Nonsteroidal Anti-inflammatory Drugs Treatment Research Articles

Effects of short-term addition of NSAID to diuretics and/or RAAS-inhibitors on blood pressure and renal function

The combined post-operative use of diuretics and/or renin-angiotensin-aldosterone system (RAAS) inhibitors may increase the risk of nonsteroidal anti-inflammatory drug (NSAID) associated renal failure because of a drug-drug interaction. The aim of this study was to investigate the effect of the short-term (<4 days) post-operative combined use of NSAIDs with diuretics and/or RAAS inhibitors on renal function and blood pressure. One teaching hospital in the Netherlands. The study-design was a prospective, observational cohort-study. Based on postoperative treatment with NSAIDs, the intervention-group was compared to a control-group (no NSAIDs treatment). Systolic blood pressure and renal function expressed by the estimated glomular filtration rate (eGFR) calculated with the modification of renal desease formula. 97 patients were included in the intervention-group, 53 patients in the control-group. Patient characteristics were comparable except for one variable: 'combined use of a diuretic with a RAAS inhibitor' which was higher in the control-group (62 vs. 43 %, p = 0.046). Odds ratio for clinically relevant increase in systolic blood pressure was 0.66 (CI95 % 0.3-1.5). Odds ratio for clinical relevant decrease in renal function was 2.44 (CI95 % 1.1-5.2). On day 4 eGFR of 3 patients in the intervention- and 1 in the control-group was <50 ml/min/1.73 m(2). Odds ratios showed no significant difference of a clinically relevant increase in systolic blood pressure but showed a higher risk for a clinically relevant decrease in renal function in the intervention group. However this decrease resulted in a relevant impaired renal function (<50 ml/min/1.73 m(2)) in only 3 patients in the interventiongroup and 1 patient in the control-group. In the post-operative patient, without preexisting impaired renal function, concurrent diuretics and/or renin-angiotensinaldosterone system inhibitor therapy can be combined with short-term NSAID treatment.

Downregulation of Prominin 1/CD133 expression in colorectal cancer by NSAIDs following short-term preoperative treatment

Expression of Prominin 1/CD133 is associated with poor prognosis and chemoresistance in several types of solid tumors. The aim of the present study was, therefore, to evaluate Prominin 1/CD133 expression in colorectal carcinoma after short-term preoperative treatment by non-steroidal anti-inflammatory drugs (NSAIDs). Patients aimed at curative operation for colon cancer were randomized to receive NSAIDs (indomethacin 50 mg x2 or celecoxib 100 mg x2) three days preoperatively. Antisecretory prophylaxis (esomeprasol 40 mg x1) was provided to all patients and served as sham intake. CD133 expression in tumor tissue was also assessed in tumors from Dukes' B patients selected for either long or short postoperative survival. No patients received perioperative chemoradiotherapy. Tumor tissue was collected at surgery for quantification of mRNAs (Prom1 and Wnt4) by qPCR. Immunohistochemistry stained for CD133, Ep-CAM, CD34 and CD45. PGE2 content in tumor tissue was determined. Transcript of CD133 in tumor tissue was lower in patients treated with NSAIDs (0.28 ± 0.07 vs. 0.51 ± 0.08; p<0.03) as well as some other stem cell-related transcripts. In treated patients 36% of all tumors stained positive for CD133 compared to 71% in sham-treated control patients (p<0.05). Short survivors with Dukes' B tumors displayed 78% CD133 expression as compared to 33% of tumors in long-term survivors (p<0.002). Tumor tissue PGE(2) content was negatively related to patient survival. Our results show that short-term preoperative NSAID treatment downregulates colon cancer tissue expression of Prominin 1/CD133, a stem cell marker indicative of survival prognosis as confirmed.

DUEXIS® (ibuprofen 800 mg, famotidine 26.6 mg): a new approach to gastroprotection for patients with chronic pain and inflammation who require treatment with a nonsteroidal anti-inflammatory drug

Chronic pain conditions affect at least 116 million US adults and more than one-third of adults worldwide. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used extensively for the treatment of chronic pain due to their efficacy as anti-inflammatory and analgesic agents. Gastrointestinal toxicity is the most well known adverse effect of NSAID therapy and it may manifest as dyspepsia, ulcers, or bleeding. Current guidelines for the management of patients who require NSAIDs for chronic pain and inflammation recognize the potential toxicity associated with these drugs and the need for gastroprotection. DUEXIS(®) (ibuprofen 800 mg, famotidine 26.6 mg) is a proprietary combination, immediate release tablet containing 800 mg of ibuprofen and 26.6 mg of famotidine. The efficacy of DUEXIS(®) taken three times daily has been demonstrated in two large-scale controlled clinical trials (Registration Endoscopic Studies to Determine Ulcer Formation of HZT-501 Compared with Ibuprofen: Efficacy and Safety Studies (REDUCE) and REDUCE-2) which showed that this new formulation significantly reduced the risk of endoscopic upper gastrointestinal ulcers compared with ibuprofen alone (REDUCE-1, p < 0.0001, REDUCE-2, p <0.05). DUEXIS(®) was also superior to ibuprofen in decreasing the risk for gastric ulcers (REDUCE-1, p < 0.001, REDUCE-2, p < 0.05) as well as duodenal ulcers (REDUCE-1, p < 0.05, REDUCE-2, p < 0.05). Safety results from these two studies indicated that treatment-emergent adverse events occurred in 55% of patients treated with DUEXIS(®)versus 58.7% for ibuprofen, and serious adverse events were recorded for 3.2% of patients treated with DUEXIS(®)versus 3.3% of those on ibuprofen. Adverse events leading to discontinuation occurred in 6.7% of patients treated with DUEXIS(®) and 7.6% for ibuprofen. The combination of ibuprofen and famotidine in a single tablet has the potential to improve adherence to gastroprotective therapy in patients who require NSAID treatment and the use of a histamine type 2 receptor antagonist rather than a proton-pump inhibitor may decrease the risk for clinically significant drug interactions and adverse events (e.g. interaction with clopidogrel, fracture, pneumonia, Clostridium difficile infection).

Abstract 4673: The anti-proliferative effects of non-steroidal anti-inflammatory drugs (NSAIDs) diclofenac and indomethacin in ovarian cancer cells

Abstract Epidemiological studies have shown that the regular use of non-steroidal anti-inflammatory (NSAIDs) drugs is associated with a reduced risk of various cancers. In addition, in vitro and preclinical mouse model experiments have demonstrated that NSAIDs decrease tumor initiation and/or progression of several cancers. In an attempt to clarify the mechanisms of tumor prevention by NSAIDs, we have studied the effects of two NSAIDs, diclofenac and indomethacin, in several ovarian cancer cell lines. Diclofenac and indomethacin treatment decreased cell growth by inducing cell cycle arrest and/or apoptosis. To identify the possible molecular pathways mediating the effects of NSAID treatment in ovarian cancer, ovarian cancer cell lines were treated with diclofenac or indomethacin and microarray analysis was performed. Among the genes differentially expressed in the different cell lines were genes involved in signaling, metabolism, and cell cycle regulation. Some of the genes found downregulated following diclofenac or indomethacin treatment are transcriptional target genes of E2F1 and E2F4, suggesting involvement of these transcription factors in the response of ovarian cancer cells to NSAID treatment. In addition, E2F1 was found downregulated at the protein level upon treatment with diclofenac and indomethacin. The levels of phosphorylated Rb protein also decreased upon treatment with NSAIDs, suggesting activation of Rb and involvement of the Rb/E2F pathway in the effects of NSAID treatment in ovarian cancer cells. In conclusion, NSAIDs diclofenac and indomethacin exert an anti-proliferative effect in ovarian cancer cells and we have identified a number of target genes and pathways that may be important for the NSAID-induced cell cycle arrest and apoptosis. Current efforts are focused on determining the exact roles of these genes and pathways in NSAID-mediated cancer growth inhibition. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4673. doi:1538-7445.AM2012-4673

Inhibition of medullary prostaglandin E2 (PGE2) by non‐steroidal anti‐inflammatory drugs (NSAIDs) adversely affects medullary blood flow

NSAIDs are known to be nephrotoxic and act to inhibit cyclooxygenases (COX) and thus production of PGE2. Here we use the kidney slice model to investigate (i) the effect of PGE2 on in situ vasa recta pericytes (ii) the ability of PGE2 to attenuate ET‐1 and Ang‐II‐evoked vasoconstriction of vasa recta, (iii) the effect of NSAIDs on in situ vasa recta pericytes, and (iv) whether NSAIDs attenuate PGE2 and bradykinin‐mediated vasa recta dilation. Kidney slices were collected as previously described1. Real‐time images of in situ vasa recta were recorded and vasa recta diameter at pericyte and non‐pericyte sites measured off‐line. PGE2 evoked dilation of vasa recta specifically at pericyte sites and significantly attenuated pericyte‐mediated constriction of vasa recta evoked by both ET‐1 and Ang‐II. NSAIDs, indomethacin&gt;SC560&gt; celecoxib&gt;meloxicam, evoked significantly greater constriction of vasa recta capillaries at pericyte sites than at non‐pericyte sites and indomethacin significantly attenuated the pericyte‐mediated vasodilation of vasa recta evoked by both PGE2 and bradykinin. These data indicate PGE2 is key in attenuating vasa recta diameter and thus medullary blood flow (MBF). Inhibition of PGE2 that occurs during chronic NSAID treatment causes constriction of vasa recta by pericytes. Thus pericytes may be key in NSAID‐evoked reduction in MBF and any ensuing nephrotoxicity.

Management of Helicobacter pylori-related disorders

The discovery of Helicobacter pylori has opened new opportunities in the management of gastrointestinal disorders, with the cure of chronic ulcer disease now being possible for the first time. The 1994 United States National Institutes of Health Consensus Conference recommended that patients with duodenal or gastric ulcers unrelated to the use of non-steroidal anti-inflammatory drugs (NSAID) should be given eradication therapy. These guidelines were refined at a conference held recently in Maastricht. The updated guidelines strongly recommend treatment in patients with duodenal or gastric ulcer disease, low-grade mucosa-associated lymphoid tissue (MALT) gastric lymphoma, gastritis with severe macro-or microscopic changes and after resection of early gastric cancer. Despite a lack of hard scientific evidence, the guidelines also suggest that eradication treatment is advisable in patients with unequivocally diagnosed functional dyspepsia, a family history of gastric cancer, long-term treatment with proton-pump inhibitors for gastro-oesophageal reflux disease (GORD), planned or existing NSAID treatment, after gastric surgery for ulcer or cancer, or if the patient wants to be treated. Many different therapeutic regimens have been used previously, but at present the best treatment is proton-pump inhibitor-based triple therapy, comprising a proton-pump inhibitor plus two drugs out of clarithromycin, a nitroimidazole and amoxycillin. One-week low-dose triple therapy cures 85-95% of infected patients.

The upright posture improves plantar stepping and alters responses to serotonergic drugs in spinal rats

Recent studies on the restoration of locomotion after spinal cord injury have employed robotic means of positioning rats above a treadmill such that the animals are held in an upright posture and engage in bipedal locomotor activity. However, the impact of the upright posture alone, which alters hindlimb loading, an important variable in locomotor control, has not been examined. Here we compared the locomotor capabilities of chronic spinal rats when placed in the horizontal and upright postures. Hindlimb locomotor movements induced by exteroceptive stimulation (tail pinching) were monitored with video and EMG recordings. We found that the upright posture alone significantly improved plantar stepping. Locomotor trials using anaesthesia of the paws and air stepping demonstrated that the cutaneous receptors of the paws are responsible for the improved plantar stepping observed when the animals are placed in the upright posture.We also tested the effectiveness of serotonergic drugs that facilitate locomotor activity in spinal rats in both the horizontal and upright postures. Quipazine and (±)-8-hydroxy-2-(dipropylamino)tetralin hydrobromide (8-OH-DPAT) improved locomotion in the horizontal posture but in the upright posture either interfered with or had no effect on plantar walking. Combined treatment with quipazine and 8-OH-DPAT at lower doses dramatically improved locomotor activity in both postures and mitigated the need to activate the locomotor CPG with exteroceptive stimulation. Our results suggest that afferent input from the paw facilitates the spinal CPG for locomotion. These potent effects of afferent input from the paw should be taken into account when interpreting the results obtained with rats in an upright posture and when designing interventions for restoration of locomotion after spinal cord injury.

Vesiculobullous Skin Reaction Temporally Related to Firocoxib Treatment in a White Rhinoceros (Ceratotherium simum)

A 40 yr-old female white rhinoceros (Ceratotherium simum) suffered from chronic nail-bed abscesses. Due to worsening of clinical signs, the animal's nonsteroidal anti-inflammatory treatment was switched to firocoxib. Approximately 7 days after this change, the animal developed multifocal vesicles and bullae along the lateral aspects of the thorax and abdomen, the dorsum, and the proximal limbs. Cytology and culture did not identify an infectious etiology. Histologically, the lesions consisted of a severe, subacute vesiculobullous dermatitis with intraepidermal to subepidermal clefting with areas of individual keratinocyte necrosis and minor neutrophilic epidermal infiltrates. These findings are similar to those seen in some drug reactions in people; therefore an adverse drug reaction to the firocoxib was suspected.

Study shows how NSAIDs inhibit lymphatic metastasis

www.thelancet.com/oncology Vol 13 April 2012 e144 A new study investigating lymphatic metastasis has led to a possible explanation for the eff ectiveness of non-steroidal anti-infl ammatory drugs (NSAIDs) as anti-cancer agents. Researchers at the Peter MacCallum Cancer Centre (Melbourne, VIC, Australia) used mouse xenograft models of lymphogenous spread to show how VEGF-D secreted by primary tumours induces dilation of collecting lymphatic vessels during metastasis by downregulating the expression of the enzyme 15-hydroxyprostaglandin dehydrogenase (PGDH), the key function of which is the degradation of prostaglandins. They showed that NSAIDs could be used to inhibit VEGFD-driven metastasis by interfering with the prostaglandin pathway and blocking lymphatic vessel dilation. Steven Stacker (Peter MacCallum Cancer Centre), co-author of the study, told The Lancet Oncology: “our data suggest that NSAIDs could restrict the rate of metastatic spread of tumour cells by reducing the dilation of collecting lymphatics, particularly in epithelial cancers such as gastrointestinal, breast, prostate and lung, which are more likely to metastasise through the lymphatic system”. “Given that restricting or blocking metastatic spread is a critical factor in ensuring cancer survival, adapting NSAID treatment to reduce metastasis should lead to fewer deaths”, Stacker added. Commenting on the research, Peter Rothwell (University of Oxford, Oxford, UK) said: “there is evidence that aspirin, and possibly other NSAIDs, might reduce blood-borne metastasis, but these new fi ndings are interesting in that they suggest a possible mechanism for an eff ect on lymphatic spread”. “Clinical evidence of an eff ect of aspirin or NSAIDs on risk of metastasis is mainly limited to observational studies and appears to be stronger for distant metastasis than for local and regional metastasis, but small eff ects on lymphatic spread have not been excluded”, Rothwell continued. Discussing previous clinical research, Stacker said: “We believe our data are consistent with the fi ndings of longterm randomised trials using NSAIDs, which found that cancer deaths were reduced in patients treated with aspirin”. John Burn (Newcastle University, Newcastle upon Tyne, UK) said that “this is an exciting and important report which off ers one mechanism for the observed benefi ts of aspirin as an adjuvant treatment in colorectal cancer”. He added: “it adds weight to the case for aspirin use as a routine adjuvant in addition to the growing case for its use as a chemopreventive in those with increased genetic risk”.

Nonsteroidal Anti-Inflammatory Drugs Induce Apoptosis in Cutaneous T-Cell Lymphoma Cells and Enhance Their Sensitivity for TNF-Related Apoptosis-Inducing Ligand

Cutaneous T-cell lymphomas (CTCL) form a heterogeneous group of non-Hodgkin's lymphomas of the skin. In previous studies, we had characterized CTCL cells as resistant to the death ligand tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), which correlated to pronounced expression of the caspase-8/-10 inhibitor c-FLIP. For identification of proapoptotic strategies in CTCL cells and for overcoming their death ligand resistance, we investigated the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid, sodium salicylate, and diclofenac (DF). These drugs strongly enhanced apoptosis, as well as decreased CTCL cell proliferation and vitality, and DF furthermore sensitized for TRAIL-induced apoptosis. Full activation of the caspase cascade (caspase-3, -8, -9) and decreased mitochondrial membrane potential were characteristic for NSAID treatment, whereas cytochrome c release was seen only for DF. Downregulation of Mcl-1 and enhanced surface expression of TRAIL were seen in response to NSAIDs. Most characteristic for apoptosis induction was the downregulation of c-FLIP. In agreement with the critical role of c-FLIP for apoptosis deficiency of CTCL cells, its overexpression decreased NSAID-mediated apoptosis and its downregulation by small hairpin RNA-enhanced apoptosis. The study provides a rationale for the use of NSAIDs as a new therapeutic option for CTCL patients. Supporting this concept, ex vivo lymphoma cells of CTCL patients also revealed significant sensitivity for NSAID treatment.

Clinically important improvement in the WOMAC and predictor factors for response to non-specific non-steroidal anti-inflammatory drugs in osteoarthritic patients: a prospective study

BackgroundThe aims of the present study were first to detect MCID for WOMAC in a Moroccan population, and second, to identify the best pre-treatment predictors on the change of health after treatment by non-specific, non-steroidal anti-inflammatory drugs (NSAIDs), and to evaluate whether the predictors were dependent on the choice of the response criterion.MethodsThe study involved 173 patients with osteoarthritis in whom primary care physicians decided to start treatment with non-selective NSAIDs. Assessments at admission and after 6 weeks were conducted. In order to determine the threshold levels associated with a definition of clinically important improvement, the receiver operating characteristic method was used. Three different measures of response to a 6-week NSAIDs treatment were used: one indirect measure (MCID in the total WOMAC score), one direct measure (transition question) and a combination of both criteria.ResultsEighty patients (46.3%) reported "a slightly better" general health status compared to that of 6 weeks before NSAIDs treatment. The MCID proportion is a 16.0% reduction in WOMAC. The most stable pre-treatment predictors on the improvement of health after treatment by NSAIDs were the absence of previous knee injury and a high level of education.ConclusionsIn our data, a 16.0% reduction of the total WOMAC score from baseline was associated with the highest degree of improvement on the transition scale category. This cut-off point had good accuracy, and should be appropriate for use in the interpretation of clinical studies results, as well as in clinical care.

Late-onset cystoid macular edema as a presenting symptom of anca-negative pauciimmune crescentic glomerulonephritis.

The purpose of this study was to report the appearance of late-onset cystoid macular edema (CME) as an initial manifestation of antineutrophil cytoplasmic antibody-negative pauciimmune glomerulonephritis. Optical coherence tomography was obtained on a female patient after presentation of CME after cataract surgery in the right eye. Follow-up optical coherence tomographies were obtained after resolution of symptoms and on development and resolution of CME in the fellow eye. The patient developed unilateral CME 6 months after uncomplicated cataract surgery and after a seizure was diagnosed with antineutrophil cytoplasmic antibody-negative pauciimmune glomerulonephritis. The CME resolved within 2 months of initiating topical nonsteroidal antiinflammatory drug and steroid treatment. Several months later, after undergoing uncomplicated cataract surgery in the fellow eye, the patient developed CME 4 weeks after surgery despite topical nonsteroidal antiinflammatory drug and steroid prophylaxis. The CME quickly resolved with topical treatment, and there has been no recurrent CME in either eye. Review of the literature shows a potential shared mechanism of CME and antineutrophil cytoplasmic antibody-negative pauciimmune glomerulonephritis. These findings demonstrate a potential association between CME and antineutrophil cytoplasmic antibody-negative pauciimmune glomerulonephritis. Patients with this form of glomerulonephritis may benefit from pre- and postoperative topical antiinflammatory prophylaxis.

NSAIDs and Acidic Environment Induce Gastric Mucosal Cellular Mitochondrial Dysfunction

Non-steroidal anti-inflammatory drugs (NSAIDs) often cause gastrointestinal complications such as gastric ulcers and erosions. Recent studies on the pathogenesis have revealed that NSAIDs induce lipid peroxidation in gastric epithelial cells by generating superoxide in mitochondria, independently with cyclooxygenase inhibition and the subsequent prostaglandin deficiency. More recently, gastric hydrochloric acid (HCl) has been regarded as an inciting factor of gastric mucosal injuries, and reportedly induced cellular lipid peroxidation in vitro. We hypothesized that gastric acid and NSAID treatment synergistically induce cellular injury in gastric epithelial cells. We treated gastric epithelial RGM1 cells with acidic solutions and NSAIDs, and examined cellular injury, lipid peroxidation, mitochondrial transmenbrane potential and mitochondrial superoxide. We pretreated RGM1 cells with the acidic solutions for 0.5 h and after that treated them with each NSAID for 15 h and found that the exposure to acid and NSAIDs indeed induced cellular injury. We hypothesized that gastric acid and NSAID treatment synergistically induce mitochondrial superoxide production, which induces gastric cellular injury.

Metabolic syndrome and neurotrophins: effects of metformin and non-steroidal antiinflammatory drug treatment.

Metabolic syndrome (MS) presents with central obesity, impaired glucose metabolism, dyslipidemia and hypertension. Our aim was to examine the effect of metformin treatment either alone or in combination with non-steroidal anti-inflammatory drugs (NSAID) on plasma levels of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) in patients with early stage MS (MS-es) and generalized MS (MS-ge). The study compared 35 female patients with MS-es (mean age of 43.39±1.54 years) and 40 patients with MS-ge (mean age of 45.69±2.18 years) to 10 age-matched controls each. Patients with MS-es were administered 850 mg metformin twice daily. The patients with MS-ge were divided into two groups of 20 patients per group. One group received metformin alone, while the other group received metformin in combination with 500 mg aspirin and 150 mg Diclac daily. Plasma NGF and BDNF levels were measured by ELISA. Statistical data analysis was performed using ANOVA. Plasma NGF and BDNF levels were significantly higher in MS-es patients and lower in MS-ge patients than in controls. NGF levels were decreased in both groups after treatment with metformin. NGF levels were significantly higher in MS-ge patients on combined therapy than in those on metformin only. The combination of metformin and NSAID treatment is more effective than metformin alone on NGF and BDNF production as well as on metabolism-related anthropometric and laboratory features. This represents a pathogenetic therapeutic mechanism in MS due to its strong anti-inflammatory effect and improves MS-ge symptoms.

Response to Letters Regarding Article, “Duration of Treatment With Nonsteroidal Anti-Inflammatory Drugs and Impact on Risk of Death and Recurrent Myocardial Infarction in Patients With Prior Myocardial Infarction: A Nationwide Cohort Study”

We appreciate the interest in our article in Circulation 1 and welcome further discussion on this important topic. Dr Naimer, Dr Alla, and colleagues comment on the influence that stress and rheumatic diseases have on risk in patients. We agree that confounding by indication may influence observational studies such as ours, and that lack of information on nonsteroidal anti-inflammatory drug (NSAID) treatment indication is a limitation of the study. However, our findings were consistent, and we found different degree of risk between the individual NSAIDs, which were probably all used for the same indications, a clear correlation between the degree of cyclooxygenase-2 inhibition (as reported in the literature) and risk, and a clear dose-dependent increase in …

Prostaglandin E2 Inhibition of Ketorolac 0.45%, Bromfenac 0.09%, and Nepafenac 0.1% in Patients Undergoing Phacoemulsification

We compared the prostaglandin E(2) (PGE(2)) inhibition of three topical nonsteroidal antiinflammatory drugs (NSAIDs): ketorolac 0.45%, bromfenac 0.09%, and nepafenac 0.1% at peak dosing levels in patients previously scheduled to undergo phacoemulsification. This was a single-center, double-masked observational study of 121 patients randomized to one of three NSAID treatment arms. Patients were instructed to take the NSAID per on-label dosing (twice daily [b.i.d.] for ketorolac 0.45% and bromfenac 0.09%, three times a day [t.i.d.] for nepafenac 0.1%) for 1 day before surgery, and were to instill one drop the morning of surgery. Each patient received an additional four doses 1 hour prior to undergoing phacoemulsification. After completion of the paracentesis site with a super blade, aqueous humor (0.15 mL) was collected through the peripheral clear cornea with a 30 G needle attached to a tuberculin (TB) syringe. Aqueous humor samples were stored at -40°C prior to analysis, and diluted 1:10 with diluent. Assays were conducted on multiple plates in duplicate (seven standards per plate). The mean (±SD) PGE(2) concentrations were 224.8±164.87 pg/mL for ketorolac 0.45% (n=42), 288.7±226.05 pg/mL for bromfenac 0.09% (n=41), and 320.4±205.6 pg/mL for nepafenac 0.1% (n=38). The difference between ketorolac 0.45% and nepafenac 0.1% was statistically significant (P=0.025). The difference between bromfenac 0.09% and nepafenac 0.1% was not significantly different (P=0.516). Ketorolac 0.45% achieved the greatest inhibition of PGE(2) compared to nepafenac 0.1% and bromfenac 0.09%. Ketorolac 0.45% may be more efficacious at controlling inflammation at the time of cataract surgery versus nepafenac 0.1% and bromfenac 0.09%.

Bone Marrow Niche Attenuation by Non-Steroidal Anti-Inflammatory Drugs Mobilizes Hematopoietic Stem and Progenitor Cells by Differing Mechanisms

Abstract 724Hematopoeitic stem (HSC) and progenitor cells (HPC) are localized in niches contained within the bone marrow (BM) microenvironment. To facilitate acquisition of HSC/HPC for hematopoietic transplantation, donors can be treated with granulocyte-colony stimulating factor (G-CSF) to “mobilize” HSC/HPC from the BM niche to the peripheral system. Our laboratory has recently discovered that short term administration of non-steroidal anti-inflammatory drugs (NSAIDs) also mobilizes HSC/HPC and works in synergy with G-CSF. To understand the mechanisms underlying this novel therapeutic utility of NSAIDs we analyzed the BM niche post-NSAID and G-CSF treatment.Femurs of mice were analyzed after a 4 day regimen of the NSAID Meloxicam (3mg/kg, bid) and compared to control or G-CSF treated mice. Gross histological analysis showed a remarkable osteoblast (OB) “flattening” similar to that seen with G-CSF. Goldners trichrome staining revealed significantly reduced osteoid bone surfaces, with ∼3-fold increase in quiescent surfaces. Similarly, dynamic bone formation analysis using calcein/tetracycline labeling demonstrated reductions in mineral apposition rate and bone formation rate. There were no significant alterations in trabecular bone as determined by MicroCT. TRAP+ osteoclasts (OCs) were slightly elevated in both Meloxicam and G-CSF treated groups. To further assess the role of OCs, mice were mobilized with or without zoledronic acid (ZA) treatment, which inhibits OC activity. Similar to a recent report (Winkler, Blood, 2010), ZA resulted in an increase in HSC/HPC mobilization by both Meloxicam and G-CSF, suggesting that increased OC activity is not a mitigating mechanism for NSAID-mediated mobilization. Immunohistochemical (IHC) staining showed marked reductions in osteopontin (OPN), stromal-derived factor-1 (SDF-1) and N-cadherin expression by Meloxicam and G-CSF treated mice. In a separate set of experiments, OBs and mesenchymal stem cells (MSCs) were sorted by flow cytometry and gene expression assessed by Taq-Man assay. Similar to IHC analysis, Meloxicam treatment resulted in reduced SDF-1, OPN, Jagged-1, Runx2 and VCAM-1 gene expression.While the interaction of SDF-1 with its hematopoietically expressed receptor CXCR4 is a well known mediator of niche retention, both HSC and HPC were significantly mobilized by Meloxicam in CXCR4 knockout (KO) mice, suggesting that while reduced SDF-1 expression may concurrently play a role in NSAID mediated mobilization, it is not the definitive mechanism. In contrast, when OPN KO mice were mobilized with Meloxicam or G-CSF, Meloxicam unexpectedly increased mobilization of HPC only, and not HSC, while both HPC and HSC were mobilized by G-CSF. This surprising result indicates that NSAID-mediated OPN reduction is specifically responsible for the observed HSC mobilization, while HPC mobilization appears to be mediated by another mechanism(s).Recently, it has been reported that G-CSF reduces resident F4/80+ monocytes/macrophages (MOs), which normally support niche OBs and MSCs, and this reduction is at least partially responsible for niche attenuation and hematopoietic mobilization. However, in contrast to G-CSF, IHC analysis showed no reduction in F4/80+ cells after Meloxicam treatment, nor was there a reduction in CD169+ BM macrophages as assessed by flow cytometry. Therefore, while NSAIDs and G-CSF attenuate the niche microenvironment similarly, these agents function through independent mechanisms, perhaps explaining the synergistic mobilization seen by the two.In conclusion, NSAID treatment results in significant attenuation of the BM niche, including the niche components SDF-1, OPN, and N-cadherin. NSAID-mediated mobilization is independent of reduced SDF-1/CXCR4 signaling, as CXCR4 KO mice can be mobilized by NSAID. OPN KO specifically blocks the NSAID mobilization of HSC, but not HPC, suggesting differing mechanisms, or possibly multiple niche locations for these two populations; an intriguing finding suggesting that other mobilization strategies may be able to specifically target HSC or HPC. While G-CSF treatment results in reduced MOs, NSAIDs do not alter BM levels of these supportive cells. These results define not only a novel strategy for mobilization of HSC/HPC, but also suggest a possible strategy for targeted niche attenuation for other therapeutic applications, such as reduced conditioning regimens. Disclosures:Hoggatt:Fate Therapeutics: Consultancy. Pelus:Fate Therapeutics: Consultancy.

Duloxetine added to oral nonsteroidal anti-inflammatory drugs for treatment of knee pain due to osteoarthritis: results of a randomized, double-blind, placebo-controlled trial

Objective:To determine the efficacy, tolerability, and safety of duloxetine when added to oral nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with osteoarthritis (OA) of the knee with pain of moderate or greater severity.Research design and methods:This was a 10-week randomized, double-blind, flexible-dose (duloxetine 60/120 mg/day), placebo-controlled trial that enrolled adult outpatients who had persistent moderate pain (≥4 on a 0–10 numerical rating scale) due to OA of the knee, despite, per protocol, having received optimized oral NSAID therapy (specific drug, dose, and frequency at investigator discretion).Clinical trials registration:Trial registration: ClinicalTrials.gov identifier: NCT01018680.Main outcome measure:Patients entered daily pain ratings in a telephone-based diary. The primary efficacy outcome was the weekly mean of the daily average pain rating at week 8. Safety outcomes were assessed during the entire 10-week study.Results:A total of 524 patients randomly received duloxetine 60/120 mg/day (N = 264) or placebo (N = 260). In total, 74% of the patients completed the study. Mean age was 61 years (SD 9.2), 57% were female, and 81% were white. Duloxetine-treated patients had significantly greater pain reduction at week 8 (p < 0.001) than placebo-treated patients. In addition, relative to placebo at week 8, duloxetine-treated patients had significant improvements in physical function as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (p < 0.001), and Patient Global Impression of Improvement (p < 0.001). Compared to placebo, significantly more nausea, dry mouth, constipation, fatigue and decreased appetite were reported by patients taking duloxetine (each p < 0.05). Discontinuation due to adverse events occurred more commonly in the duloxetine group than the placebo group (p = 0.03).Conclusion:Duloxetine added to oral NSAID therapy provided additional significant pain reduction, improved function, and patient-rated impression of improvement. Adverse events were consistent with those seen in previous duloxetine trials. The short duration of the study may not reflect the longer term efficacy and safety of NSAID/duloxetine cotherapy.

Improvement of Non-Steroidal Anti-Inflammatory Drug-Induced Gastrointestinal Symptoms during Proton Pump Inhibitor Treatment: Are G-Protein β3 Subunit Genotype, Helicobacter pylori Status, and Environmental Factors Response Modifiers?

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with significant upper and lower gastrointestinal (GI) morbidity. Aim: To determine the efficacy and safety of pantoprazole versus placebo in controlling GI symptoms during treatment with NSAIDs and to evaluate the influence of potential response modifiers. Methods: 800 patients with GI complaints during NSAID treatment were randomized to pantoprazole 20 mg once daily or placebo for 4 weeks in this double-blind, multicenter trial. Assessments included the difference in cumulated overall symptom load of any GI complaint during treatment (primary endpoint), proportion of days without GI symptoms, and influence of risk factors such as gender, age, alcohol consumption, smoking, Helicobacter pylori status, and GNB3 genotype SNP rs5443 (825C>T) on symptom load. Results: At 4 weeks, cumulated overall symptom load was significantly lower in pantoprazole than placebo recipients [p < 0.0001; intent-to-treat (ITT)]; the effect was statistically significant after 7 days’ treatment. Pantoprazole versus placebo recipients had 54 versus 29% of days without GI symptoms (p < 0.0001; ITT). Neither common risk factors nor GNB3 genotype were significantly associated with therapeutic response, while GNB3 825TT versus CT was associated with a significantly higher baseline symptom load (p < 0.05). Conclusion: In the population studied, treatment with the proton pump inhibitor pantoprazole significantly improves GI symptoms during NSAID therapy, irrespective of the risk factors investigated or GNB3 genotype.

COX inhibitors directly alter gene expression: role in cancer prevention?

Inflammation is an important contributor to the development and progression of human cancers. Inflammatory lipid metabolites, prostaglandins, formed from arachidonic acid by prostaglandin H synthases commonly called cyclooxygenases (COXs) bind to specific receptors that activate signaling pathways driving the development and progression of tumors. Inhibitors of prostaglandin formation, COX inhibitors, or nonsteroidal anti-inflammatory drugs (NSAIDs) are well documented as agents that inhibit tumor growth and with long-term use prevent tumor development. NSAIDs also alter gene expression independent of COX inhibition and these changes in gene expression also appear to contribute to the anti-tumorigenic activity of these drugs. Many NSAIDs, as illustrated by sulindac sulfide, alter gene expressions by altering the expression or phosphorylation status of the transcription factors specificity protein 1 and early growth response-1 with the balance between these two events resulting in increases or decreases in specific target genes. In this review, we have summarized and discussed the various genes altered by this mechanism after NSAID treatment and how these changes in expression relate to the anti-tumorigenic activity. A major focus of the review is on NSAID-activated gene (NAG-1) or growth differentiation factor 15. This unique member of the TGF-β superfamily is highly induced by NSAIDs and numerous drugs and chemicals with anti-tumorigenic activities. Investigations with a transgenic mouse expressing the human NAG-1 suggest it acts to suppress tumor development in several mouse models of cancer. The biochemistry and biology of NAG-1 were discussed as potential contributor to cancer prevention by COX inhibitors.