University Hospital, P. O. Box 4950, Nydalen N-0424 Oslo, Norway
| | - David M. Swanson
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Blindern, P.O. Box 1122, N-0317 Oslo, Norway
| | - Lasse A. Skoglund
- Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Blindern, P. O. Box 1119, N-0317 Nydalen Oslo, Norway
- Department of Maxillofacial Surgery, Oslo University Hospital, P. O. Box 4950, Nydalen N-0424 Oslo, Norway
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24
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da Costa BR, Pereira TV, Saadat P, Rudnicki M, Iskander SM, Bodmer NS, Bobos P, Gao L, Kiyomoto HD, Montezuma T, Almeida MO, Cheng PS, Hincapié CA, Hari R, Sutton AJ, Tugwell P, Hawker GA, Jüni P. Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis. BMJ 2021; 375:n2321. [PMID: 34642179 PMCID: PMC8506236 DOI: 10.1136/bmj.n2321] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of different preparations and doses of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol for knee and hip osteoarthritis pain and physical function to enable effective and safe use of these drugs at their lowest possible dose. DESIGN Systematic review and network meta-analysis of randomised trials. DATA SOURCES Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, regulatory agency websites, and ClinicalTrials.gov from inception to 28 June 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised trials published in English with ≥100 patients per group that evaluated NSAIDs, opioids, or paracetamol (acetaminophen) to treat osteoarthritis. OUTCOMES AND MEASURES The prespecified primary outcome was pain. Physical function and safety outcomes were also assessed. REVIEW METHODS Two reviewers independently extracted outcomes data and evaluated the risk of bias of included trials. Bayesian random effects models were used for network meta-analysis of all analyses. Effect estimates are comparisons between active treatments and oral placebo. RESULTS 192 trials comprising 102 829 participants examined 90 different active preparations or doses (68 for NSAIDs, 19 for opioids, and three for paracetamol). Five oral preparations (diclofenac 150 mg/day, etoricoxib 60 and 90 mg/day, and rofecoxib 25 and 50 mg/day) had ≥99% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. Topical diclofenac (70-81 and 140-160 mg/day) had ≥92.3% probability, and all opioids had ≤53% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. 18.5%, 0%, and 83.3% of the oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of dropouts due to adverse events. 29.8%, 0%, and 89.5% of oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of any adverse event. Oxymorphone 80 mg/day had the highest risk of dropouts due to adverse events (51%) and any adverse event (88%). CONCLUSIONS Etoricoxib 60 mg/day and diclofenac 150 mg/day seem to be the most effective oral NSAIDs for pain and function in patients with osteoarthritis. However, these treatments are probably not appropriate for patients with comorbidities or for long term use because of the slight increase in the risk of adverse events. Additionally, an increased risk of dropping out due to adverse events was found for diclofenac 150 mg/day. Topical diclofenac 70-81 mg/day seems to be effective and generally safer because of reduced systemic exposure and lower dose, and should be considered as first line pharmacological treatment for knee osteoarthritis. The clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the harm it might cause in patients with osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO number CRD42020213656.
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Affiliation(s)
- Bruno R da Costa
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Tiago V Pereira
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Pakeezah Saadat
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Martina Rudnicki
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Ophthalmology, University College London, London, UK
| | - Samir M Iskander
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - Nicolas S Bodmer
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine, University of Zurich, Zurich, Switzerland
| | - Pavlos Bobos
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Western's Bone and Joint Institute, Western University, London, ON, Canada
| | - Li Gao
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | | | - Thais Montezuma
- Health Technology Assessment Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Matheus O Almeida
- Health Technology Assessment Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
- Master Program in Physical Therapy, Universidade Ibirapuera, São Paulo, Brazil
| | - Pai-Shan Cheng
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cesar A Hincapié
- Department of Chiropractic Medicine, Faculty of Medicine, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Roman Hari
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Tugwell
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Ayoub NF, Choby G, Turner JH, Abuzeid WM, Raviv JR, Thamboo A, Ma Y, Chandra RK, Chowdhury NI, Stokken JK, O’Brien EK, Shah S, Akbar N, Roozdar P, Nayak JV, Patel ZM, Hwang PH. Assessment of Opioid Use and Analgesic Requirements After Endoscopic Sinus Surgery: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 147:811-819. [PMID: 34351376 PMCID: PMC8343514 DOI: 10.1001/jamaoto.2021.1839] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/21/2021] [Indexed: 02/01/2023]
Abstract
Importance The opioid epidemic has generated interest in optimizing opioid prescribing after common surgeries. Recent studies have shown a broad range of analgesic prescription patterns following endoscopic sinus surgery (ESS). Objective To compare the efficacy of different analgesic regimens after ESS. Design, Setting, and Participants This multi-institutional, nonblinded randomized clinical trial was conducted at 6 tertiary centers across the US and Canada and included participants who underwent ESS for acute or chronic rhinosinusitis. The study was conducted from March 2019 to March 2020, and the data were analyzed in November to December 2020. Interventions All participants received acetaminophen, 650 mg, as the first-line analgesic. From there, patients were randomized to either oxycodone rescue (oxycodone, 5 mg, as second-line therapy) or ibuprofen rescue (ibuprofen, 600 mg, as second-line therapy, with oxycodone, 5 mg, reserved for breakthrough pain). Main Outcomes and Measures Baseline characteristics and disease severity were collected at enrollment. Medication logs, pain scores, and epistaxis measures were collected until postoperative day 7. The primary outcome was the postoperative visual analog scale score for pain. Brief Pain Inventory Pain Severity and Pain Interference Scores were also collected. Results A total of 118 patients were randomized (62 [52.5%] oxycodone rescue, 56 [47.5%] ibuprofen rescue; mean [SD] age, 46.7 [16.3] years; 44 women [44.0%]; 83 White [83.0%], 7 Black [7.0%], and 7 Asian individuals [7.0%]). After exclusions for loss to follow-up and noncompliance, 51 remained in the oxycodone rescue group and 49 in the ibuprofen rescue group. The groups had similar demographic characteristics and disease severity. Thirty-two (63%) in the oxycodone rescue group had adequate pain management with acetaminophen only, while 19 (37%) consumed at least 1 oxycodone dose. In the ibuprofen rescue group, 18 (16%) required only acetaminophen, 28 (57%) used only acetaminophen and ibuprofen, and the remaining 13 (26%) consumed 1 or more oxycodone doses. The groups had similar average acetaminophen (9.69 vs 7.96 doses; difference, 1.73; 95% CI, -1.37 to 4.83) and oxycodone (1.89 vs 0.77 doses; difference, 1.13; 95% CI, -0.11 to 2.36) use. Both groups had similar postoperative visual analog scale scores. A subanalysis that compared opioids users with nonusers showed clinically significant lower pain scores in nonusers at multiple postoperative points. Conclusions and Relevance In this randomized clinical trial, most patients who underwent ESS could be treated postoperatively using a nonopioid regimen of either acetaminophen alone or acetaminophen and ibuprofen. Ibuprofen as a second-line therapy did not reduce overall narcotic consumption, but the overall narcotic use was low in both groups. Trial Registration ClinicalTrials.gov Identifier: NCT03783702.
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Affiliation(s)
- Noel F. Ayoub
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Garret Choby
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Justin H. Turner
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology, Vanderbilt Health, Nashville, Tennessee
| | - Waleed M. Abuzeid
- Division of Rhinology and Skull Base Surgery, Department of Otolaryngology–Head & Neck Surgery, University of Washington, Seattle
| | - Joseph R. Raviv
- Division of Otolaryngology–Head and Neck Surgery, NorthShore University Health System, Chicago, Illinois
| | - Andrew Thamboo
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yifei Ma
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Rakesh K. Chandra
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology, Vanderbilt Health, Nashville, Tennessee
| | - Naweed I. Chowdhury
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology, Vanderbilt Health, Nashville, Tennessee
| | - Janalee K. Stokken
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Erin K. O’Brien
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Sharan Shah
- Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Nadeem Akbar
- Department of Otolaryngology–Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Pooya Roozdar
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Jayakar V. Nayak
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Zara M. Patel
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter H. Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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26
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Zeng C, Doherty M, Persson MSM, Yang Z, Sarmanova A, Zhang Y, Wei J, Kaur J, Li X, Lei G, Zhang W. Comparative efficacy and safety of acetaminophen, topical and oral non-steroidal anti-inflammatory drugs for knee osteoarthritis: evidence from a network meta-analysis of randomized controlled trials and real-world data. Osteoarthritis Cartilage 2021; 29:1242-1251. [PMID: 34174454 DOI: 10.1016/j.joca.2021.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 05/08/2021] [Accepted: 06/13/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Current global guidelines regarding the first-line analgesics (acetaminophen, topical or oral non-steroidal anti-inflammatory drugs [NSAIDs]) for knee osteoarthritis remain controversial and their comparative risk-benefit profiles have yet to be adequately assessed. DESIGN Pubmed, Embase, Cochrane Library, and Web of Science were searched from database inception to March 2021 for randomized controlled trials (RCTs) comparing acetaminophen, topical NSAIDs and oral NSAIDs directly or indirectly in knee osteoarthritis. Bayesian network meta-analyses were conducted. A propensity-score matched cohort study was also conducted among patients with knee osteoarthritis in The Health Improvement Network database. RESULTS 122 RCTs (47,113 participants) were networked. Topical NSAIDs were superior to acetaminophen (standardized mean difference [SMD] = -0.29, 95% credible interval [CrI]: -0.52 to -0.06) and not statistically different from oral NSAIDs (SMD = 0.03, 95% CrI: -0.16 to 0.22) for function. It had lower risk of gastrointestinal adverse effects (AEs) than acetaminophen (risk ratio [RR] = 0.52, 95%CrI: 0.35 to 0.76) and oral NSAIDs (RR = 0.46, 95%CrI: 0.34 to 0.61) in RCTs. In real-world data, topical NSAIDs showed lower risks of all-cause mortality (hazard ratio [HR] = 0.59, 95% confidence interval [CI]: 0.52 to 0.68), cardiovascular diseases (HR = 0.73, 95%CI: 0.63 to 0.85) and gastrointestinal bleeding (HR = 0.53, 95%CI: 0.41 to 0.69) than acetaminophen during the one-year follow-up (n = 22,158 participants/group). A better safety profile was also observed for topical than oral NSAIDs (n = 14,218 participants/group). CONCLUSIONS Topical NSAIDs are more effective than acetaminophen but not oral NSAIDs for function improvement in people with knee osteoarthritis. Topical NSAIDs are safer than acetaminophen or oral NSAIDs in trials and real-world data.
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Affiliation(s)
- C Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA; The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - M Doherty
- Academic Rheumatology, Clinical Sciences Building, University of Nottingham, City Hospital, Nottingham, UK; Arthritis Research UK Pain Centre, Nottingham, UK
| | - M S M Persson
- Academic Rheumatology, Clinical Sciences Building, University of Nottingham, City Hospital, Nottingham, UK; Arthritis Research UK Pain Centre, Nottingham, UK
| | - Z Yang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - A Sarmanova
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Y Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA; The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - J Wei
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA; The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, USA; Health Management Center, Xiangya Hospital, Central South University, Changsha, China
| | - J Kaur
- Academic Rheumatology, Clinical Sciences Building, University of Nottingham, City Hospital, Nottingham, UK; Arthritis Research UK Pain Centre, Nottingham, UK
| | - X Li
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China
| | - G Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China; Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China; Hunan Engineering Research Center of Osteoarthritis, Changsha, China; National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
| | - W Zhang
- Academic Rheumatology, Clinical Sciences Building, University of Nottingham, City Hospital, Nottingham, UK; Arthritis Research UK Pain Centre, Nottingham, UK.
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Liu J, Di J, Zhang Y, Xing E. Oxycodone-paracetamol tablet exhibits increased analgesic efficacy for acute postoperative pain, higher satisfaction and comparable safety profiles compared with celecoxib in patients underwent arthroscopic knee surgery. Inflammopharmacology 2021; 29:1091-1099. [PMID: 34181148 DOI: 10.1007/s10787-021-00828-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/29/2021] [Indexed: 10/21/2022]
Abstract
This randomized, controlled study compared the efficacy and safety between oxycodone-paracetamol tablet and celecoxib for postoperative analgesia in patients who underwent arthroscopic knee surgery (AKS). Totally, 232 patients scheduled to undergo AKS were enrolled and were randomly assigned to either the oxycodone-paracetamol (OPT group) or the celecoxib group (CEL group). Pain at rest/motion (based on pain visual analog scale (VAS) score), rescue analgesia consumption, satisfaction level and adverse events were assessed after AKS. Pain VAS score at rest was decreased at 6 h, 12 h post-AKS in the OPT group compared with the CEL group. Similarly, pain VAS score at motion was reduced at 6 h, 12 h, 24 h post-AKS in the OPT group compared to the CEL group. Furthermore, both rescue analgesia rate (14.7% vs. 33.6%) and accumulated pethidine consumption (3.7 ± 8.9 mg vs. 14.0 ± 21.2 mg) were lower in OPT group compared with the CEL group. Patients satisfaction score was either at 24 h, 48 h in OPT group compared with the CEL group. Further subgroup analyses indicated that the effect of oxycodone-paracetamol versus (vs. celecoxib) on post-AKS management was more apparent in the elderly patients and male patients. In addition, the adverse events were well tolerable (including nausea, constipation, vomiting, drowsiness and dizziness) and were of no different between the two groups. In conclusion, oxycodone-paracetamol tablet presents increased analgesic efficacy for acute postoperative pain, with higher patient satisfaction and comparable safety profiles compared with celecoxib in patients underwent AKS.
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Affiliation(s)
- Junchuan Liu
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China.
| | - Jun Di
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Yanlong Zhang
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
| | - Enzeng Xing
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, China
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28
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Tavabie OD, Karvellas CJ, Salehi S, Speiser JL, Rose CF, Menon K, Prachalias A, Heneghan MA, Agarwal K, Lee WM, McPhail MJW, Aluvihare VR. A novel microRNA-based prognostic model outperforms standard prognostic models in patients with acetaminophen-induced acute liver failure. J Hepatol 2021; 75:424-434. [PMID: 33857547 PMCID: PMC10668489 DOI: 10.1016/j.jhep.2021.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Acetaminophen (APAP)-induced acute liver failure (ALF) remains the most common cause of ALF in the Western world. Conventional prognostic models, utilising markers of liver injury and organ failure, lack sensitivity for mortality prediction. We previously identified a microRNA signature that is associated with successful regeneration post-auxiliary liver transplant and with recovery from APAP-ALF. Herein, we aimed to use this microRNA signature to develop outcome prediction models for APAP-ALF. METHODS We undertook a nested, case-control study using serum samples from 194 patients with APAP-ALF enrolled in the US ALF Study Group registry (1998-2014) at early (day 1-2) and late (day 3-5) time-points. A microRNA qPCR panel of 22 microRNAs was utilised to assess microRNA expression at both time-points. Multiple logistic regression was used to develop models which were compared to conventional prognostic models using the DeLong method. RESULTS Individual microRNAs confer limited prognostic value when utilised in isolation. However, incorporating them within microRNA-based outcome prediction models increases their clinical utility. Our early time-point model (AUC = 0.78, 95% CI 0.71-0.84) contained a microRNA signature associated with liver regeneration and our late time-point model (AUC = 0.83, 95% CI 0.76-0.89) contained a microRNA signature associated with cell-death. Both models were enhanced when combined with model for end-stage liver disease (MELD) score and vasopressor use and both outperformed the King's College criteria. The early time-point model combined with clinical parameters outperformed the ALF Study Group prognostic index and the MELD score. CONCLUSIONS Our findings demonstrate that a regeneration-linked microRNA signature combined with readily available clinical parameters can outperform existing prognostic models for ALF in identifying patients with poor prognosis who may benefit from transplantation. LAY SUMMARY While acute liver failure can be reversible, some patients will die without a liver transplant. We show that blood test markers that measure the potential for liver recovery may help improve identification of patients unlikely to survive acute liver failure who may benefit from a liver transplant.
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Affiliation(s)
| | - Constantine J Karvellas
- Division of Gastroenterology and Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Siamak Salehi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Jaime L Speiser
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, North Carolina, USA
| | - Christopher F Rose
- Hepato-neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Krishna Menon
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | | | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Texas, USA
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29
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Reddoch-Cardenas KM, Cheppudira BP, Garza T, Hopkins CD, Bunker KD, Slee DH, Cap AP, Bynum JA, Christy RJ. Evaluation of KP-1199: a novel acetaminophen analog for hemostatic function and antinociceptive effects. Transfusion 2021; 61 Suppl 1:S234-S242. [PMID: 34269435 DOI: 10.1111/trf.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acetaminophen (APAP) is a widely self-prescribed analgesic for mild to moderate pain, but overdose or repeat doses can lead to liver injury and death. Kalyra Pharmaceuticals has developed a novel APAP analog, KP-1199, currently in Phase 1 clinical studies, which lacks hepatotoxicity. In this study, the authors evaluated the antinociceptive effect of KP-1199 on thermal injury-induced nociceptive behaviors as well as hemostatic parameters using human blood samples. METHODS Full-thickness thermal injury was induced in anesthetized adult male Sprague-Dawley rats. On day 7 post-injury, KP-1199 (30 and 60 mg/kg) or APAP (60 mg/kg) was administered orally. Antinociception of KP-1199 and APAP were assessed at multiple time points using Hargreaves' test. In separate experiments, human whole blood was collected and treated with either KP-1199, APAP, or Vehicle (citrate buffer) at 1× (214 μg/ml) and 10× (2140 μg/ml) concentrations. The treated blood samples were assessed for: clotting function, thrombin generation, and platelet activation. RESULTS APAP did not produce antinociceptive activity. KP-1199 treatment significantly increased the nociceptive threshold, and the antinociceptive activity persisted up to 3 h post-treatment. In human samples, 10× APAP caused significantly prolonged clotting times and increased platelet activation, whereas KP-1199 had caused no negative effects on either parameter tested. CONCLUSION These results suggest that KP-1199 possesses antinociceptive activity in a rat model of thermal injury. Since KP-1199 does not induce platelet activation or inhibit coagulation, it presents an attractive alternative to APAP for analgesia, especially for battlefield or surgical scenarios where blood loss and blood clotting are of concern.
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Affiliation(s)
| | - Bopaiah P Cheppudira
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Thomas Garza
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Chad D Hopkins
- Kalyra Pharmaceuticals, Inc., San Diego, California, USA
| | - Kevin D Bunker
- Kalyra Pharmaceuticals, Inc., San Diego, California, USA
| | | | - Andrew P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Robert J Christy
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
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Kshirsagar RS, Xiao C, Luetzenberg FS, Luu L, Jiang N. Reducing opioid use in post-operative otolaryngology patients: A quality improvement project. Am J Otolaryngol 2021; 42:102991. [PMID: 33640800 DOI: 10.1016/j.amjoto.2021.102991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE In opioid-naive patients, many low-risk surgical procedures are associated with an increased risk of chronic opioid use. The goal of this quality improvement project was to reduce the amount of opioid prescriptions after commonly performed surgeries in otolaryngology. MATERIALS AND METHODS Pre-intervention opioid prescribing state was measured using anonymous provider and patient surveys, as well as pharmacy provider prescription data. Next, this information was used to develop an opioid prescription protocol that both standardized opioid prescribing practices and encouraged multimodal analgesia following routine surgery. Finally, post-intervention data were gathered and compared to pre-intervention data to assess changes in prescribing patterns. RESULTS By patient survey, the worst pain and average pain after surgery (scale of 1-10) were unchanged after the intervention (5.1 to 4.8, p = 0.52; 4.1 to 3.6, p = 0.35, respectively). Post-intervention, 41% of patients reported receiving no opiates, whereas pre-intervention 100% of patients surveyed received opiates. The amount of ibuprofen and acetaminophen prescribed post-intervention increased 113% and 71%, respectively. By survey, the average number of opioid doses decreased from 24.0 ± 7.0 to 18.4 ± 6.6 (p = 0.018). CONCLUSIONS The implementation of a standardized physician opioid prescription protocol did not affect patient pain perceptions, resulted in an increase in multimodal analgesia prescription, and increased provider awareness of opioid over prescription.
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Affiliation(s)
- Rijul S Kshirsagar
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA.
| | - Christopher Xiao
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | | | - Latonia Luu
- Department of Pharmacy, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Nancy Jiang
- Department of Head and Neck Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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Saifuddin A, Koesnoe S, Kurniati N, Sirait S, Arisanty R, Yunihastuti E. COVID Arm After Moderna Booster in Healthcare Worker: A Case Report. Acta Med Indones 2021; 53:326-330. [PMID: 34611073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
SARS CoV-2 virus has infected more than 200 million people worldwide and more than 4.4 million in Indonesia. The vaccination program has become one of the solutions launched by many countries globally, including Indonesia, to reduce the transmission rate of COVID-19. Various vaccination platforms are produced, such as inactivated, viral vector, mRNA, and protein subunit. The vaccination booster program with mRNA platform (Moderna) was launched by the Indonesian government to give better protection for health care workers, particularly from delta variant. In this case report, we discuss one of the typical side effects of Moderna vaccine, which is referred to as the COVID arm.
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Affiliation(s)
- Anshari Saifuddin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
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Krause BC, Kriegel FL, Tartz V, Jungnickel H, Reichardt P, Singh AV, Laux P, Shemis M, Luch A. Combinatory Effects of Cerium Dioxide Nanoparticles and Acetaminophen on the Liver-A Case Study of Low-Dose Interactions in Human HuH-7 Cells. Int J Mol Sci 2021; 22:6866. [PMID: 34202329 PMCID: PMC8268126 DOI: 10.3390/ijms22136866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/12/2022] Open
Abstract
The interactions between pharmaceuticals and nanomaterials and its potentially resulting toxicological effects in living systems are only insufficiently investigated. In this study, two model compounds, acetaminophen, a pharmaceutical, and cerium dioxide, a manufactured nanomaterial, were investigated in combination and individually. Upon inhalation, cerium dioxide nanomaterials were shown to systemically translocate into other organs, such as the liver. Therefore we picked the human liver cell line HuH-7 cells as an in vitro system to investigate liver toxicity. Possible synergistic or antagonistic metabolic changes after co-exposure scenarios were investigated. Toxicological data of the water soluble tetrazolium (WST-1) assay for cell proliferation and genotoxicity assessment using the Comet assay were combined with an untargeted as well as a targeted lipidomics approach. We found an attenuated cytotoxicity and an altered metabolic profile in co-exposure experiments with cerium dioxide, indicating an interaction of both compounds at these endpoints. Single exposure against cerium dioxide showed a genotoxic effect in the Comet assay. Conversely, acetaminophen exhibited no genotoxic effect. Comet assay data do not indicate an enhancement of genotoxicity after co-exposure. The results obtained in this study highlight the advantage of investigating co-exposure scenarios, especially for bioactive substances.
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Affiliation(s)
- Benjamin C. Krause
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
| | - Fabian L. Kriegel
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
- NUVISAN ICB GmbH, Preclinical Compound Profiling, Muellerstrasse 178, 13353 Berlin, Germany
| | - Victoria Tartz
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
| | - Harald Jungnickel
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
| | - Philipp Reichardt
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
| | - Ajay Vikram Singh
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
| | - Peter Laux
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
| | - Mohamed Shemis
- Department of Biochemistry & Molecular Biology, Theodor Bilharz Research Institute, Warak El-Hadar, Kornish El-Nile, P.O. Box 30 Imbaba, Giza 12411, Egypt;
| | - Andreas Luch
- Department of Chemical & Product Safety, German Federal Institute for Risk Assessment, Max-Dohrn-Straße 8-10, 10589 Berlin, Germany; (F.L.K.); (V.T.); (H.J.); (P.R.); (A.V.S.); (P.L.); (A.L.)
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Mundaca‐Uribe R, Karshalev E, Esteban‐Fernández de Ávila B, Wei X, Nguyen B, Litvan I, Fang RH, Zhang L, Wang J. A Microstirring Pill Enhances Bioavailability of Orally Administered Drugs. Adv Sci (Weinh) 2021; 8:2100389. [PMID: 34194949 PMCID: PMC8224427 DOI: 10.1002/advs.202100389] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/10/2021] [Indexed: 05/15/2023]
Abstract
Majority of drugs are administered orally, yet their efficient absorption is often difficult to achieve, with a low dose fraction reaching the blood compartment. Here, a microstirring pill technology is reported with built-in mixing capability for oral drug delivery that greatly enhances bioavailability of its therapeutic payload. Embedding microscopic stirrers into a pill matrix enables faster disintegration and dissolution, leading to improved release profiles of three widely used model drugs, aspirin, levodopa, and acetaminophen, without compromising their loading. Unlike recently developed drug-carrying nanomotors, drug molecules are not associated with the microstirrers, and hence there is no limitation on the loading capacity. These embedded microstirrers are fabricated through the asymmetric coating of titanium dioxide thin film onto magnesium microparticles. In vitro tests illustrate that the embedded microstirrers lead to substantial enhancement of local fluid transport. In vivo studies using murine and porcine models demonstrate that the localized stirring capability of microstirrers leads to enhanced bioavailability of drug payloads. Such improvements are of considerable importance in clinical scenarios where fast absorption and high bioavailability of therapeutics are critical. The encouraging results obtained in porcine model suggest that the microstirring pill technology has translational potential and can be developed toward practical biomedical applications.
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Affiliation(s)
- Rodolfo Mundaca‐Uribe
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
| | - Emil Karshalev
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
| | | | - Xiaoli Wei
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
| | - Bryan Nguyen
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
| | - Irene Litvan
- Department of NeurosciencesUniversity of California San DiegoLa JollaCA92093USA
| | - Ronnie H. Fang
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
| | - Liangfang Zhang
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
| | - Joseph Wang
- Department of Nanoengineering and Chemical Engineering ProgramUniversity of California San DiegoLa JollaCA92093USA
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Abstract
This study describes oral temperatures in a large sample of nonsurgical inpatients without infections to inform evaluation of fever in the hospital.
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Affiliation(s)
- Sidra L. Speaker
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Elizabeth R. Pfoh
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Matthew A. Pappas
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Bo Hu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Gleneadie HJ, Baker AH, Batis N, Bryant J, Jiang Y, Clokie SJH, Mehanna H, Garcia P, Gendoo DMA, Roberts S, Burley M, Molinolo AA, Gutkind JS, Scheven BA, Cooper PR, Parish JL, Khanim FL, Wiench M. The anti-tumour activity of DNA methylation inhibitor 5-aza-2'-deoxycytidine is enhanced by the common analgesic paracetamol through induction of oxidative stress. Cancer Lett 2021; 501:172-186. [PMID: 33359448 PMCID: PMC7845757 DOI: 10.1016/j.canlet.2020.12.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/07/2020] [Accepted: 12/19/2020] [Indexed: 12/31/2022]
Abstract
The DNA demethylating agent 5-aza-2'-deoxycytidine (DAC, decitabine) has anti-cancer therapeutic potential, but its clinical efficacy is hindered by DNA damage-related side effects and its use in solid tumours is debated. Here we describe how paracetamol augments the effects of DAC on cancer cell proliferation and differentiation, without enhancing DNA damage. Firstly, DAC specifically upregulates cyclooxygenase-2-prostaglandin E2 pathway, inadvertently providing cancer cells with survival potential, while the addition of paracetamol offsets this effect. Secondly, in the presence of paracetamol, DAC treatment leads to glutathione depletion and finally to accumulation of ROS and/or mitochondrial superoxide, both of which have the potential to restrict tumour growth. The benefits of combined treatment are demonstrated here in head and neck squamous cell carcinoma (HNSCC) and acute myeloid leukaemia cell lines, further corroborated in a HNSCC xenograft mouse model and through mining of publicly available DAC and paracetamol responses. The sensitizing effect of paracetamol supplementation is specific to DAC but not its analogue 5-azacitidine. In summary, the addition of paracetamol could allow for DAC dose reduction, widening its clinical usability and providing a strong rationale for consideration in cancer therapy.
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Affiliation(s)
- Hannah J Gleneadie
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B5 7EG, UK; Present Address: MRC London Institute of Medical Sciences, Imperial College London, London, W12 0NN, UK
| | - Amy H Baker
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B5 7EG, UK
| | - Nikolaos Batis
- Institute of Head and Neck Studies and Education (InHANSE), The University of Birmingham, Birmingham, B15 2TT, UK
| | - Jennifer Bryant
- Institute of Head and Neck Studies and Education (InHANSE), The University of Birmingham, Birmingham, B15 2TT, UK
| | - Yao Jiang
- Institute of Clinical Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Samuel J H Clokie
- West Midlands Regional Genetics Laboratory, Birmingham Women's and Children's Hospital, Birmingham, B15 2TG, UK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), The University of Birmingham, Birmingham, B15 2TT, UK
| | - Paloma Garcia
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Deena M A Gendoo
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Sally Roberts
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Megan Burley
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Alfredo A Molinolo
- Moores Cancer Center and Department of Pathology, University of California San Diego, La Jolla, CA, 92093, USA
| | - J Silvio Gutkind
- Department of Pharmacology and Moores Cancer Center, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ben A Scheven
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B5 7EG, UK
| | - Paul R Cooper
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B5 7EG, UK; Present Address: Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand
| | - Joanna L Parish
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Farhat L Khanim
- Institute of Clinical Sciences, The University of Birmingham, Birmingham, B15 2TT, UK
| | - Malgorzata Wiench
- School of Dentistry, Institute of Clinical Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B5 7EG, UK; Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, The University of Birmingham, Birmingham, B15 2TT, UK.
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Naim S, Fernandez-Marrero Y, de Brot S, Bachmann D, Kaufmann T. Loss of BOK Has a Minor Impact on Acetaminophen Overdose-Induced Liver Damage in Mice. Int J Mol Sci 2021; 22:ijms22063281. [PMID: 33807047 PMCID: PMC8004760 DOI: 10.3390/ijms22063281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/14/2021] [Accepted: 03/20/2021] [Indexed: 12/27/2022] Open
Abstract
Acetaminophen (APAP) is one of the most commonly used analgesic and anti-pyretic drugs, and APAP intoxication is one of the main reasons for liver transplantation following liver failure in the Western world. While APAP poisoning ultimately leads to liver necrosis, various programmed cell death modalities have been implicated, including ER stress-triggered apoptosis. The BCL-2 family member BOK (BCL-2-related ovarian killer) has been described to modulate the unfolded protein response and to promote chemical-induced liver injury. We therefore investigated the impact of the loss of BOK following APAP overdosing in mice. Surprisingly, we observed sex-dependent differences in the activation of the unfolded protein response (UPR) in both wildtype (WT) and Bok-/- mice, with increased activation of JNK in females compared with males. Loss of BOK led to a decrease in JNK activation and a reduced percentage of centrilobular necrosis in both sexes after APAP treatment; however, this protection was more pronounced in Bok-/- females. Nevertheless, serum ALT and AST levels of Bok-/- and WT mice were comparable, indicating that there was no major difference in the overall outcome of liver injury. We conclude that after APAP overdosing, loss of BOK affects initiating signaling steps linked to ER stress, but has a more minor impact on the outcome of liver necrosis. Furthermore, we observed sex-dependent differences that might be worthwhile to investigate.
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Affiliation(s)
- Samara Naim
- Institute of Pharmacology, University of Bern, Inselspital, INO-F, 3010 Bern, Switzerland; (S.N.); (Y.F.-M.); (D.B.)
| | - Yuniel Fernandez-Marrero
- Institute of Pharmacology, University of Bern, Inselspital, INO-F, 3010 Bern, Switzerland; (S.N.); (Y.F.-M.); (D.B.)
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada
| | - Simone de Brot
- COMPATH, Institute of Animal Pathology, University of Bern, Laenggassstrasse 122, CH-3012 Bern, Switzerland;
| | - Daniel Bachmann
- Institute of Pharmacology, University of Bern, Inselspital, INO-F, 3010 Bern, Switzerland; (S.N.); (Y.F.-M.); (D.B.)
| | - Thomas Kaufmann
- Institute of Pharmacology, University of Bern, Inselspital, INO-F, 3010 Bern, Switzerland; (S.N.); (Y.F.-M.); (D.B.)
- Correspondence:
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Can Ö, Kıyan GS, Yalçınlı S. Comparison of intravenous ibuprofen and paracetamol in the treatment of fever: A randomized double-blind study. Am J Emerg Med 2021; 46:102-106. [PMID: 33740568 DOI: 10.1016/j.ajem.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Fever is one of the frequent reasons for admission to the emergency department. Studies comparing oral forms of non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol with intravenous (IV) forms for fever are common in the literature. Our study is the first emergency department study comparing IV forms of ibuprofen and paracetamol in the treatment of febrile patients. METHODS A randomized, double-blind study was conducted in a tertiary university emergency department for a six-month period. Patients aged 18-65 years who had a fever of ≥38.0 °C were included. Patients were administered 400 mg of IV ibuprofen and 1000 mg of IV paracetamol. The primary aim of the study was to determine whether there was a difference in the effect of the two drugs on fever. The secondary aim was to investigate whether there was a difference in terms of numeric rating scale (NRS) measurements and the need for additional antipyretic therapy. RESULTS A total of 200 people, 100 of whom were female, were included in the study. The mean age was 30.77 ± 10.61 years. The mean initial temperature for ibuprofen and paracetamol was 38.79 ± 0.470 °C and 38.70 ± 0.520 °C, respectively, with no difference noted between the groups (p = 0.380). It was found that both drugs significantly provided fever control in the first 30 min (p < 0.001), with no difference between them in terms of fever reduction (p = 0.980). Both drugs significantly improved in accompanying symptoms, although both drugs did not show superiority to each other (p = 0.0226). When evaluated in terms of a need for rescue medication, no significant difference was found between the two drugs (p = 0.404). No side effects were encountered during the study. CONCLUSION In adult age group patients admitted to the emergency department with high fever, the IV forms of 1000 mg paracetamol and 400 mg ibuprofen effectively and equally reduce complaints, such as fever and accompanying pain. They can be effectively used as each other's rescue medicine and as an alternative to each other in patients with comorbid diseases.
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Affiliation(s)
- Özge Can
- Department of Emergency Medicine, Ege University, 35100 Izmir, Turkey.
| | | | - Sercan Yalçınlı
- Department of Emergency Medicine, Ege University, 35100 Izmir, Turkey.
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Culebras M, Pishnamazi M, Walker GM, Collins MN. Facile Tailoring of Structures for Controlled Release of Paracetamol from Sustainable Lignin Derived Platforms. Molecules 2021; 26:1593. [PMID: 33805704 PMCID: PMC8000009 DOI: 10.3390/molecules26061593] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/19/2021] [Accepted: 03/10/2021] [Indexed: 12/25/2022] Open
Abstract
Nowadays, sustainable materials are receiving significant attention due to the fact that they will be crucial for the development of the next generation of products and devices. In the present work, hydrogels have been successfully synthesized using lignin which is non-valorized biopolymer from the paper industry. Hydrogels were prepared via crosslinking with Poly(ethylene) glycol diglycidyl ether (PEGDGE). Different crosslinker ratios were used to determine their influence on the structural and chemical properties of the resulting hydrogels. It has been found that pore size was reduced by increasing crosslinker amount. The greater crosslinking density increased the swelling capacity of the hydrogels due to the presence of more hydrophilic groups in the hydrogel network. Paracetamol release test showed higher drug diffusion for hydrogels produced with a ratio lignin:PEGDGE 1:1. The obtained results demonstrate that the proposed approach is a promising route to utilize lignocellulose waste for producing porous materials for advanced biomedical applications in the pharmacy industry.
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Affiliation(s)
- Mario Culebras
- Stokes Laboratories, School of Engineering, Bernal Institute and AMBER, University of Limerick, V94 T9PX Limerick, Ireland;
| | - Mahboubeh Pishnamazi
- Pharmaceutical Centre (SSPC), University of Limerick, V94 T9PX Limerick, Ireland; (M.P.); (G.M.W.)
| | - Gavin M. Walker
- Pharmaceutical Centre (SSPC), University of Limerick, V94 T9PX Limerick, Ireland; (M.P.); (G.M.W.)
| | - Maurice N. Collins
- Stokes Laboratories, School of Engineering, Bernal Institute and AMBER, University of Limerick, V94 T9PX Limerick, Ireland;
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Shariare MH, Masum AA, Alshehri S, Alanazi FK, Uddin J, Kazi M. Preparation and Optimization of PEGylated Nano Graphene Oxide-Based Delivery System for Drugs with Different Molecular Structures Using Design of Experiment (DoE). Molecules 2021; 26:1457. [PMID: 33800115 PMCID: PMC7962195 DOI: 10.3390/molecules26051457] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 12/03/2022] Open
Abstract
Graphene oxide (GO), due to its 2D planar structure and favorable physical and chemical properties, has been used in different fields including drug delivery. This study aimed to investigate the impact of different process parameters on the average size of drug-loaded PEGylated nano graphene oxide (NGO-PEG) particles using design of experiment (DoE) and the loading of drugs with different molecular structures on an NGO-PEG-based delivery system. GO was prepared from graphite, processed using a sonication method, and functionalized using PEG 6000. Acetaminophen (AMP), diclofenac (DIC), and methotrexate (MTX) were loaded onto NGO-PEG particles. Drug-loaded NGO-PEG was then characterized using dynamic light scattering (DLS), Fourier transform infrared (FTIR), scanning electron microscopy (SEM), differential scanning calorimetry (DSC), XRD. The DLS data showed that the drug-loaded NGO-PEG suspensions were in the size range of 200 nm-1.3 µm. The sonication time and the stirring rate were found to be the major process parameters which affected the average size of the drug-loaded NGO-PEG. FTIR, DSC, XRD, and SEM demonstrated that the functionalization or coating of the NGO occurred through physical interaction using PEG 6000. Methotrexate (MTX), with the highest number of aromatic rings, showed the highest loading efficiency of 95.6% compared to drugs with fewer aromatic rings (diclofenac (DIC) 70.5% and acetaminophen (AMP) 65.5%). This study suggests that GO-based nano delivery systems can be used to deliver drugs with multiple aromatic rings with a low water solubility and targeted delivery (e.g., cancer).
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Affiliation(s)
- Mohammad Hossain Shariare
- Department of Pharmaceutical Sciences, North South University, Dhaka 1229, Bangladesh; (M.H.S.); (A.-A.M.)
| | - Abdullah-Al Masum
- Department of Pharmaceutical Sciences, North South University, Dhaka 1229, Bangladesh; (M.H.S.); (A.-A.M.)
| | - Sultan Alshehri
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (F.K.A.)
| | - Fars K. Alanazi
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (F.K.A.)
| | - Jamal Uddin
- Center for Nanotechnology, Department of Natural Sciences, Coppin State University, Baltimore, MD 21216, USA;
| | - Mohsin Kazi
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (F.K.A.)
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Zhang J, Xu P, Vo AQ, Repka MA. Oral drug delivery systems using core-shell structure additive manufacturing technologies: a proof-of-concept study. J Pharm Pharmacol 2021; 73:152-160. [PMID: 33793804 PMCID: PMC7940344 DOI: 10.1093/jpp/rgaa037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/23/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to couple fused deposition modelling 3D printing with melt extrusion technology to produce core-shell-structured controlled-release tablets with dual-mechanism drug-release performance in a simulated intestinal fluid medium. Coupling abovementioned technologies for personalized drug delivery can improve access to complex dosage formulations at a reasonable cost. Compared with traditional pharmaceutical manufacturing, this should facilitate the following: (1) the ability to manipulate drug release by adjusting structures, (2) enhanced solubility and bioavailability of poorly water-soluble drugs and (3) on-demand production of more complex structured dosages for personalized treatment. METHODS Acetaminophen was the model drug and the extrusion process was evaluated by a series of physicochemical characterizations. The geometries, morphologies, and in vitro drug-release performances were compared between directly compressed and 3D-printed tablets. KEY FINDINGS Initially, 3D-printed tablets released acetaminophen more rapidly than directly compressed tablets. Drug release became constant and steady after a pre-determined time. Thus, rapid effectiveness was ensured by an initially fast acetaminophen release and an extended therapeutic effect was achieved by stabilizing drug release. CONCLUSIONS The favourable drug-release profiles of 3D-printed tablets demonstrated the advantage of coupling HME with 3D printing technology to produce personalized dosage formulations.
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Affiliation(s)
- Jiaxiang Zhang
- Department of Pharmaceutics and Drug Delivery, The University of Mississippi, University, MS, USA
| | - Pengchong Xu
- Department of Pharmaceutics and Drug Delivery, The University of Mississippi, University, MS, USA
| | - Anh Q Vo
- Department of Pharmaceutics and Drug Delivery, The University of Mississippi, University, MS, USA
| | - Michael A Repka
- Department of Pharmaceutics and Drug Delivery, The University of Mississippi, University, MS, USA
- Pii Center for Pharmaceutical Innovation and Instruction, The University of Mississippi, University, MS, USA
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Costales TG, Greenwell PH, Chapman DM, Volkmann MC, Dalury DF. Average narcotic usage in a group of TKA patients following a modern TKA protocol. Knee 2021; 29:426-431. [PMID: 33725664 DOI: 10.1016/j.knee.2021.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 02/01/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The optimal dosing of post-operative total knee arthroplasty (TKA) narcotics is unclear. We report on the average narcotic usage in a group of patients treated with an identical multimodal pain protocol following TKA. MATERIALS AND METHODS 49 patients undergoing TKA participated in the survey. Patients with pre-op narcotic use, recent prior total joint arthroplasty or study refusal were excluded. All patients received a spinal anesthetic. No pre-surgery narcotics were given. All received an identical local infiltrative anesthetic combination along with a multimodal pain protocol. Patients were placed into an identical rapid rehab program. Narcotic usage during hospitalization was recorded in morphine equivalent doses (MED). Patients were given a journal to record their daily narcotic utilization. RESULTS Pre-operative pain scores of the excluded groups had slightly higher but clinically insignificant differences compared to the study group. In the hospital, POD1 study group daily MED averaged 28 (range 0-110). POD2 had an average of 33.6 and POD 3 daily usages averaged 28.6 (range 0-100). By the end of week two, the average daily use was 19.2 and 24% patients were off all narcotics. By the end of week four, the average daily usage was 7.5 and 63% of patients were off all narcotics. By 8 weeks, there were no patients still taking narcotics. KSS averaged 76.9 (range 51-97) at the 6 week visit, and 94.2 at the 3-month visit (range 72-100). SUMMARY This study documents the average needs of an average TKA patient treated with modern pain protocols. The majority of these patients were off narcotics by week four.
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Affiliation(s)
- Timothy G Costales
- University of Maryland Medical Center, 110 South Paca Street 6(th) Floor Suite 300, Baltimore, MD 21201, United States
| | - Patrick H Greenwell
- University of Maryland Medical Center, 110 South Paca Street 6(th) Floor Suite 300, Baltimore, MD 21201, United States
| | - Danielle M Chapman
- The University of Maryland St. Joseph Medical Center, 7601 Osler Dr., Towson, MD 21204, United States
| | - Mary C Volkmann
- The University of Maryland St. Joseph Medical Center, 7601 Osler Dr., Towson, MD 21204, United States
| | - David F Dalury
- The University of Maryland St. Joseph Medical Center, 7601 Osler Dr., Towson, MD 21204, United States.
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Vélez-Rivera SM, Rodríguez-Rodríguez NJ, Ortiz-Vera YA, Parambil A, Hernández-Muñoz JJ. Appropriateness of Acetaminophen Dosing by Caregivers of Pediatric Patients Presenting to the Emergency Department at the University Pediatric Hospital in Puerto Rico. P R Health Sci J 2021; 40:19-25. [PMID: 33876914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Evaluate the appropriateness of acetaminophen dosing by caregivers seeking care for their children/wards at the emergency department of a pediatric hospital. METHODS Design: Cross-sectional descriptive study. Setting: The emergency department of the University Pediatric Hospital in San Juan, Puerto Rico. Participants: Eighty-eight caregivers who had, in the past 24 hours, administered a known quantity of acetaminophen to a pediatric patient under their care and were visiting the emergency room with that patient. Intervention: The caregivers were interviewed by the investigators, using a standardized questionnaire. Main outcome measures: The appropriateness of the acetaminophen doses administered by caregivers. The product's dosage form and strength, measurement device used (if any), and demographic data (of the caregiver and child) were also collected. Doses of 10 to 15 mg/kg of acetaminophen were considered appropriate. RESULTS Overall, 45% of the caregivers had administered an inappropriate dose. Of these, 70% were subtherapeutic and 30% were supratherapeutic. Although 74% of the caregivers knew their child's/ward's weight, only 50% had used it to determine the dose. Caregivers with previous experience (as caregivers) were most likely to have administered an inappropriate dose (P = 0.03). Physicians were the source most consulted (40%) by caregivers, followed by the product's label (35%). Only 9% of the caregivers consulted a pharmacist for dosing recommendations. CONCLUSION Nearly half of all the caregivers administered an incorrect acetaminophen dose, suggesting that there is a need for better caregiver education. Due to their accessibility at the point of sale of OTC medications and pharmacotherapy knowledge, pharmacists could have an active role in promoting the safe and effective use of acetaminophen.
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Affiliation(s)
- Suzette M Vélez-Rivera
- Department of Pharmacy Practice, University of Puerto Rico School of Pharmacy, San Juan, Puerto Rico
| | | | - Yakelin A Ortiz-Vera
- Department of Pharmacy Practice, University of Puerto Rico School of Pharmacy, San Juan, Puerto Rico
| | - Ashley Parambil
- Texas A&M University College of Pharmacy, College Station, Texas
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Akgun E, Boyacioglu M, Kum S. The potential protective role of folic acid against acetaminophen-induced hepatotoxicity and nephrotoxicity in rats. Exp Anim 2021; 70:54-62. [PMID: 32963203 PMCID: PMC7887621 DOI: 10.1538/expanim.20-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Folic acid (FA), is a group B vitamin, has high reactive oxygen radicals quenching ability, resulting in protection against oxidative damage in aerobic cell. Acetaminophen (N-acetyl-p-aminophenol, APAP) is a nonsteroidal anti-inflammatory drug, and can promote oxidative damage in liver and kidney tissues. The aim of this study was to investigate whether folic acid has protective effects on oxidative liver and kidney injury caused by experimental APAP toxication. Forty female Sprague dawley rats were divided into 5 groups; control, APAP, FA, APAP+FA, and APAP+N-acetylcysteine (NAC) groups. APAP toxication was induced by oral gavage (3 g/kg bodyweight). FA (20 mg/kg bodyweight) and NAC (150 mg/kg bodyweight) were given by oral gavage to the specified groups. Oxidant and antioxidant parameter were determined in liver and kidney tissues. In addition, the liver and kidney tissues were histological evaluated. When compared with APAP group, superoxide dismutase (SOD) and catalase activities and glutathione levels were statistically higher, malondialdehyde (MDA) level and myeloperoxidase activity (except liver tissue) were statistically lower in both APAP+FA and APAP+NAC. Liver and kidney MDA level and kidney SOD activity were significantly lower in APAP+NAC group compared with APAP+FA group. Co-administration of NAC with APAP was found to provide protection, but hepatic cords were defective in some places and some glomerular tubules also had dilatation. Necrotic areas was reduced in the liver and the glomerular structure was in good condition in the APAP+FA group. As a result, FA might have a protective effect against APAP-induced hepato-nephrotoxicity and oxidative stress in rat.
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Affiliation(s)
- Emrah Akgun
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Aydin Adnan Menderes University, Isikli, 09016, Aydin, Turkey
| | - Murat Boyacioglu
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Aydin Adnan Menderes University, Isikli, 09016, Aydin, Turkey
| | - Sadiye Kum
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Aydin Adnan Menderes University, Isikli, 09016, Aydin, Turkey
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Kudelin AI, Papathanasiou K, Isaeva V, Caro J, Salmi T, Kustov LM. Microwave-Assisted Synthesis, Characterization and Modeling of CPO-27-Mg Metal-Organic Framework for Drug Delivery. Molecules 2021; 26:molecules26020426. [PMID: 33467467 PMCID: PMC7830474 DOI: 10.3390/molecules26020426] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/04/2023] Open
Abstract
The coordination polymer CPO-27-Mg was rapidly synthesized under microwave irradiation. This material exhibits a sufficiently high drug loading towards aspirin (~8% wt.) and paracetamol (~14% wt.). The binding of these two molecules with the inner surface of the metal-organic framework was studied employing the Gaussian and Plane Wave approach of the Density Functional Theory. The structure of CPO-27-Mg persists after the adsorption of aspirin or paracetamol and their desorption energies, being quite high, decrease under solvent conditions.
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Affiliation(s)
- Anton I. Kudelin
- Russian Academy of Sciences, N. D. Zelinsky Institute of Organic Chemistry, Russian Federation, Leninsky Prosp. 47, 119991 Moscow, Russia; (A.I.K.); (V.I.)
| | - Konstantinos Papathanasiou
- International Laboratory of Nanochemistry and Ecology, National University of Science and Technology MISiS, Moscow, Leninsky Prosp. 4, 119991 Moscow, Russia;
| | - Vera Isaeva
- Russian Academy of Sciences, N. D. Zelinsky Institute of Organic Chemistry, Russian Federation, Leninsky Prosp. 47, 119991 Moscow, Russia; (A.I.K.); (V.I.)
- International Laboratory of Nanochemistry and Ecology, National University of Science and Technology MISiS, Moscow, Leninsky Prosp. 4, 119991 Moscow, Russia;
| | - Juergen Caro
- Laboratory of Nano and Quantum Engineering, Leibniz University Hannover, 30167 Hanover, Germany;
| | - Tapio Salmi
- Faculty of Science and Engineering, Abo Akademy University, FI-20500 Turku, Finland;
| | - Leonid M. Kustov
- Russian Academy of Sciences, N. D. Zelinsky Institute of Organic Chemistry, Russian Federation, Leninsky Prosp. 47, 119991 Moscow, Russia; (A.I.K.); (V.I.)
- International Laboratory of Nanochemistry and Ecology, National University of Science and Technology MISiS, Moscow, Leninsky Prosp. 4, 119991 Moscow, Russia;
- Faculty of Chemistry, Lomonosov Moscow State University, 119992 Moscow, Russia
- Correspondence:
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Pishnamazi M, Hafizi H, Pishnamazi M, Marjani A, Shirazian S, Walker GM. Controlled release evaluation of paracetamol loaded amine functionalized mesoporous silica KCC1 compared to microcrystalline cellulose based tablets. Sci Rep 2021; 11:535. [PMID: 33436819 PMCID: PMC7804127 DOI: 10.1038/s41598-020-79983-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/15/2020] [Indexed: 01/11/2023] Open
Abstract
In the pharmaceutical manufacturing, drug release behavior development is remained as one of the main challenges to improve the drug effectiveness. Recently, more focus has been done on using mesoporous silica materials as drug carriers for prolonged and superior control of drug release in human body. In this study, release behavior of paracetamol is developed using drug-loaded KCC-1-NH2 mesoporous silica, based on direct compaction method for preparation of tablets. The purpose of this study is to investigate the utilizing of pure KCC-1 mesoporous silica (KCC-1) and amino functionalized KCC-1 (KCC-1-NH2) as drug carriers in oral solid dosage formulations compared to common excipient, microcrystalline cellulose (MCC), to improve the control of drug release rate by manipulating surface chemistry of the carrier. Different formulations of KCC-1 and KCC-NH2 are designed to investigate the effect of functionalized mesoporous silica as carrier on drug controlled-release rate. The results displayed the remarkable effect of KCC-1-NH2 on drug controlled-release in comparison with the formulation containing pure KCC-1 and formulation including MCC as reference materials. The pure KCC-1 and KCC-1-NH2 are characterized using different evaluation methods such as FTIR, SEM, TEM and N2 adsorption analysis.
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Affiliation(s)
- Marieh Pishnamazi
- Department of Chemistry, Arak Branch, Islamic Azad University, Arak, Iran
| | - Hamid Hafizi
- Department of Chemical Sciences, Bernal Institute, Synthesis and Solid-State Pharmaceutical Centre (SSPC), University of Limerick, Limerick, Ireland
| | - Mahboubeh Pishnamazi
- Department of Chemical Sciences, Bernal Institute, Synthesis and Solid-State Pharmaceutical Centre (SSPC), University of Limerick, Limerick, Ireland
- Institute of Research and Development, Duy Tan University, Da Nang, 550000, Vietnam
- The Faculty of Pharmacy, Duy Tan University, Da Nang, 550000, Vietnam
| | - Azam Marjani
- Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Vietnam.
- Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam.
| | - Saeed Shirazian
- Department of Chemical Sciences, Bernal Institute, Synthesis and Solid-State Pharmaceutical Centre (SSPC), University of Limerick, Limerick, Ireland
- Institute of Research and Development, Duy Tan University, Da Nang, 550000, Vietnam
- The Faculty of Environmental and Chemical Engineering, Duy Tan University, Da Nang, 550000, Vietnam
- Laboratory of Computational Modeling of Drugs, South Ural State University, Chelyabinsk, 454080, Russian Federation
| | - Gavin M Walker
- Department of Chemical Sciences, Bernal Institute, Synthesis and Solid-State Pharmaceutical Centre (SSPC), University of Limerick, Limerick, Ireland
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Wuytack F, Smith V, Cleary BJ. Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2021; 1:CD011352. [PMID: 33427305 PMCID: PMC8092572 DOI: 10.1002/14651858.cd011352.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many women experience perineal pain after childbirth, especially after having sustained perineal trauma. Perineal pain-management strategies are an important part of postnatal care. Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly-used type of medication in the management of postpartum pain, and their effectiveness and safety should be assessed. This is an update of a review first published in 2016. OBJECTIVES To determine the effectiveness of a single dose of an oral NSAID for relief of acute perineal pain in the early postpartum period. SEARCH METHODS For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 December 2019), OpenSIGLE and ProQuest Dissertations and Theses (28 February 2020), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing a single dose of a NSAID versus a single dose of placebo, paracetamol or another NSAID for women with perineal pain in the early postpartum period. We excluded quasi-RCTs and cross-over trials. We included papers in abstract format only if they had sufficient information to determine that they met the review's prespecified inclusion criteria. DATA COLLECTION AND ANALYSIS Two review authors (FW and VS) independently assessed all identified papers for inclusion and risks of bias, resolving any discrepancies through discussion. Two review authors independently conducted data extraction, including calculations of pain relief scores, and checked it for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 35 studies examining 16 different NSAIDs and involving 5136 women (none were breastfeeding). Studies were published between 1967 and 2013. Risk of bias due to random sequence generation, allocation concealment and blinding of outcome assessors was generally unclearly to poorly reported, but participants and caregivers were blinded, and outcome data were generally complete. We downgraded the certainty of evidence due to risk of bias, suspected publication bias, and imprecision for small numbers of participants. NSAID versus placebo Compared to women who receive a placebo, more women who receive a single-dose NSAID may achieve adequate pain relief at four hours (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.64 to 2.23; 10 studies, 1573 women; low-certainty evidence) and at six hours (RR 1.92, 95% CI 1.69 to 2.17; 17 studies, 2079 women; very low-certainty evidence), although we are less certain about the effects at six hours. At four hours after administration, women who receive a NSAID are probably less likely to need additional analgesia compared to women who receive placebo (RR 0.39, 95% CI 0.26 to 0.58; 4 studies, 486 women; moderate-certainty evidence) and may be less likely to need additional analgesia at six hours after initial administration, although the evidence was less certain at six hours (RR 0.32, 95% CI 0.26 to 0.40; 10 studies, 1012 women; very low-certainty evidence). One study reported that no adverse events were observed at four hours post-administration (90 women). There may be little or no difference in maternal adverse effects between NSAIDs and placebo at six hours post-administration (RR 1.38, 95% CI 0.71 to 2.70; 13 studies, 1388 women; low-certainty evidence). Fourteen maternal adverse effects were reported in the NSAID group (drowsiness (5), abdominal discomfort (2), weakness (1), dizziness (2), headache (2), moderate epigastralgia (1), not specified (1)) and eight in the placebo group (drowsiness (2), light-headedness (1), nausea (1), backache (1), dizziness (1), epigastric pain (1), not specified (1)), although not all studies assessed adverse effects. Neonatal adverse effects were not assessed in any of the studies. NSAID versus paracetamol NSAIDs may lead to more women achieving adequate pain relief at four hours, compared with paracetamol (RR 1.54, 95% CI 1.07 to 2.22; 3 studies, 342 women; low-certainty evidence). We are uncertain if there is any difference in adequate pain relief between NSAIDs and paracetamol at six hours post-administration (RR 1.82, 95% CI 0.61 to 5.47; 2 studies, 99 women; very low-certainty evidence) or in the need for additional analgesia at four hours (RR 0.55, 95% CI 0.27 to 1.13; 1 study, 73 women; very low-certainty evidence). NSAIDs may reduce the risk of requiring additional analgesia at six hours compared with paracetamol (RR 0.28, 95% CI 0.12 to 0.67; 1 study, 59 women; low-certainty evidence). One study reported that no maternal adverse effects were observed at four hours post-administration (210 women). Six hours post-administration, we are uncertain if there is any difference between groups in the number of maternal adverse effects (RR 0.74, 95% CI 0.27 to 2.08; 3 studies, 300 women; very low-certainty evidence), with one case of pruritis in the NSAID group and one case of sleepiness in the paracetamol group. Neonatal adverse effects were not assessed in any of the included studies. Comparisons of different NSAIDs or doses did not demonstrate any differences in effectiveness for any primary outcome measures; however, few data were available on some NSAIDs. None of the included studies reported on any of this review's secondary outcomes. AUTHORS' CONCLUSIONS In women who are not breastfeeding and who sustained perineal trauma, NSAIDs (compared to placebo or paracetamol) may provide greater pain relief for acute postpartum perineal pain and fewer women need additional analgesia, but uncertainty remains, as the evidence is rated as low- or very low-certainty. The risk of bias was unclear for many studies, adverse effects were often not assessed and breastfeeding women were not included. While this review provides some indication of the likely effect, there is uncertainty in our conclusions. The main reasons for downgrading were the inclusion of studies at high risk of bias and inconsistency in the findings of individual studies. Future studies could examine NSAIDs' adverse effects, including neonatal effects and the compatibility of NSAIDs with breastfeeding, and could assess other secondary outcomes. Future research could consider women with and without perineal trauma, including perineal tears. High-quality studies could be conducted to further assess the efficacy of NSAIDs versus paracetamol and the efficacy of multimodal treatments.
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Affiliation(s)
- Francesca Wuytack
- School of Nursing and Midwifery, National University of Ireland, Galway, Galway, Ireland
| | - Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Brian J Cleary
- Department of Pharmacy, Rotunda Hospital, Dublin 1, Ireland
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
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Nakhaee S, Dastjerdi M, Roumi H, Mehrpour O, Farrokhfall K. N-acetylcysteine dose-dependently improves the analgesic effect of acetaminophen on the rat hot plate test. BMC Pharmacol Toxicol 2021; 22:4. [PMID: 33413696 PMCID: PMC7791802 DOI: 10.1186/s40360-020-00469-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/22/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acetaminophen (APAP) induced hepatotoxicity is a clinically important problem. Up to now, interventive therapy with n-acetylcysteine (NAC) has been considered as a gold-standard treatment for APAP overdose. However, no study has focused on the efficacy of these drugs' concurrent administration on probable enhancing therapeutic outcomes. Thus, this study was aimed to investigate the analgesic effect of co-administration of NAC and acetaminophen in male rats. The NAC-APAP drug formulation may demonstrate the stranger antinociceptive effect. METHODS Forty-eight male Sprague-Dawley rats (12-14 weeks) randomly divided into six equal groups; control, APAP (received 300 mg/kg APAP), NAC (received 600 mg/kg NAC) and APAP+ NAC groups that received simultaneously 300 mg/kg APAP with 200-600 mg/kg NAC (AN200, AN400, AN600). All administrations were done orally for once. The antinociceptive effect was recorded by measurement of latency period on a hot plate in 30, 60, and 90 min after administrations. RESULTS The results showed that NAC's concurrent administration with APAP, dose-dependently increased APAP analgesic effects (p< 0.0001). Moreover, NAC treatment exhibited an antinociceptive effect in 60 and 90 min, per se. The treatments had no adverse effect on liver enzymes and oxidative stress. CONCLUSION Co-administration of NAC with APAP can improve the antinociceptive effect of APAP. It is suggested that this compound can enhance analgesic effects of APAP and eventually lead to a reduction in acetaminophen dose. Further studies are needed to evaluate the molecular mechanism of this hyper analgesic effect.
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Affiliation(s)
- Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Mohammad Dastjerdi
- Cardiovascular Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Hesam Roumi
- Cardiovascular Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
- Mel and Enid Zuckerman, College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Khadijeh Farrokhfall
- Cardiovascular Research Center, Birjand University of Medical Sciences, Birjand, Iran.
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Abstract
BACKGROUND Total knee arthroplasty (TKA) is gradually emerging as the treatment of choice for end-stage osteoarthritis. In the past, intravenous (IV) versus oral acetaminophen (APAP) treatment is still a controversial subject in TKA. Therefore, we write this systematic review and meta-analysis to evaluate the efficacy of IV versus oral APAP on pain and recovery after TKA. METHODS Embase, Pubmed, and Cochrane Library were comprehensively searched. Randomized controlled trials, cohort studies were included in our meta-analysis. Five studies that compared IV APAP groups with oral APAP groups were included in our meta-analysis. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines to ensure the reliability and verity of results. RESULTS Pooled results indicated that no significant difference between the IV APAP groups and oral APAP groups in term of VAS score at 24 hours (P = .67), 48 hours (P = 0.08), and total morphine consumption at 24 hours (P = .07), but there was a significant difference in terms of length of hospital stay (LOS) (P = .0004). CONCLUSION IV APAP was not found to be superior to oral APAP in patients undergoing TKA in terms of VAS scores at 24 hours, 48 hours, and total morphine consumption at 24 hours. However, it can significantly reduce the LOS. We still need a large of high-quality research to verify the relationship between the oral and the IV APAP to give the conclusion.
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Affiliation(s)
| | - Yan Zhang
- Department of Nephrology, Weifang People's Hospital, Shandong, PR China
| | - Baojie Li
- Department of Orthopedics and Trauma
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Baker BH, Lugo-Candelas C, Wu H, Laue HE, Boivin A, Gillet V, Aw N, Rahman T, Lepage JF, Whittingstall K, Bellenger JP, Posner J, Takser L, Baccarelli AA. Association of Prenatal Acetaminophen Exposure Measured in Meconium With Risk of Attention-Deficit/Hyperactivity Disorder Mediated by Frontoparietal Network Brain Connectivity. JAMA Pediatr 2020; 174:1073-1081. [PMID: 32986124 PMCID: PMC7522774 DOI: 10.1001/jamapediatrics.2020.3080] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/06/2020] [Indexed: 12/19/2022]
Abstract
Importance Despite evidence of an association between prenatal acetaminophen exposure and attention-deficit/hyperactivity disorder (ADHD) in offspring, the drug is not contraindicated during pregnancy, possibly because prior studies have relied on maternal self-report, failed to quantify acetaminophen dose, and lacked mechanistic insight. Objective To examine the association between prenatal acetaminophen exposure measured in meconium (hereinafter referred to as meconium acetaminophen) and ADHD in children aged 6 to 7 years, along with the potential for mediation by functional brain connectivity. Design, Setting, and Participants This prospective birth cohort study from the Centre Hospitalier Université de Sherbrooke in Sherbrooke, Québec, Canada, included 394 eligible children, of whom 345 had meconium samples collected at delivery and information on ADHD diagnosis. Mothers were enrolled from September 25, 2007, to September 10, 2009, at their first prenatal care visit or delivery and were followed up when children were aged 6 to 7 years. When children were aged 9 to 11 years, resting-state brain connectivity was assessed with magnetic resonance imaging. Data for the present study were collected from September 25, 2007, to January 18, 2020, and analyzed from January 7, 2019, to January 22, 2020. Exposures Acetaminophen levels measured in meconium. Main Outcomes and Measures Physician diagnosis of ADHD was determined at follow-up when children were aged 6 to 7 years or from medical records. Resting-state brain connectivity was assessed with magnetic resonance imaging; attention problems and hyperactivity were assessed with the Behavioral Assessment System for Children Parent Report Scale. Associations between meconium acetaminophen levels and outcomes were estimated with linear and logistic regressions weighted on the inverse probability of treatment to account for potential confounders. Causal mediation analysis was used to test for mediation of the association between prenatal acetaminophen exposure and hyperactivity by resting-state brain connectivity. Results Among the 345 children included in the analysis (177 boys [51.3%]; mean [SD] age, 6.58 [0.54] years), acetaminophen was detected in 199 meconium samples (57.7%), and ADHD was diagnosed in 33 children (9.6%). Compared with no acetaminophen, detection of acetaminophen in meconium was associated with increased odds of ADHD (odds ratio [OR], 2.43; 95% CI, 1.41-4.21). A dose-response association was detected; each doubling of exposure increased the odds of ADHD by 10% (OR, 1.10; 95% CI, 1.02-1.19). Children with acetaminophen detected in meconium showed increased negative connectivity between frontoparietal and default mode network nodes to clusters in the sensorimotor cortices, which mediated an indirect effect on increased child hyperactivity (14%; 95% CI, 1%-26%). Conclusions and Relevance Together with the multitude of other cohort studies showing adverse neurodevelopment associated with prenatal acetaminophen exposure, this work suggests caution should be used in administering acetaminophen during pregnancy. Research into alternative pain management strategies for pregnant women could be beneficial.
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Affiliation(s)
- Brennan H. Baker
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York
| | - Claudia Lugo-Candelas
- Department of Psychiatry, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
| | - Haotian Wu
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York
| | - Hannah E. Laue
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Amélie Boivin
- Departement de Pédiatrie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Virginie Gillet
- Departement de Pédiatrie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Natalie Aw
- New York State Psychiatric Institute, New York, New York
| | - Tonima Rahman
- New York State Psychiatric Institute, New York, New York
| | - Jean-François Lepage
- Departement de Pédiatrie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Kevin Whittingstall
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Science, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Diagnostic Radiology, Faculty of Medicine and Health Science, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jean-Philippe Bellenger
- Department of Chemistry, Faculty of Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Jonathan Posner
- Department of Psychiatry, Columbia University Medical Center, New York, New York
- New York State Psychiatric Institute, New York, New York
- Sackler Institute for Developmental Psychobiology, Columbia University Medical Center, New York, New York
| | - Larissa Takser
- Departement de Pédiatrie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Departement de Psychiatrie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Andrea A. Baccarelli
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York
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Lewis SR, Baker PE, Andrews PJ, Cheng A, Deol K, Hammond N, Saxena M. Interventions to reduce body temperature to 35 ⁰C to 37 ⁰C in adults and children with traumatic brain injury. Cochrane Database Syst Rev 2020; 10:CD006811. [PMID: 33126293 PMCID: PMC8094748 DOI: 10.1002/14651858.cd006811.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability, with an estimated 5.5 million people experiencing severe TBI worldwide every year. Observational clinical studies of people with TBI suggest an association between raised body temperature and unfavourable outcome, although this relationship is inconsistent. Additionally, preclinical models suggest that reducing temperature to 35 °C to 37.5 °C improves biochemical and histopathological outcomes compared to reducing temperature to a lower threshold of 33 °C to 35 °C. It is unknown whether reducing body temperature to 35 °C to 37.5 °C in people admitted to hospital with TBI is beneficial, has no effect, or causes harm. This is an update of a review last published in 2014. OBJECTIVES To assess the effects of pharmacological interventions or physical interventions given with the intention of reducing body temperature to 35 °C to 37.5 °C in adults and children admitted to hospital after TBI. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and PubMed on 28 November 2019. We searched clinical trials registers, grey literature and references lists of reviews, and we carried out forward citation searches of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) with participants of any age admitted to hospital following TBI. We included interventions that aimed to reduce body temperature to 35 °C to 37.5 °C: these included pharmacological interventions (such as paracetamol, or non-steroidal anti-inflammatory drugs), or physical interventions (such as surface cooling devices, bedside fans, or cooled intravenous fluids). Eligible comparators were placebo or usual care. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of the evidence with GRADE. MAIN RESULTS We included one RCT with 41 participants. This study recruited adult participants admitted to two intensive care units in Australia, and evaluated a pharmacological intervention. Researchers gave participants 1 g paracetamol or a placebo intravenously at four-hourly intervals for 72 hours. We could not be certain whether intravenous paracetamol influenced mortality at 28 days (risk ratio 2.86, 95% confidence interval 0.32 to 25.24). We judged the evidence for this outcome to be very low certainty, meaning we have very little confidence in this effect estimate, and the true result may be substantially different to this effect. We downgraded the certainty for imprecision (because the evidence was from a single study with very few participants), and study limitations (because we noted a high risk of selective reporting bias). This study was otherwise at low risk of bias. The included study did not report the primary outcome for this review, which was the number of people with a poor outcome at the end of follow-up (defined as death or dependency, as measured on a scale such as the Glasgow Outcome Score), or any of our secondary outcomes, which included the number of people with further intracranial haemorrhage, extracranial haemorrhage, abnormal intracranial pressure, or pneumonia or other serious infections. The only other completed trial that we found was of a physical intervention that compared advanced fever control (using a surface cooling device) versus conventional fever control in 12 participants. The trial was published as an abstract only, with insufficient details to allow inclusion, so we have added this to the 'studies awaiting classification' section, pending further information from the study authors or publication of the full study report. We identified four ongoing studies that will contribute evidence to future updates of the review if they measure relevant outcomes and, in studies with a mixed population, report data separately for participants with TBI. AUTHORS' CONCLUSIONS One small study contributed very low-certainty evidence for mortality to this review. The uncertainty is largely driven by limited research into reduction of body temperature to 35 °C to 37.5 °C in people with TBI. Further research that evaluates pharmacological or physical interventions, or both, may increase certainty in this field. We propose that future updates of the review, and ongoing and future research in this field, incorporate outcomes that are important to the people receiving the interventions, including side effects of any pharmacological agent (e.g. nausea or vomiting), and discomfort caused by physical therapies.
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Affiliation(s)
- Sharon R Lewis
- Lancaster Patient Safety Research Unit, Royal Lancaster Infirmary, Lancaster, UK
| | - Philip E Baker
- Academic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Jd Andrews
- Intensive Care & Pain Medicine, University of Edinburgh, Lead Clinician, Critical Care Services, Western General Hospital, LUHD, Edinburgh, UK
| | - Andrew Cheng
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Kiran Deol
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Naomi Hammond
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, Australia
| | - Manoj Saxena
- Intensive Care Unit, St George Hospital, Sydney, Australia
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