Effect of risk factors on complicated and uncomplicated ulcers in the TARGET lumiracoxib outcomes study

BACKGROUND ; AIMS: Selective cyclooxygenase-2 inhibitors were developed to reduce the gastrointestinal risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs). The Therapeutic Arthritis Research and Gastrointestinal Event Trial was the largest study to evaluate primarily the gastrointestinal safety outcomes of selective cyclooxygenase-2 inhibitors. Data from the Therapeutic Arthritis Research and Gastrointestinal Event Trial were used to identify risk factors and investigate the safety of lumiracoxib in subgroups. METHODS: Patients with osteoarthritis (age, >or=50 y) were randomized to receive lumiracoxib 400 mg once daily, naproxen 500 mg twice daily, or ibuprofen 800 mg 3 times daily for 12 months. Events were categorized by a blinded adjudication committee. The primary end point was all definite or probable ulcer complications. RESULTS: For patients taking NSAIDs, factors associated with an increased risk of ulcer complications were age 65 years or older (hazard ratio [HR], 2.30; 95% confidence interval [CI], 1.48-3.59), previous history of gastrointestinal bleed or ulcer (HR, 3.61; 95% CI, 1.86-7.00), non-Caucasian racial origin (HR, 2.10; 95% CI, 1.35-3.27), and male sex (HR, 1.70; 95% CI, 1.08-2.68). With lumiracoxib, significant risk factors were age 65 years or older (HR, 3.18; 95% CI, 1.40-7.20), male sex (HR, 2.60; 95% CI, 1.25-5.40), non-Caucasian racial origin (HR, 2.16; 95% CI, 1.02-4.59), and concomitant aspirin use (HR, 2.89; 95% CI, 1.40-5.97). Increased risks in patients age 65 years and older were increased further if other risk factors were present. Lumiracoxib maintained an advantage over NSAIDs across all subgroups except aspirin use. CONCLUSIONS: Lumiracoxib was associated with a reduced risk of ulcer complications compared with NSAIDs in all significant subgroups except aspirin users.

Bioavailability of pharmaceuticals in waters close to wastewater treatment plants: use of fish bile for exposure assessment

Pharmaceuticals are ubiquitous in surface waters as a consequence of discharges from municipal wastewater treatment plants. However, few studies have assessed the bioavailability of pharmaceuticals to fish in natural waters. In the present study, passive samplers and rainbow trout were experimentally deployed next to three municipal wastewater treatment plants in Finland to evaluate the degree of animal exposure. Pharmaceuticals from several therapeutic classes (in total 15) were analyzed by liquid chromatography-tandem mass spectrometry in extracts of passive samplers and in bile and blood plasma of rainbow trout held at polluted sites for 10 d. Each approach indicated the highest exposure near wastewater treatment plant A and the lowest near that of plant C. Diclofenac, naproxen, and ibuprofen were found in rainbow trout, and their concentrations in bile were 10 to 400 times higher than in plasma. The phase I metabolite hydroxydiclofenac was also detected in bile. Hence, bile proved to be an excellent sample matrix for the exposure assessment of fish. Most of the monitored pharmaceuticals were found in passive samplers, implying that they may overestimate the actual exposure of fish in receiving waters. Two biomarkers, hepatic vitellogenin and cytochrome P4501A, did not reveal clear effects on fish, although a small induction of vitellogenin mRNA was observed in trout caged near wastewater treatment plants B and C.

Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis.

BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are the backbone of osteoarthritis pain management. We aimed to assess the effectiveness of different preparations and doses of NSAIDs on osteoarthritis pain in a network meta-analysis. METHODS For this network meta-analysis, we considered randomised trials comparing any of the following interventions: NSAIDs, paracetamol, or placebo, for the treatment of osteoarthritis pain. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the reference lists of relevant articles for trials published between Jan 1, 1980, and Feb 24, 2015, with at least 100 patients per group. The prespecified primary and secondary outcomes were pain and physical function, and were extracted in duplicate for up to seven timepoints after the start of treatment. We used an extension of multivariable Bayesian random effects models for mixed multiple treatment comparisons with a random effect at the level of trials. For the primary analysis, a random walk of first order was used to account for multiple follow-up outcome data within a trial. Preparations that used different total daily dose were considered separately in the analysis. To assess a potential dose-response relation, we used preparation-specific covariates assuming linearity on log relative dose. FINDINGS We identified 8973 manuscripts from our search, of which 74 randomised trials with a total of 58 556 patients were included in this analysis. 23 nodes concerning seven different NSAIDs or paracetamol with specific daily dose of administration or placebo were considered. All preparations, irrespective of dose, improved point estimates of pain symptoms when compared with placebo. For six interventions (diclofenac 150 mg/day, etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day, and rofecoxib 25 mg/day and 50 mg/day), the probability that the difference to placebo is at or below a prespecified minimum clinically important effect for pain reduction (effect size [ES] -0·37) was at least 95%. Among maximally approved daily doses, diclofenac 150 mg/day (ES -0·57, 95% credibility interval [CrI] -0·69 to -0·46) and etoricoxib 60 mg/day (ES -0·58, -0·73 to -0·43) had the highest probability to be the best intervention, both with 100% probability to reach the minimum clinically important difference. Treatment effects increased as drug dose increased, but corresponding tests for a linear dose effect were significant only for celecoxib (p=0·030), diclofenac (p=0·031), and naproxen (p=0·026). We found no evidence that treatment effects varied over the duration of treatment. Model fit was good, and between-trial heterogeneity and inconsistency were low in all analyses. All trials were deemed to have a low risk of bias for blinding of patients. Effect estimates did not change in sensitivity analyses with two additional statistical models and accounting for methodological quality criteria in meta-regression analysis. INTERPRETATION On the basis of the available data, we see no role for single-agent paracetamol for the treatment of patients with osteoarthritis irrespective of dose. We provide sound evidence that diclofenac 150 mg/day is the most effective NSAID available at present, in terms of improving both pain and function. Nevertheless, in view of the safety profile of these drugs, physicians need to consider our results together with all known safety information when selecting the preparation and dose for individual patients. FUNDING Swiss National Science Foundation (grant number 405340-104762) and Arco Foundation, Switzerland.

Occurrence and analysis of selected pharmaceutical compounds in soil from Spanish agricultural fields

This work describes the analysis of 15 pharmaceutical compounds, belonging to different therapeutic classes (anti-inflammatory/analgesics, lipid regulators, antiepileptics, ?-blockers and antidepressants) and with diverse physical?chemical properties, in Spanish soils with different farmland uses. The studied compounds were extracted from soil by ultrasound-assisted extraction (UAE) and determined, after derivatization, by gas chromatography with mass spectrometric detection (GC?MS). The limits of detection (LODs) ranged from 0.14 ng g?1 (naproxen) to 0.65 ng g?1 (amitriptyline). At least two compounds where detected in all samples, being ibuprofen, salicylic acid, and paracetamol, the most frequently detected compounds. The highest levels found in soil were 47 ng g?1 for allopurinol and 37 ng g?1 for salicylic acid. The influence of the type of crop and the sampling area on the levels of pharmaceuticals in soil, as well as their relationship with soil physical?chemical properties, was studied. The frequent and widespread detection of some of these compounds in agricultural soils show a diffuse contamination, although the low levels found do not pose a risk to the environment or the human health.

Complexos de dirutênio com os fármacos ibuprofeno, ácido acetilsalicílico, naproxeno, indometacina, e com ácido y-linolêncio: Síntese, caracterização, avaliação da ação antiproliferativa sobre células tumorais e estudo da interação da unidade dimetálica com adenina e adenosina

Este trabalho tem como principal objetivo contribuir para o desenvolvimento de novos potenciais metalofármacos de rutênio. Nele são descritas a síntese, a caracterização e a avaliação da ação antiproliferativa de alguns complexos de dirutênio (II,III) com os fármacos antiinflamatórios não-esteróides (AINEs): ibuprofeno (ibp), ácido acetilsalicílico (aas), naproxeno (npx) e indometacina (ind) e também com o ácido γ-linolênico (lin), sobre células cancerígenas. Os compostos obtidos foram caracterizados por análise elementar, espectroscopia de absorção eletrônica, medidas de susceptibilidade magnética, espectroscopia vibracional FTIR e Raman, difratometria de raios X de pó, medidas de condutividade molar e análise térmica (TG, OTAe OSC). Todos os complexos sintetizados apresentam estrutura em gaiola, com os carboxilatos derivados dos fármacos AINEs coordenados à unidade dimetálica Ru2( (II,III), em ponte equatorial, estabilizando assim a ligação direta rutênio-rutênio. As posições axiais são ocupadas por íons cloreto, no caso dos complexos [Ru2(O2(CR)4(Cl] (O2(CR = ibp, aas, npx ou ind), ou por moléculas de água, nas espécies do tipo [Ru2(O2(CR)4(H2O)2]PF6(O2CR =npx e ind). Ensaios biológicos demonstraram que os compostos [Ru2(ibp) 4Cl]•½H2O e [Ru2(npx)4(H2O)2]PF6 apresentam ação antiproliferativa sobre células de glioma de rato C6 in vitro, dependendo do tempo de exposição do meio celular ao complexo. O complexo [Ru2 (lin)4Cl] também apresenta efeito sobre a proliferação de células C6; entretanto, nesse caso, efeitos significativos são observaçlos já nas primeiras 24 h de exposição. Estudos mostraram que as bases adenina e adenosina reagem com o complexo [Ru2(OAc)4(H2O)2]PF6 sem que ocorra quebra da estrutura em gaiola. As bases nitrogenadas substituem axialmente as moléculas de água, formando pontes axiais entre duas unidades de dirutênio (II,III) no estado sólido.

Interactions métaboliques entre le bisphénol A et le naproxène dans un modèle de foie de rat isolé et perfusé

L'exposition aux mélanges de contaminants (environnementaux, alimentaires ou thérapeutiques) soulève de nombreuses interrogations et inquiétudes vis-à-vis des probabilités d'interactions toxicocinétiques et toxicodynamiques. Une telle coexposition peut influencer le mode d’action des composants du cocktail et donc de leur toxicité, suite à un accroissement de leurs concentrations internes. Le bisphénol A (4 dihydroxy-2,2-diphenylpropane) est un contaminant chimique répandu de manière ubiquitaire dans notre environnement, largement utilisé dans la fabrication des plastiques avec l’un des plus grands volumes de production à l’échelle mondiale. Il est un perturbateur endocrinien par excellence de type œstrogèno-mimétique. Cette molécule est biotransformée en métabolites non toxiques par un processus de glucuronidation. L'exposition concomitante à plusieurs xénobiotiques peut induire à la baisse le taux de glucuronidation du polluant chimique d'intérêt, entre autres la co-exposition avec des médicaments. Puisque la consommation de produits thérapeutiques est un phénomène grandissant dans la population, la possibilité d’une exposition simultanée est d’autant plus grande et forte. Sachant que l'inhibition métabolique est le mécanisme d'interaction le plus plausible pouvant aboutir à une hausse des niveaux internes ainsi qu’à une modulation de la toxicité prévue, la présente étude visait d'abord à confirmer et caractériser ce type d'interactions métaboliques entre le bisphénol A et le naproxène, qui est un anti-inflammatoire non stéroïdiennes (AINS), sur l'ensemble d'un organe intact en utilisant le système de foie de rat isolé et perfusé (IPRL). Elle visait ensuite à déterminer la cinétique enzymatique de chacune de ces deux substances, seule puis en mélange binaire. Dans un second temps, nous avons évalué aussi l’influence de la présence d'albumine sur la cinétique métabolique et le comportement de ces deux substances étudiées en suivant le même modèle de perfusion in vivo au niveau du foie de rat. Les constantes métaboliques ont été déterminées par régression non linéaire. Les métabolismes du BPA et du NAP seuls ont montré une cinétique saturable avec une vélocité maximale (Vmax) de 8.9 nmol/min/ mg prot de foie et une constante d'affinité de l'enzyme pour le substrat (Km) de 51.6 μM pour le BPA et de 3 nmol/min/mg prot de foie et 149.2 μM pour le NAP. L'analyse des expositions combinées suggère une inhibition compétitive partielle du métabolisme du BPA par le NAP avec une valeur de Ki estimée à 0.3542 μM. Les résultats obtenus montrent que l’analyse de risque pour les polluants environnementaux doit donc prendre en considération la consommation des produits pharmaceutiques comme facteur pouvant accroitre le niveau interne lors d’une exposition donnée. Ces données in vivo sur les interactions métaboliques pourraient être intégrées dans un modèle pharmacocinétique à base physiologique (PBPK) pour prédire les conséquences toxicococinétique (TK) de l'exposition d'un individu à ces mélanges chimiques.

Interactions métaboliques entre le bisphénol A et le naproxène dans un modèle de foie de rat isolé et perfusé

L'exposition aux mélanges de contaminants (environnementaux, alimentaires ou thérapeutiques) soulève de nombreuses interrogations et inquiétudes vis-à-vis des probabilités d'interactions toxicocinétiques et toxicodynamiques. Une telle coexposition peut influencer le mode d’action des composants du cocktail et donc de leur toxicité, suite à un accroissement de leurs concentrations internes. Le bisphénol A (4 dihydroxy-2,2-diphenylpropane) est un contaminant chimique répandu de manière ubiquitaire dans notre environnement, largement utilisé dans la fabrication des plastiques avec l’un des plus grands volumes de production à l’échelle mondiale. Il est un perturbateur endocrinien par excellence de type œstrogèno-mimétique. Cette molécule est biotransformée en métabolites non toxiques par un processus de glucuronidation. L'exposition concomitante à plusieurs xénobiotiques peut induire à la baisse le taux de glucuronidation du polluant chimique d'intérêt, entre autres la co-exposition avec des médicaments. Puisque la consommation de produits thérapeutiques est un phénomène grandissant dans la population, la possibilité d’une exposition simultanée est d’autant plus grande et forte. Sachant que l'inhibition métabolique est le mécanisme d'interaction le plus plausible pouvant aboutir à une hausse des niveaux internes ainsi qu’à une modulation de la toxicité prévue, la présente étude visait d'abord à confirmer et caractériser ce type d'interactions métaboliques entre le bisphénol A et le naproxène, qui est un anti-inflammatoire non stéroïdiennes (AINS), sur l'ensemble d'un organe intact en utilisant le système de foie de rat isolé et perfusé (IPRL). Elle visait ensuite à déterminer la cinétique enzymatique de chacune de ces deux substances, seule puis en mélange binaire. Dans un second temps, nous avons évalué aussi l’influence de la présence d'albumine sur la cinétique métabolique et le comportement de ces deux substances étudiées en suivant le même modèle de perfusion in vivo au niveau du foie de rat. Les constantes métaboliques ont été déterminées par régression non linéaire. Les métabolismes du BPA et du NAP seuls ont montré une cinétique saturable avec une vélocité maximale (Vmax) de 8.9 nmol/min/ mg prot de foie et une constante d'affinité de l'enzyme pour le substrat (Km) de 51.6 μM pour le BPA et de 3 nmol/min/mg prot de foie et 149.2 μM pour le NAP. L'analyse des expositions combinées suggère une inhibition compétitive partielle du métabolisme du BPA par le NAP avec une valeur de Ki estimée à 0.3542 μM. Les résultats obtenus montrent que l’analyse de risque pour les polluants environnementaux doit donc prendre en considération la consommation des produits pharmaceutiques comme facteur pouvant accroitre le niveau interne lors d’une exposition donnée. Ces données in vivo sur les interactions métaboliques pourraient être intégrées dans un modèle pharmacocinétique à base physiologique (PBPK) pour prédire les conséquences toxicococinétique (TK) de l'exposition d'un individu à ces mélanges chimiques.

Risk of serious NSAID-related gastrointestinal events during long-term exposure: a systematic review

Objective: Exposure to non-steroidal anti-inflammatory drugs (NSAIDs) is associated wit increased risk of serious gastrointestinal (GI) events compared with non-exposure. We investigated whether that risk is sustained over time. Data sources: Cochrane Controlled Trials Register (to 2002); MEDLINE, EMBASE, Derwent Drug File and Current Contents (1999-2002); manual searching of reviews (1999-2002). Study selection: From 479 search results reviewed and 221 articles retrieved, seven studies of patients exposed to prescription non-selective NSAIDs for more than 6 months and reporting time-dependent serious GI event rates were selected for quantitative data synthesis. These were stratified into two groups by study design. Data extraction: Incidence of GI events and number of patients at specific time points were extracted. Data synthesis: Meta-regression analyses were performed. Change in risk was evaluated by testing whether the slope of the regression line declined over time. Four randomised controlled trials (RCTs) provided evaluable data from five NSAID arms (aspirin, naproxen, two ibuprofen arms, and diclofenac). When the RCT data were combined, a small significant decline in annualised risk was seen: -0.005% (95% Cl, -0.008% to -0.001%) per month. Sensitivity analyses were conducted because there was disparity within the RCT data. The pooled estimate from three cohort studies showed no significant decline in annualised risk over periods up to 2 years: -0.003% (95% Cl, -0.008% to 0.003%) per month. Conclusions: Small decreases in risk over time were observed; these were of negligible clinical importance. For patients who need long-term (> 6 months) treatment, precautionary measures should be considered to reduce the net probability of serious GI events over the anticipated treatment duration. The effect of intermittent versus regular daily therapy on long-term risk needs further investigation.

Development and formulation of wax-based transdermal drug delivery systems

Topical and transdermal formulations are promising platforms for the delivery of drugs. A unit dose topical or transdermal drug delivery system that optimises the solubility of drugs within the vehicle provides a novel dosage form for efficacious delivery that also offers a simple manufacture technique is desirable. This study used Witepsol® H15 wax as a abase for the delivery system. One aspect of this project involved determination of the solubility of ibuprofen, flurbiprofen and naproxen in the was using microscopy, Higuchi release kinetics, HyperDSC and mathematical modelling techniques. Correlations between the results obtained via these techniques were noted with additional merits such as provision of valuable information on drug release kinetics and possible interactions between the drug and excipients. A second aspect of this project involved the incorporation of additional excipients: Tween 20 (T), Carbopol®971 (C) and menthol (M) to the wax formulation. On in vitro permeation through porcine skin, the preferred formulations were: ibuprofen (5% w/w) within Witepsol®H15 + 1% w/w T; flurbiprofen (10% w/w) within Witepsol®H15 + 1% w/w T; naproxen (5% w/w) within Witepsol®H15 + 1% w/w T + 1% C and sodium diclofenac (10% w/w) within Witepsol®H15 + 1% w/w T + 1% w/w T + 1% w/w C + 5% w/w M. Unit dose transdermal tablets containing ibuprofen and diclofenac were produced with improved flux compared to marketed products; Voltarol Emugel® demonstrated flux of 1.68x10-3 cm/h compared to 123 x 10-3 cm/h for the optimised product as detailed above; Ibugel Forte® demonstrated a permeation coefficient value of 7.65 x 10-3 cm/h compared to 8.69 x 10-3 cm/h for the optimised product as described above.

Ocorrência de compostos de interesse emergente no aquífero Dunas-Barreiras e nos esgotos de Natal/RN

The detection of emerging interest microcontaminants in environmental samples of surface water, groundwater, drinking water, wastewater and effluents from water and sewage treatment plants (WTP and STP), in many countries, suggests these pollutants are widespread in the environment, mainly in urban areas. This is a reason for great concern, since many of these compounds are potentially harmful for humans other living beings, and they are not efficiently removed in the majority of WTP and STP, which is exacerbated by precariousness of water supply and sanitation services. In Natal, like other Brazilian cities, the sewage system serves only part of the urban area (about 30%), so that the rest of the wastewater is infiltrated in the sandy soil of the region in cesspool-dry well systems. This has resulted in contamination of groundwater in the area (sand-dune barrier aquifer, which supplies more than 50% of the city population), which has been observed by the increase in nitrate concentration in supply wells. The vulnerability of the sanddune barrier aquifer, combined with reports of the presence of emerging interest microcontaminants in Brazil and worldwide, led to this research, which investigated the occurrence of fifteen microcontaminants in Natal groundwater and sewage. Samples were collected at five wells used for water supply, the raw sewage and the effluents from biological reactors from STP (UASB and activated sludge reactors). Two samples of each sample were taken, with one week apart between the samples. To determine the contaminants, extraction of aquifer water, and raw and treated sewage samples were performed, through the technique of using SPE Strata X cartridge (Phenomenex®) to the aquifer water, and Strata SAX and Strata X (Phenomenex® ) for samples of raw and treated sewage. Subsequently the extracts were analyzed using GC-MS technique. Much of the analyzed microcontaminants were detected in groundwater and sewage. The concentrations in groundwater are generally lower than those found in the sewers. Some of the compounds (estrone, estradiol, bisphenol A, caffeine, diclofenac, naproxen, paracetamol and ibuprofen) are partially removed at STP.

Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials

Objective: To assess the effects of selective cyclo-oxygenase-2 (COX 2) inhibitors and traditional non-steroidal anti-inflammatory drugs (NSAIDs) on the risk of vascular events. Design: Meta-analysis of published and unpublished tabular data from randomised trials, with indirect estimation of the effects of traditional NSAIDs. Data sources: Medline and Embase (January 1966 to April 2005); Food and Drug Administration records; and data on file from Novartis, Pfizer, and Merck. Review methods: Eligible studies were randomised trials that included a comparison of a selective COX 2 inhibitor versus placebo or a selective COX 2 inhibitor versus a traditional NSAID, of at least four weeks' duration, with information on serious vascular events (defined as myocardial infarction, stroke, or vascular death). Individual investigators and manufacturers provided information on the number of patients randomised, numbers of vascular events, and the person time of follow-up for each randomised group. Results: In placebo comparisons, allocation to a selective COX 2 inhibitor was associated with a 42% relative increase in the incidence of serious vascular events (1.2%/year v 0.9%/year; rate ratio 1.42, 95% confidence interval 1.13 to 1.78; P = 0.003), with no significant heterogeneity among the different selective COX 2 inhibitors. This was chiefly attributable to an increased risk of myocardial infarction (0.6%/year v 0.3%/year; 1.86, 1.33 to 2.59; P = 0.0003), with little apparent difference in other vascular outcomes. Among trials of at least one year's duration (mean 2.7 years), the rate ratio for vascular events was 1.45 (1.12 to 1.89; P = 0.005). Overall, the incidence of serious vascular events was similar between a selective COX 2 inhibitor and any traditional NSAID (1.0%/year v 0.9/%year; 1.16, 0.97 to 1.38; P = 0.1). However, statistical heterogeneity (P = 0.001) was found between trials of a selective COX 2 inhibitor versus naproxen (1.57, 1.21 to 2.03) and of a selective COX 2 inhibitor versus non-naproxen NSAIDs (0.88, 0.69 to 1.12). The summary rate ratio for vascular events, compared with placebo, was 0.92 (0.67 to 1.26) for naproxen, 1.51 (0.96 to 2.37) for ibuprofen, and 1.63 (1.12 to 2.37) for diclofenac. Conclusions: Selective COX 2 inhibitors are associated with a moderate increase in the risk of vascular events, as are high dose regimens of ibuprofen and diclofenac, but high dose naproxen is not associated with such an excess.