Injectable Nonsteroidal Anti-inflammatory Drugs Research Articles

Non-Steroidal Anti-Inflammatory Drugs Administered Intra-Articularly in Temporomandibular Joint Disorders: A Systematic Review and Meta-Analysis.

Objectives: This systematic review was designed to summarize randomized controlled trials of intra-articular administration of non-steroidal anti-inflammatory drugs (NSAIDs) for temporomandibular disorders. Methods: Randomized controlled trials regarding intra-articular injections of non-steroidal anti-inflammatory drugs for temporomandibular disorders were included in the review. The final search was conducted on 16 June 2024 in the Bielefeld Academic Search Engine, PubMed, and Scopus databases. Results: Of the 173 identified studies, 6 were eligible for review. In trials comparing arthrocentesis alone to arthrocentesis with NSAIDs, slight differences in joint pain were noted. For tenoxicam, differences were under 1 point on a 0-10 scale after 4 weeks, with inconsistent results. Piroxicam showed no significant difference, and pain levels were minimal in both groups. For maximum mouth opening (MMO), tenoxicam showed no significant difference. Piroxicam increased MMO by nearly 5 mm, based on one small trial with bias concerns. Conclusions: Currently, there is no strong scientific evidence supporting the injection of NSAIDs into the temporomandibular joint to relieve pain or increase jaw movement. Preliminary reports on piroxicam with arthrocentesis and tenoxicam or diclofenac without rinsing justify further research.

Improved Pain and Function With Triamcinolone Acetonide Extended-Release and Cryoneurolysis for Knee Osteoarthritis: Use of a New Real-World Registry

BackgroundKnee osteoarthritis (OA) affects 19% of American adults aged more than 45 years and costs $27+ billion annually. A wide range of nonoperative treatment options are available. This study compared 6 treatments: cryoneurolysis with deep genicular nerve block (Cryo-Deep/Both), cryoneurolysis with superficial nerve block (Cryo-Superficial), intra-articular hyaluronic acid (IA-HA) injections, nonsteroidal anti-inflammatory drug injections (IA-NSAIDs), IA-corticosteroids (IA-CS) injections, or IA-triamcinolone extended release (IA-TA-ER) injections over 4 months for: (1) pain severity and analgesic use; and (2) physical function (from Knee Injury and Osteoarthritis Outcome Score for Joint Replacement). MethodsPatients who had unilateral knee OA and received nonoperative intervention were enrolled in the Innovations in Genicular Outcomes Research registry, a novel, multicenter real-world registry, between September 2021 and February 2024. A total of 480 patients were enrolled. Both pain and functional outcomes were assessed at baseline, weekly, and monthly, which were analyzed by overall trend, magnitude changes pretreatment to post-treatment, and distribution-based minimally clinically important difference (MCID) score. Multivariate linear regressions with adjustments for 7 confounding factors were used to compare follow-up outcomes among 6 treatment groups. ResultsUse of IA-TA-ER injections was associated with the lowest pain, greatest pain reduction, and highest prevalence of patients achieving MCID relative to other treatments (P < .001). Deep/Both-Cryo and IA-CS were associated with a higher prevalence of achieving MCID than IA-HA, IA-NSAIDs, and Cryo-Superficial (P ≤ .001). Use of IA-TA-ER was also associated with the greatest functional score, improvement from baseline, and highest prevalence of patients achieving MCID than other treatments (P ≤ .003). ConclusionsThe IA-TA-ER appears to outperform other treatments in terms of pain relief and functional improvement for up to 4 months following treatment. In addition, outcomes in the novel cryoneurolysis and conventional IA-CS were similar to one another and better than those in IA-HA and IA-NSAIDs.

Colic incidence, risk factors, and therapeutic management in a working horse population in Tuban, Indonesia.

Colic is the primary problem affecting equestrian care worldwide. The primary cause of colic is digestive diseases; however, they can also affect organs from different systems in the abdominal region. In addition to a prior history of the disease and its treatment, risk factors may be assessed to determine the etiology of the disease in horses without or with a history of colic. This study aimed to present a summary of the incidence, risk factors, and medical procedures for colic in horses. Based on owner reports, 223 horses in Tuban, Indonesia, suspected of having colic were investigated. During the investigation of clinical parameters, investigators went door-to-door with interested horse owners to gather information about potential risk factors related to equine colic. Information on horses diagnosed with colic was obtained from the medical records of treatment. A Chi-square test was used to investigate the potential association between the risk factors, medical protocol, and the outcome of colic in horses. Of the 187 cases, spasmodic colic was the most common (48.13%), but 17 (9.09%) had no definitive diagnosis. Poor body condition scores (χ2 = 58.73; p < 0.001), wheat bran feeding (χ2 = 26.79; p < 0.001), concentrate (χ2 = 10.66; p < 0.01), less access to water (χ2 = 128.24; p < 0.001), recurrence of colic (χ2 = 85.64; p < 0.001), no deworming program (χ2 = 54.76; p < 0.001), the presence of gastrointestinal parasites (χ2 = 56.79; p < 0.001), stressed physical activity (χ2 = 28.53; p < 0.001), and summer season (χ2 = 7.83; p < 0.01) were the risk factors for colic. We further reported that 185 (98.93%) patients who received the following medical interventions recovered: injection of non-steroidal anti-inflammatory drugs was necessary, Vitamin B complex (χ2 = 39.98; p < 0.001), fluid therapy (χ2 = 92.99; p < 0.001), and gastric intubation (χ2 = 4.09; p < 0.05). The importance of colic was demonstrated in 187 (83.86%) of the 223 horses investigated in Tuban, Indonesia, documented. In this study, recommendations for medical procedures when colic risk factors have been determined are presented.

Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis.

Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions. Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed. A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups. NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Robenacoxib versus meloxicam following ovariohysterectomy in cats: A randomised, prospective clinical trial involving owner-based assessment of pain.

Injectable non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to queens undergoing ovariohysterectomy (OVH), but the requirement for postoperative administration is unclear and practices vary. Existing studies assessing efficacy rely on pain scoring by experienced clinicians. However, following OVH, most cats are discharged within hours of recovery. Cats undergoing OVH were randomly assigned to two treatment groups: MEL and ROB. Cats in the MEL group (n = 76) received meloxicam (0.2mg/kg) and those in the ROB group (n = 65) received robenacoxib (2mg/kg). Owners were contacted by a blinded assessor 3 days postoperatively and asked to identify physical or behavioural changes and to assign pain scores using a numerical rating scale. More cats in theROB group displayed abnormal behaviours than cats in the MEL group (p = 0.03). Most owners assigned a pain score of 0 (72%) (n = 101), but pain scores were significantly higher in the ROB group than in the MEL group (p = 0.005). Methods of owner assessment of pain in cats have not been validated. Both meloxicam and robenacoxib are effective in controlling postoperative pain. Meloxicam may have improved efficacy in certain patient populations. Applying a blanket approach to prescribing NSAIDs to cats undergoing OVH postoperatively may not be necessary. This has safety, environmental and cost implications.

Incidence, risk factors, and therapeutic management of equine colic in Lamongan, Indonesia.

Colic is among the common health issues in equine health management. Gastrointestinal (GI) disorders are the most frequent causes of colic, but dysfunction of other organs and systems inside the abdominal cavity may also contribute. Therefore, it is crucial to identify risk factors for colic of specific etiologies. This study aimed to examine the incidence, risk factors, and best therapeutic management practices for horses with colic. A cohort of 256 horses living in Lamongan, East Java, Indonesia, was randomly recruited based on reports of colic symptoms by owners. Diagnosis and treatment were then conducted with the help of owners. Symptom profiles, risk factors, and therapeutic management strategies were analyzed by Chi-square tests. Of 256 horses enrolled, 217 (84%) were diagnosed with colic, of which 172 (79.3%) were cases of spasmodic colic, 33 (15.2%) of impaction colic, and 12 (5.5%) of intestinal obstruction/displacement. Male sex (χ2 = 16.27; p < 0.001), wheat bran feeding (χ2 = 15.49; p < 0.001), concentrate feed intake >5 kg/day (χ2 = 24.95; p < 0.001), no regular anthelmintic drug treatment (χ2 = 67.24; p < 0.001), GI parasite infection (χ2 = 65.11; p < 0.001), recurrent colic (χ2 = 91.09; p < 0.001), poor body condition score (χ2 = 71.81; p < 0.001), limited daily water access (χ2 = 127.92; p < 0.001), and indications of dental disease (χ2 = 9.03; p < 0.001) were identified as risk factors. The most effective therapies were gastric intubation (χ2 = 153.54; p < 0.001), Vitamin B complex injection (χ2 = 32.09; p < 0.001), fluid therapy (χ2 = 42.59; p < 0.001), and non-steroidal anti-inflammatory drug injection (NSAID). Colic is highly prevalent among horses in Lamongan, East Java, Indonesia. Proper diet, workload management, regular access to clean drinking water, and dental care can reduce colic risk. Recommended therapies include NSAID injection without other analgesics or spasmolytics, fluid therapy, Vitamin B complex, and gastric intubation.

Comparison of the Effect of Intracarpal Injection of Ketorolac With Triamcinolone in Carpal Tunnel Syndrome: A Randomized Controlled Trial.

The most prevalent entrapment neuropathy is carpal tunnel syndrome (CTS). Although nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed for musculoskeletal disorders, oral NSAIDs do not provide any additional benefits for CTS. Nevertheless, the use of NSAID phonophoresis has shown significant improvement, possibly due to increased concentration in the target tissue. The effects of intracarpal injection of NSAIDs on CTS have not been studied. We conducted a controlled trial to compare the efficacy of ketorolac and triamcinolone in treating CTS. Mild to moderate CTS patients were randomly assigned to receive either a local injection of 30 mg ketorolac or 40 mg triamcinolone. Patients were evaluated using visual analog scale (VAS) for pain, severity, function, electrodiagnostic findings, patient satisfaction, and any complications at the injection site, at baseline and 12 weeks after the procedures. Fifty patients participated, and 43 completed the study. Both groups showed significant improvement in the VAS, severity, function, and electrodiagnostic scores at 3 months compared with the baseline. A comparison of the groups showed significant differences in VAS, severity, and function, with the improvement being significantly higher in the triamcinolone group. The present study showed that injection of triamcinolone or ketorolac into the carpal tunnel relieved pain, increased function, and improved electrodiagnostic findings in patients with mild to moderate CTS. It also showed that triamcinolone was superior to ketorolac in terms of analgesic effect and resulted in greater improvement in symptom severity and function.

Anaesthesia for elite athletes.

Sports participation has been growing rapidly since the 1960s. Anaesthesiologists are increasingly confronted with athletes in a peri-operative setting. The right choice of type of anaesthesia technique, pain management of injuries, specific physiologic adaptations of the athlete and knowledge of prohibited substances are eminent for a correct approach of this subpopulation. This review aims to give an overview of athletes' specific anaesthetic management in peri-operative and postoperative settings and to guide the nonspecialised anaesthetist. We comprehensively reviewed the literature, gathered all the information available on, and synthesised it in a narrative way, regarding preoperative evaluation, intraoperative implications and postoperative pain management of the elite athlete undergoing a surgical procedure. An anaesthesiologist should recognise the most common benign ECG findings in athletes like bradycardia, isolated left ventricle hypertrophy on voltage criteria and early repolarisation as normal features in the athlete's heart. Isotonic physiology typically produces four-chamber dilation. In contrast, isometric stress creates high intravascular pressure leading to left ventricular hypertrophy. Pre-operative evaluation should also identify possible consumers of performance-enhancing drugs. Intraoperative points of interest for the anaesthesiologist is mainly avoiding drugs on the prohibited list of the World Anti-Doping Agency (WADA). Postoperative and chronic pain management are still developing fields in this population. The International Olympic Committee (IOC) proposed treating acute pain with a combination of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, injectable NSAIDs and local anaesthetics. It may be suggested that chronic pain management in elite athletes could benefit from treatment in specialised multidisciplinary pain clinics. This literature review aims to serve as a guide for the anaesthesiologist taking care of the elite athlete.

The histological effect of the injection of nonsteroidal anti-inflammatory drugs on sciatic nerve of rats

The ongoing work aims to compare the effect of extraneural and intraneural injection of therapeutic doses of meloxicam and diclofenac sodium on the sciatic nerve of rats. Six groups of adult albino rats were used with five animals per group. Control group (A), group (B), and group (C) received a single extraneural injection of normal saline (NS) 0.25 ml/kg/rat, meloxicam (M) 0.11 mg/kg/0.25ml/rat and diclofenac sodium (V) 1.1 mg/kg/0.25ml/rat respectively. In contrast, control group (D), group (E), and group (F) received a single intraneural injection of the same doses of normal saline, meloxicam, and diclofenac sodium, respectively. Histological evaluation reveals an increased thickening of epineurium, dilatation, congestion of epineurial blood vessels, intrafascicular edema, axonal degeneration, myelin degeneration, and vacuolization in group (C) which was higher than those in the group (B). These changes were also greater in group (F) compared to groups (D) and (E). The histopathological changes of the sciatic nerve were greatest in the case of intraneural injection of saline, meloxicam, and diclofenac sodium, which means that the damaging effect of intraneural injection of the drug was greater than the extraneural injection of the same drug. It is concluded that extraneural and intraneural injections of therapeutic doses of meloxicam cause less damage to the sciatic nerve compared to diclofenac sodium. Thus it is considered to be more secure than diclofenac sodium after intramuscular injection. Sciatic nerve injury can occur following intramuscular injection into the gluteal region, particularly if the needle hits the nerve.

Retrospective Analysis of the Use of Tiludronate in Equine Practice: Safety on 1804 Horses, Efficacy on 343 Horses

The objective of this retrospective study was to assess the safety and efficacy of a slow IV administration of 1mg/kg tiludronate in a large number of horses. Each horse that received at least one tiludronate-based treatment between 2006 and August 2019 at Virginia Equine Imaging or Fairfield Equine was included in the study. Concomitant medical treatments, preliminary nonsteroidal anti-inflammatory drug injection and potential side effects were recorded after each administration. Horses for which follow-up was available over 1 year were subject to clinical evolution assessment via lameness grade evolution and performance data when available. Collected data suggest excellent tolerance to tiludronate with only 0.9% of the 2,497 injections (1,804 horses) inducing potential side effects, mild colics being the most frequent. Clinical follow-up was available over more than 1 year for 343 horses. Most horses (>80%) presented an initial lameness score over 1.5/5, approximately half of the population was sound by 30 days and remained so after a year. Mean lameness score improved by more than one grade during the follow-up period compared to initial examination. Performance data were available for 129 horses. One year after treatment, 89 (69%) horses were still competing, 73 (82%) of them at a better or similar level. These data suggest good efficacy of tiludronate over a year after treatment. Despite limitations inherent to any field study, this is the first retrospective study of the use of bisphosphonates in horses combining a large group with long-term follow-ups.

Pharmacokinetics, safety and efficacy of intra-articular non-steroidal anti-inflammatory drug injections for the treatment of osteoarthritis: A narrative review.

What is known and ObjectiveOsteoarthritis (OA) is a common cause of joint disease and activity limitation in adults. Common therapies to treat OA‐related pain are oral and topical non‐steroidal anti‐inflammatory drugs (NSAIDs) and intra‐articular (IA) corticosteroids. However, prolonged courses of oral NSAIDs are associated with systemic adverse effects and repeat IA corticosteroid injections may cause cartilage degeneration. IA NSAIDs may be an alternative therapy possibly minimizing systemic side effects while maintaining efficacy. Therefore, we sought to summarize the pharmacokinetics, safety and efficacy of IA NSAIDs to help providers make a more informed decision on the use of IA NSAIDs.MethodsWe searched the National Library of Medicine Database with terms “intraarticular and nsaid”, yielding 1032 results. Only traditional formulations of NSAIDs were considered for inclusion. Animal studies were included if animals were healthy or if the method of arthritis induction was a reasonable model of osteoarthritis. Human studies were included if humans were healthy or if the primary disease studied was osteoarthritis of a large joint. Of 1032 results, 31 research articles met the inclusion criteria and were summarized in this review.Results and DiscussionWe found that single doses of IA NSAIDs provided far less total systemic and synovial exposure compared to a one week course of oral NSAIDs, but maximum concentrations to the synovium with IA administration were much higher. IA NSAIDs had an excellent safety profile in small animals, large animals and humans, although these injections were associated with non‐specific cartilage inflammation in healthy animals. In animal models, IA NSAIDs had similar efficacy to PO NSAIDs in treating OA‐related pain. In humans, IA NSAIDs had similar efficacy to PO NSAIDS and IA corticosteroids in treating OA‐related pain; however, many trials did not have a placebo control and outcome measures were heterogeneous.What is new and ConclusionOverall, single doses of IA NSAIDs appear safe and efficacious across animals and humans. The optimal use of IA NSAIDs is still to be determined and further research is needed. However IA NSAIDs may be an additional beneficial therapy to treat OA‐related pain. Potential uses may be to augment IA corticosteroids injections, to interrupt multiple IA corticosteroid injections or as an alternative in patients that are high risk for corticosteroid‐related adverse events.

Superficial parotidectomy: three-year experience using modified Blair's incision

Background: This study presents a series of parotidectomy for superficial benign parotid tumors.Methods: 18 patients had freely mobile superficial benign parotid lesions of grade zero on House-Brackmann facial nerve grading system underwent parotidectomy through modified Blair incision, with meticulous dissection of the main trunk and branches of facial and the greater auricular nerves with parotid duct sparing. Postoperative (PO) facial nerve functions were assessed and graded after patient was fully conscious, on the 5th PO day, and 6th PO month. Collected data included operative time, intraoperative blood loss, duration of hospital stay, wound drainage and PO complications.Results: Mean operative time was 115 (±20.4) minutes and mean intraoperative blood loss was 250 (±60). PO analgesia was provided as non-steroidal anti-inflammatory drugs injection on patient's request. Mean duration of PO hospital stay was 8 (±1.9) hours and of wound drainage was 3 (±0.7) days. No wound infection nor seroma had developed and stitches were allowed for spontaneous removal. Immediate postoperatively 4 patients (22.2%) had incomplete facial nerve weakness; 3 of grade II and one of grade III, at the 5th day PO, two patients still had grade II nerve affection and at the 6th PO month, one patient (5.5%) still had grade II nerve affection.Conclusions: superficial parotidectomy through modified Blair's incision is feasible, safe and allows nerve, vessels and duct sparing even for cases with recurrent swelling. Incomplete facial weakness was encountered in only one patient at the 6th month PO, but was of grade II.

Inflammation, Infiltration, Necrosis, Abscess and Nicolau Syndrome after Injection of Nonsteroidal Anti-inflammatory Drugs: What is the Reason?

It has been established that some nonsteroidal anti-inflammatory drugs (NSAIDs) when administered through injectable preparations have a local irritating effect, even though the preparations are considered high-quality. It seems that this local irritant action is not related to any specific pharmacological action but with the physicochemical properties of the preparation that grossly violate the homeostasis of the tissues. It seems that the local complications at injection sites can be caused by the nonspecific properties of the injectable preparations: denaturing (cauterizing), hypertonic and acidic activity. Each such property, or their combination, has a locally irritating effect, which can cause abscess, necrosis, and acute aseptic inflammation of reversible or irreversible nature, that follows immediately after subcutaneous or intramuscular administration, a condition named “Nicolau Syndrome”. Conversely, injectable preparations of NSAIDs having isotonic or hypotonic osmolarity associated with a neutral or weakly alkaline pH (about pH 7.4), produce a minimal short-term reversible local inflammatory effect and do not cause Nicolau Syndrome after administration.

Second-line interventions for migraine in the emergency department: A narrative review.

Millions of patients present to US emergency departments (ED) annually for the treatment of migraine. First-line treatments, including metoclopramide, prochlorperazine, and sumatriptan, fail to provide sufficient relief in up to one-third of treated patients. In this narrative review, we discuss the evidence supporting the use of injectable (intravenous, intramuscular, or subcutaneous) medications for patients in the ED who fail to improve sufficiently after treatment with first-line medication. We used the American Headache Society's guideline, "Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies," published in 2016, to identify first-line medications for migraine. We then conducted a PubMed search to determine whether any evidence supported the use of these medications as second-line therapy and whether any evidence existed to support the use of injectable therapies not discussed in the guideline as second-line therapy. We identified only scant high-quality randomized data of second-line therapy. Therefore, we based our recommendations on medications that have reliably demonstrated efficacy as first-line treatment of migraine. These medications include injectable non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. Dihydroergotamine and valproic acid have some data supporting efficacy. More recently, greater occipital nerve blocks (GONBs) have been shown to be efficacious. With the exception of meperidine, opioids have been shown to be not efficacious. Most data published to date demonstrate no role for propofol and ketamine. There are no evidence-based second-line treatments of migraine in the ED setting. For patients with migraine, who fail to improve after treatment with a first-line medication, it is reasonable to use an intravenous NSAID or intravenous acetaminophen. Alternatively, clinicians adept at performing a GONB may offer this treatment.

Non-steroidal anti-inflammatory drugs (NSAIDs) for trigger finger.

Trigger finger is a common hand condition that occurs when movement of a finger flexor tendon through the first annular (A1) pulley is impaired by degeneration, inflammation, and swelling. This causes pain and restricted movement of the affected finger. Non-surgical treatment options include activity modification, oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and local injections with anti-inflammatory drugs. To review the benefits and harms of non-steroidal anti-inflammatory drugs (NSAIDs) versus placebo, glucocorticoids, or different NSAIDs administered by the same route for trigger finger. We searched CENTRAL, MEDLINE, Embase, CINAHL, CNKI (China National Knowledge Infrastructure), ProQuest Dissertations and Theses, www.ClinicalTrials.gov, and the WHO trials portal until 30 September 2020. We applied no language or publication status restrictions. We searched for randomised controlled trials (RCTs) and quasi-randomised trials of adult participants with trigger finger that compared NSAIDs administered topically, orally, or by injection versus placebo,glucocorticoid, or different NSAIDs administered by the same route. Two or more review authors independently screened the reports, extracted data, and assessed risk of bias and GRADE certainty of evidence. The seven major outcomes were resolution of trigger finger symptoms, persistent moderate or severe symptoms, recurrence of symptoms, total active range of finger motion, residual pain, patient satisfaction, and adverse events. Treatment effects were reported as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). Two RCTs conducted in an outpatient hospital setting were included (231adult participants, mean age 58.6 years, 60% female, 95% to 100% moderate to severe disease). Both studies compared a single injection of a non-selective NSAID (12.5 mg diclofenac or 15.0 mg ketorolac) given at lower than normal doseswith a single injection of a glucocorticoid (triamcinolone20 mg or 5 mg),with maximum follow-up duration of 12 weeks or 24 weeks. In both studies, we detected risk of attrition and performance bias. One study also had risk of selection bias. The effects of treatment were sensitive to assumptions about missing outcomes. All seven outcomes were reported in one study, and five in the other. NSAID injection may offer little to no benefit over glucocorticoid injection, based on low- to very low-certainty evidence from two trials. Evidence was downgraded for bias and imprecision. There may be little to no difference between groups in resolution of symptoms at 12 to 24 weeks (34% with NSAIDs, 41% with glucocorticoids; absolute effect 7% lower, 95% confidence interval (CI) 16% lower to 5% higher; 2 studies, 231 participants; RR 0.83, 95% CI 0.62 to 1.11; low-certainty evidence). The rate of persistent moderate to severe symptoms may be higher at 12 to 24 weeks in the NSAIDs group (28%) compared to the glucocorticoid group (14%) (absolute effect 14% higher, 95% CI 2% to 33% higher; 2 studies, 231 participants; RR 2.03, 95% CI 1.19 to 3.46; low-certainty evidence). We are uncertain whether NSAIDs result in fewer recurrences at 12 to 24 weeks (1%) compared to glucocorticoid (21%) (absolute effect 20% lower, 95% CI 21% to 13% lower; 2 studies, 231 participants; RR 0.07, 95% CI 0.01 to 0.38; very low-certainty evidence). There may be little to no difference between groups in mean total active motion at 24 weeks (235 degrees with NSAIDs, 240 degrees with glucocorticoid) (absolute effect 5% lower, 95% CI 34.54% lower to 24.54% higher; 1 study, 99 participants; MD -5.00, 95% CI -34.54 to 24.54; low-certainty evidence). There may be little to no difference between groups in residual pain at 12 to 24 weeks (20% with NSAIDs, 24% with glucocorticoid) (absolute effect 4% lower, 95% CI 11% lower to 7% higher; 2 studies, 231 participants; RR 0.84, 95% CI 0.54 to 1.31; low-certainty evidence). There may be little to no difference between groups in participant-reported treatment success at 24 weeks (64% with NSAIDs, 68% with glucocorticoid) (absolute effect 4% lower, 95% CI 18% lower to 15% higher; 1 study, 121 participants; RR 0.95, 95% CI 0.74 to 1.23; low-certainty evidence). We are uncertain whether NSAID injection has an effect on adverse events at 12 to 24 weeks (1% with NSAIDs, 1% with glucocorticoid) (absolute effect 0% difference, 95% CI 2% lower to 3% higher; 2 studies, 231 participants; RR 2.00, 95% CI 0.19 to 21.42; very low-certainty evidence). For adults with trigger finger, by 24 weeks' follow-up, results from two trials show that compared to glucocorticoid injection, NSAID injection offered little to no benefit in the treatment of trigger finger. Specifically, there was no difference in resolution, symptoms, recurrence, total active motion, residual pain, participant-reported treatment success, or adverse events.

The effects of a single-dose subacromial injection of a nonsteroidal anti-inflammatory drug in geriatric patients with subacromial impingement syndrome: a randomized double-blind study.

BackgroundAs nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids have similar effects, steroids can be avoided to reduce adverse effects. This study aimed to compare the differences in symptom improvement after subacromial injection of steroids or NSAIDs.MethodsSixty patients with rotator cuff syndrome for at least 3 months were enrolled and divided into steroid and NSAID groups. The steroid group received a mixture of 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of lidocaine hydrochloride 2%, while the NSAID group received a mixture of 1 mL of Ketorolac Tromethamine (30 mg/mL) and 1 mL of lidocaine hydrochloride 2%. The patients were assessed before and at 3, 6, and 12 weeks after the procedure. Shoulder scores from visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) were used for evaluation.ResultsBoth groups showed improvements in the clinical outcomes. Overall VAS, ASES, and UCLA scores improved from 6.9, 32.7, and 16.0 before the procedure to 2.0, 1.2, and 1.1; 81.5, 87.6, and 88.5; and 29.7, 31.8, and 32.0 at weeks 3, 6, and 12 weeks after the procedure, respectively. Twenty-six patients (86.7%) in the steroid group and 28 (93.3%) in the NSAID group reported satisfactory treatment outcomes. There were no significant differences in the outcomes between the two groups (p=0.671).ConclusionsSubacromial injection of NSAIDs for rotator cuff tendinitis with shoulder pain had equivalent outcomes with those of steroid injection at the 12-week follow-up.

Abstract 16285: Use of Non-steroidal Anti-inflammatory Drugs and Risk of First Hospitalization for Heart Failure in Diabetic Patients

Introduction: Patients with diabetes mellitus are prone to have heart failure (HF), either as new onset or worsening. Non-steroidal anti-inflammatory drugs (NSAIDs) cause sodium, water retention and increase the risk of HF. Hypothesis: NSAIDs associated risk of HF in diabetic patients has not been well evaluated. Methods: Cohort study with a nested case-control analysis was done based on the Korean National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) database. Among overall 78,453 diabetic patients, 1569 cases with first hospitalization for HF were identified and compared with 1:10 matched controls (n = 15,325). Current user of NSAIDs was defined as the most recent prescription lasted until the index date or ended in the 30 days before the index date. Results: In HF group, mean age was older and tended to have more previous HF, ischemic heart disease compared to control. Current NSAIDs user was much higher in HF group compared with control (534, 34 % vs 3,778, 25%, p &lt; 0.001). The risk of a first hospital admission for HF associated with current use of NSAIDs was 1.60 (95% confidence interval (CI) 1.28 to 2.09) after controlling for major confounding factors. Multiple combination, high dose and injection of NSAIDs increased the risk of HF hospitalization (multiple combination; odds ratio (OR): 2.14, CI: 1.64 to 2.78, high dose; OR: 1.72, CI: 1.30 to 2.29, injection; OR: 2.36, CI: 1.79 to 3.09). NSAIDs associated risk of HF hospitalization was more significant, especially in diabetic patients with progressive diabetic retinopathy (OR: 2.23, CI 1.34 to 3.72) or overt neuropathy (OR: 4.59, CI: 2.84 to 7.43). Conclusions: Use of NSAIDs increased the risk of hospitalization for HF in diabetic patients, particularly with diabetic retinopathy and overt nephropathy as microvasculopathies. Therefore, the risk stratification for HF should be recommended in diabetic patients when the NSAIDs are prescribed.

Comparative effectiveness of various treatment strategies for trigger finger by pairwise meta-analysis

Objective: To compare the efficacy of various strategies in the treatment of trigger finger. Data sources: A systematic literature search for randomized controlled trials to compare treatments for trigger finger was conducted through three online databases, Pubmed, Embase and Cochrane Library, from their inception dates to 22 May 2020. Methods: Relative risk (RR) with 95% confidence interval (CI) was used to evaluate the effect sizes in success rate for included articles. Results: Sixteen articles (n = 1185) were included in our meta-analysis. The results showed that the efficacy of steroid injection was significantly better than the placebo group at short-term follow-ups (RR = 19.00, 95% CI = 1.17–309.77 for one-week; RR = 3.70, 95% CI = 3.70, 95% CI = 1.61–8.53 for one-month), and then became non-significant at four months (RR = 3.21, 95% CI = 0.88–11.79). There was no significant difference in success rate between steroid injection and nonsteroidal anti-inflammatory drug injection, and between open surgery and percutaneous release at all the follow-ups. Only surgical treatment had significantly better efficacy in success rate than steroid injection at all follow-ups (RR = 0.48, 95% CI = 0.34–0.66 for one-month; RR = 0.87, 95% CI = 0.80–0.96 for three-month; RR = 0.58, 95% CI = 0.48–0.68 for six-month; RR = 0.38, 95% CI = 0.20–0.72 for 12-month). Conclusion: There were no differences in efficacy between steroid injection and shockwave or nonsteroidal anti-inflammatory drug injection. The surgical treatments had the best efficacy among these treatments.

Real-World Effectiveness of Common Treatment Strategies for Juvenile Idiopathic Arthritis: Results From a Canadian Cohort.

Undervaluing the effectiveness of conventional treatments may lead to overtreatment with biologic medications in children with juvenile idiopathic arthritis (JIA). Using data from a nationwide inception cohort and strict methods to control bias, the aim of our study was to estimate the real-world effectiveness of simple JIA treatment strategies recommended in current guidelines. Children with JIA who were recruited at 16 Canadian centers from 2005 to 2010 were followed for up to 5 years. For each child, all observed treatment changes over time were assessed by independent physicians using prospectively collected data and published response criteria. Success was defined as attainment of inactive disease or maintenance of this state when stepping down treatment; minimally active disease was deemed acceptable for children with polyarticular JIA. Success rates were calculated for treatments tried ≥25 times, and logistic regression analysis identified features associated with success. A total of 4,429 treatment episodes were observed in 1,352 children. Nonsteroidal antiinflammatory drug (NSAID) monotherapy was attempted 697 times, mostly as initial treatment when <5 joints were involved, with a 54.4% success rate (95% confidence interval [95% CI] 50.3-58.6). NSAIDs plus joint injections had a 64.7% success rate (95% CI 59.8-69.7). Adding methotrexate to NSAIDs and/or joint injections (attempted 566 times) had a 60.5% success rate (95% CI 55.7-65.3). In adjusted analyses, each additional active joint reduced chances of success for treatment with NSAIDs (odds ratio [OR] 0.90 [95% CI 0.85-0.94]) and for methotrexate combinations (OR 0.96 [95% CI 0.94-0.99]). Each additional year after disease onset reduced chances of success for treatment with methotrexate combinations (OR 0.83 [95% CI 0.72-0.95]). These real-world effectiveness estimates show that conventional nonbiologic treatment strategies that are recommended in current guidelines are effective in achieving treatment targets in many children with JIA.

Excessive skin toxicity in a patient receiving pegylated liposomal doxorubicin, associated with Nicolau syndrome, exacerbated by morbid obesity

Pegylated liposomal doxorubicin (PLD) is an anthracycline anticancer agent used in ovarian cancer and a form of doxorubicin enclosed in pegylated liposomes. Although it causes less cardiotoxicity than doxorubicin, it is frequently associated with cutaneous toxicity, mainly palmoplantar erythrodysesthesia. Other forms of skin toxicity – such as maculopapular rash, intertrigo-like dermatitis, psoriasiform dermatitis and radiation recall dermatitis – have also been described. Nicolau syndrome is a rare complication fol­lowing the intramuscular administration of several agents, mainly injection of nonsteroidal anti-inflammatory drugs. Obesity is not only an established risk factor for developing cancer, but can also adversely influence the course of the disease in the advanced or metastatic set­ting. In this article, we present the case of a 44-year-old mor­bidly obese woman diagnosed with platinum-resistant stage IV ovarian cancer treated with pegylated liposomal do­xo­ru­bi­cin in a second-line setting. The patient developed severe skin toxicity caused by pegylated liposomal do­xo­ru­bicin, manifested by paronychia, intertrigo-like der­ma­ti­tis with ulcerations, bleeding, infection, and pso­ria­si­form dermatitis. She also presented with associated Nicolau syndrome, due to injection of antalgics into the subcutaneous fat instead of intramuscular. These skin toxicities caused further complications, such as severe anemia and acute renal failure. We hypothesize that the morbid obesity was the main contributing factor to all of these complications. With this presentation, we want to underline the importance of maintaining a healthy body weight in cancer patients.