Oral Sulindac Research Articles

Abstract A66: Phase IIa placebo controlled trial of sulindac in individuals at increased risk for melanoma: Preliminary findings

Abstract Some epidemiological studies and several experimental publications suggest that regular use of NSAIDs may reduce the risk of melanoma. Proposed mechanisms of action include: inhibition of MAP kinase activity and nuclear translocation, reduction in the concentration of prostaglandins associated with the inhibition of VEGF and bFGF production and HIF-1α stabilization, reduction of the activation state of the VEGF and Ftl-1 genes, and inhibition of PI-3 kinase/Akt signaling pathway. However, specific information on the ability of NSAIDs to reach melanocytes in vivo and to modulate key biomarkers in pre-neoplastic lesions, such as dysplastic nevi, have not been evaluated to date. Methods: A phase IIa placebo controlled clinical intervention trial was designed with the primary end point to determine whether oral sulindac and related metabolites were present in benign nevi (BN) after an 8 week course of oral sulindac; secondary end points were included to determine whether a short exposure to sulindac had an effect on apoptosis and VEGF expression in atypical nevi (AN), as well as measurement of sulindac and metabolite levels in plasma. Exploratory objectives will evaluate the feasibility of reverse phase protein microarray to identify intervention related changes in cell signaling proteins, focusing initially on the pAKT/mTOR pathway and COX expression. Fifty healthy subjects with ≥ 4 large (≥5 mm and < 15 mm) AN and one BN were enrolled between 2/09 and 7/10. Subjects underwent clinical and dermoscopic evaluation of their melanocytic lesions with 2 AN randomized to be excised at baseline for biomarker evaluation and 2 AN to post-intervention evaluation. Subsequently, participants were randomized to receive sulindac (150 mg BID) or placebo for 8 weeks. Upon completion of the intervention the residual 2 AN and the BN were surgically removed. Results: To date, accrual has been completed and study intervention in all subjects is expected to be concluded in 09/10. The study intervention was well tolerated with some mild or moderate gastrointestinal adverse events that are possibly or probably related to the intervention. Sulindac, sulindac sulfide, sulindac sulfone concentrations were 0 — 1.4, 0 −9.07, and 0 — 6.1 µg/ml, respectively, in 41 post-intervention plasma samples analyzed to date. Sulindac, sulindac sulfide, sulindac sulfone concentrations were 0 — 5.2, 0 — 0.25, and 0 — 14.27 µg/g, respectively, in 40 postintervention BN samples. Conclusion: Current results suggest that NSAIDs, in particular sulindac and the active sulindac metabolites, can reach measurable levels in the skin, and specifically in melanocytic nevi, further supporting the need to assess the effect of this group of drugs as chemopreventive agents for melanoma. Supported by N01CN35158 from the National Cancer Institute, Division of Cancer Prevention. Citation Information: Cancer Prev Res 2010;3(12 Suppl):A66.

Single dose oral sulindac for acute postoperative pain in adults.

Sulindac is a non-steroidal anti-inflammatory drug (NSAID) licensed for use in rheumatic disease and other musculoskeletal disorders in the UK, and widely available in other countries worldwide. This review sought to evaluate the efficacy and safety of oral sulindac in acute postoperative pain, using clinical studies of patients with established pain, and with outcomes measured primarily over 6 hours using standard methods. This type of study has been used for many decades to establish that drugs have analgesic properties. To assess the efficacy of single dose oral sulindac in acute postoperative pain, and any associated adverse events. We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies up to June 2009. Randomised, double-blind, placebo-controlled clinical trials of oral sulindac for relief of acute postoperative pain in adults. Two review authors independently assessed trial quality and extracted data. We planned to use area under the "pain relief versus time" curve to derive the proportion of participants with meloxicam experiencing least 50% pain relief over 4 to 6 hours, using validated equations; to use number needed to treat to benefit (NNT); the proportion of participants using rescue analgesia over a specified time period; time to use of rescue analgesia; information on adverse events and withdrawals. No studies were identified by the searches that examined oral sulindac in patients with established postoperative pain. In the absence of evidence of efficacy, at present, for oral sulindac in acute postoperative pain, its use in this indication is not justified. Because trials clearly demonstrating analgesic efficacy in the most basic of acute pain studies is lacking, use in other indications should be evaluated carefully. Given the large number of available drugs of this and similar classes, there is no urgent research agenda.

High perinatal survival in monoamniotic twins managed by prophylactic sulindac, intensive ultrasound surveillance, and Cesarean delivery at 32 weeks' gestation

Increased perinatal mortality in monoamniotic twin pregnancies is attributed to cord accidents in utero and at delivery. We evaluated the following parameters in monoamniotic pregnancies: (1) the incidence of cord entanglement; (2) the effect of sulindac on amniotic fluid volume and stability of fetal lie; and (3) the perinatal outcome with our current management paradigm. This is a retrospective review of monoamniotic pregnancies of >or=20 weeks' gestation managed with serial ultrasound surveillance, medical amnioreduction and elective Cesarean delivery at 32 weeks' gestation. Mean amniotic fluid index (AFI) and change in AFI in monoamniotic pregnancies managed with oral sulindac was compared with 40 gestation-matched monochorionic-diamniotic controls. Among 44 monoamniotic pregnancies, 20 with two live structurally normal twins at 20 weeks' gestation satisfied the inclusion criteria. All fetuses survived to 28 days postnatally despite early prenatal cord entanglement in all but one case. Whereas AFI remained stable throughout gestation in the controls, the AFI fell in those patients on sulindac from a mean value of 21.0 cm (95% CI, 18.5-23.6 cm) at 20 weeks to a mean of 12.4 cm (95% CI, 10.1-14.6 cm) at 32 weeks (ANOVA P across gestation = 0.001) but mainly remained within normal limits. Fetal lie was stabilized in 11/20 cases in the monoamniotic group compared with 13/40 in the control group (P < 0.0001). Cord entanglement appears unpreventable, as it typically occurs in early pregnancy. Sulindac therapy reduces AFI, leads to more stable fetal lie, and may prevent intrauterine death by diminishing the risk of constricting cords that are already entangled. Perinatal survival in monoamniotic pregnancies managed by a regime of sulindac from 20 weeks' gestation, close ultrasound surveillance and elective abdominal delivery at 32 weeks' gestation seems empirically higher than that in the literature.

Prevention of retinal capillary basement membrane thickening in diabetic dogs by a non-steroidal anti-inflammatory drug.

To investigate the effect of treatment with the non-steroidal anti-inflammatory drug Sulindac on the early vascular pathology of diabetic retinopathy in the dog, and it's effect on recognised biochemical indices of hyperglycaemia-related pathophysiology. Experimental diabetes (streptozotocin/alloxan) was induced in 22 male beagle dogs and 12 of the animals were assigned at random to receive oral Sulindac (10 mg/kg daily). Age- and sex-matched control animals were maintained as non-diabetic controls. After 4 years, several morphological parameters were quantified in the retinal microvasculature of each animal group using an established stereological method. Also, the following diabetes-associated biochemical parameters were analysed: accumulation of advanced glycation end products (AGEs), red blood cell polyol levels and antioxidant status. Diabetes increased red blood cell sorbitol levels when compared to non-diabetic controls (p< or =0.05), however, there was no difference in sorbitol levels between the untreated and the treated diabetic animals. No significant differences were found in red blood cell myoinositol levels between the three groups of animals. Pentosidine and other AGEs were increased two- to three-fold in the diabetic animals (p< or =0.001) although treatment with Sulindac did not affect their accumulation in diabetic skin collagen or alter diabetes-induced rises in plasma malondialdehyde. Retinal capillary basement membrane volume was significantly increased in the untreated diabetic dogs compared to non-diabetic controls or Sulindac-treated diabetic animals (p< or =0.0001). This study has confirmed the beneficial effect of a non-steroidal anti-inflammatory drug on the early vascular pathology of diabetic retinopathy. However the treatment benefit was not dependent on inhibition of polyol pathway activity, advanced glycation, or oxidative stress.

Sulindac to prevent recurrent preterm labor: a randomized controlled trial

OBJECTIVE: To assess the efficacy of oral sulindac in low doses for prolonged duration to decrease the risk of recurrent preterm labor and extend gestation. METHODS: This was a randomized, double-blind, placebo-controlled study of patients between 24 and 34 weeks’ gestation with preterm labor treated with intravenous magnesium sulfate. After successful tocolysis, patients were randomized by the pharmacy to receive either oral sulindac (100 mg) or placebo orally every 12 hours until 34 weeks’ gestation. A power analysis required 43 patients in each group. RESULTS: Ninety-five patients were enrolled (46 in the sulindac group, 49 controls). No significant differences were found with respect to time gained in utero (39 ± 25 versus 45 ± 26 days, P = .29), delivery at more than 35 weeks’ gestation (61% versus 74%, P = .29), recurrent preterm labor (20% versus 18%, P = .86), birth weight (2562 ± 623 versus 2624 ± 543 g, P =.62), or time spent in the neonatal intensive care unit (2.8 ± 9.2 versus 2.4 ± 8.6 days, P =.83) for the sulindac and control groups, respectively. CONCLUSION: The use of oral sulindac until 34 weeks’ gestation after successful parenteral tocolysis failed to reduce the incidence of readmission for preterm labor.

Relationship between APC genotype, polyp distribution, and oral sulindac treatment in the colon and rectum of patients with familial adenomatous polyposis.

Familial adenomatous polyposis is an inherited colorectal cancer syndrome characterized by the presence of multiple adenomatous colorectal polyps. Molecular studies have revealed that germline mutations in the APC gene are the underlying cause of the disease. The nonsteroidal anti-inflammatory agent sulindac has been shown to reduce the number of colorectal adenomas. Most sulindac trials in the large bowel have focused on the distal colon and relatively little is known about its effect on the proximal colon. Moreover, it is unknown whether the site of the APC mutation affects the efficacy of sulindac. This study investigated whether there were regional differences in the effect of sulindac on the colon and whether response to sulindac was dependent on the site of mutation in the APC gene. In an open prospective study 17 patients with familial adenomatous polyposis were treated with 300 mg oral sulindac daily for four months followed by a washout phase of six months. Ten of the patients had an intact colon and seven had rectal stumps only. The number, size, and the degree of dysplasia of the adenomas were evaluated by colonoscopy at entry, end of treatment and end of the study. Overall, a statistically significant decrease in the number of adenomas was observed (120 +/- 112 to 28 +/- 64, P = 0.007). After cessation of sulindac treatment the number of adenomas increased to 48 +/- 44.5, but remained significantly lower than the values observed at baseline. In the ten patients with intact colons, adenomas decreased by sevenfold in the proximal colon (103 +/- 73 to 15.1 +/- 47.4, P = 0.011) and twofold in the distal colon (80 +/- 52 to 29.6 +/- 37.2, P = 0.005). The size of adenomas and the grade of dysplasia also decreased. No correlation could be seen between the APC mutation site and the response to treatment. These data indicate that sulindac reduces the number of adenomas in the entire colon and that the effect seems to be more pronounced in the proximal colon.

The safety and efficacy of prolonged outpatient sulindac to prevent the recurrence of preterm labor: a prospective double-blind study

Purpose: To assess the efficacy and safety of outpatient oral sulindac given until 34 weeks gestation to prevent the recurrence of preterm labor (PTL). Materials and Methods: Women were considered candidates for the study if they had an episode of preterm labor successfully treated with inpatient parenteral tocolysis, intact membranes, cervical dilatation <4 cm, and gestations <34 weeks. Candidates for the study were randomized by the pharmacy to receive either a “look-alike” placebo or sulindac, 100 mg po bid until 34 weeks gestation. The patient was seen for follow-up visits at 1 week and then every other week until 34 weeks. On follow-up visits hourly fetal urine production, amniotic fluid assessment, and ductal velocities were obtained. Results: Forty-four patients were randomized (21 sulindac and 23 placebo). All demographic and clinical variables were similar with the weeks at randomization 29.2 and 30.5 in the sulindac and placebo groups, respectively. Readmission for tocolysis occurred in 5 and 3 of the sulindac and placebo group patients, respectively ( P = NS). Twenty and 22 of the sulindac and placebo group, respectively, delivered after 7 days. Amniotic fluid index in the sulindac group at 1 week was significantly lower than in the placebo group at 10.6 vs 13.0. All neonatal outcome variables were similar between the groups, including birth weights, Apgar, cord pH, and total NICU days. Conclusion: Sulindac until 34 weeks gestation following successful tocolysis results in no apparent prolongation of gestation.

Effect of indomethacin suppositories on rectal polyposis in patients with familial adenomatous polyposis

Oral sulindac is known to reduce polyps in patients with familial adenomatous polyposis (FAP). The authors speculated that rectal administration of indomethacin would be effective therapy for adenomas in the rectal remnant of FAP. Eight patients with FAP who had been treated by total colectomy with ileorectal anastomosis were administered an indomethacin suppository (50 mg) once or twice daily during a period of 4 or 8 weeks. The number of polyps at the same site within the rectum was counted under proctoscopy prior to, at the end of, and after the treatment. In four patients, proliferative activity of the rectal mucosa was assessed by immunohistochemical staining for MIB-1. In six of the eight patients who initially had ten or more polyps, the number of polyps decreased to fewer than five, whereas such a decrease could not be observed in the remaining two patients. In the six patients, the number of polyps increased after indomethacin was discontinued. The proliferative activity of the rectal mucosa was higher at the end of treatment than it was prior to indomethacin administration. Indomethacin suppositories may be effective in the management of rectal adenomatosis in patients with FAP.

Outpatient oral sulindac to prevent recurrence of preterm labor

To assess the efficacy and safety of oral sulindac in preventing the recurrence of preterm labor. This was a randomized, double-blind, placebo-controlled study of patients between 24-34 weeks' gestation with preterm labor treated with intravenous magnesium sulfate. After successful tocolysis, patients were randomized by the pharmacy to receive either oral sulindac (200 mg) or placebo (once orally every 12 hours) for 7 days. Sixty-nine patients were enrolled (34 in the sulindac group, 35 controls). No significant differences were found with respect to time gained in utero (40 +/- 4.4 versus 31 +/- 3.4 days, P = .1), delivery at more than 35 weeks' gestation (20 versus 18, P = .70), recurrent preterm labor (11 versus 13, P = .88), birth weight (2528 +/- 646 versus 2459 +/- 707 g, P = .68), or time spent in the neonatal intensive care unit (4.2 +/- 12.9 versus 5.7 +/- 13.5 days, P = .63) for the sulindac and control groups, respectively. However, in women who failed therapy (ie, those who delivered before 37 weeks' gestation or required readmission for tocolysis), there was a significantly longer interval between the start of therapy and failure in the sulindac group (25.9 +/- 3.4 days, n = 26) than in the control group (15.2 +/- 2.8 days, n = 25; P < .05). The use of oral sulindac for 1 week after successful parenteral tocolysis failed to reduce the overall rate of preterm birth. In women who delivered prematurely or required readmission for tocolysis, oral sulindac significantly prolonged the interval from the start of therapy until delivery or readmission. Moreover, this benefit was achieved without observable adverse effects on the fetus.

Oral sulindac to prevent recurrence of preterm labor: [formula omitted], S Carlan, S Schorr, T McWeill, H Rawji, K Clark, A Fuentes. Arnold Palmer Hospital for Children & Women (APH), ORHS, Orlando, FL

Oral sulindac to prevent recurrence of preterm labor: [formula omitted], S Carlan, S Schorr, T McWeill, H Rawji, K Clark, A Fuentes. Arnold Palmer Hospital for Children & Women (APH), ORHS, Orlando, FL

Effects of sulindac and naproxen on prostaglandin excretion in patients with impaired renal function and rheumatoid arthritis

purpose: The purpose of the current investigation was to study the influence of sulindac and naproxen on renal function and urinary excretion of the stable hydration product of prostacyclin, 6-keto-PGF 1α, in patients with arthritis and impaired renal function. patients and methods: In a placebo-controlled, double-blind, cross-over design, the effects of 7 days of oral sulindac 200 mg twice a day were compared with naproxen 500 mg in the morning and 250 mg in the evening in 10 patients with polyarthritis and stable impaired renal function. Inulin and para-amino-hippurate sodium were used to calculate glomerular filtration rate and renal plasma flow. The excretion rate of 6-keto-PGF 1α was measured in urine collected overnight. After patients ingested drugs in the morning, urine was collected in fractions by spontaneous voiding. Venous blood samples were drawn repeatedly for assay of electrolytes, creatinine, proteins, hormones, and drugs. Grip strength and Ritchie articular index were recorded as indicators of symptomatic antiarthritic effectiveness. results: Naproxen decreased urine levels of 6-keto PGF 1α by 59% (p <0.01). Sulindac had no effect on renal prostaglandin excretion. Naproxen reduced the glomerular filtration rate and renal plasma flow by 18% (p <0.05) and 13% (p <0.05), respectively, while no significant change was observed during the sulindac treatment periods. Serum levels of creatinine and complement factor D were unaffected by either drug. Plasma renin activity decreased during naproxen and sulindac treatments by 38% (p <0.05) and 22% (p <0.05). No significant change in plasma aldosterone was observed during the two drug treatments, but urinary aldosterone declined significantly (p <0.05) by 34% with naproxen. Albuminuria decreased (p <0.05) during both naproxen (41%) and sulindac treatment (72%), while the albumin/creatinine clearance ratio decreased by 59% (p <0.05) only during treatment with sulindac. N-acetyl-β-D-glucosaminidase in urine was not changed by either drug. Sulindac and naproxen had no discernible effects on base excess, excretion of water, sodium, or potassium, or on osmolal clearance. However, serum potassium increased slightly but significantly (p <0.01) during treatment with naproxen. Sulindac sulfide, the active metabolite of sulindac, could not be traced in the urine from any of the patients. Mean arterial blood pressure declined significantly (p <0.05) during sulindac treatment but did not change during treatment with naproxen. Both drugs produced equal clinical improvement as measured by grip strength and the Ritchie articular index. conclusion: The results suggest that when sulindac and naproxen are given in clinical equipotent doses to patients with impaired renal function, sulindac does not affect renal prostaglandin synthesis or renal function, whereas naproxen induces suppression of renal prostaglandin synthesis and a further decrease in renal function.

A protective effect of sulindac against chemically-induced primary colonic tumours in mice.

Sulindac, a non-steroidal anti-inflammatory drug, has been reported to lead to tumour regression in cases of human polyposis coli. We have investigated the effects of this drug on the growth of 1,2-dimethylhydrazine (DMH)-induced mouse colonic tumours. In one experiment, DMH and oral sulindac were administered concurrently to a group of mice for a period of up to 24 weeks, while a control group of animals received DMH only for the same period. Sulindac caused a significant reduction in both the number of mice with colonic tumours and the number of tumours per mouse. In a second experiment, two groups of mice which had already been treated with DMH for 17 weeks received either sulindac or not for 78 days. In this experiment sulindac had no effect. These results demonstrate that sulindac has a protective effect against the chemical induction of colonic tumours in mice, but does not cause the regression of established tumours.

Chronic effects of oral sulindac on renal haemodynamics and hormones in subjects with chronic renal disease.

The effects of oral sulindac, 600 mg daily, on renal function and plasma hormones were studied in eight subjects with chronic renal failure. Renal function and plasma hormones were measured before drug administration and then after taking sulindac for 28 days. Effective renal plasma flow was reduced in all subjects after 28 days but the glomerular filtration rate did not change. Plasma renin activity, potassium and aldosterone concentrations and urinary sodium excretion did not change but urinary prostaglandin E2 excretion fell significantly. Sulindac may be a relatively renal-sparing drug in its effects on the hormonal control of glomerular function.

Acute and chronic effects of sulindac on renal function in chronic renal disease

The effects of oral sulindac on renal hemodynamics were studied in normal subjects, elderly persons with mild renal failure, and patients with chronic renal disease. Renal function was measured before dosing and 24 hours and 28 days after oral sulindac. Effective renal plasma flow was reduced in all subjects after 24 hours. Effective renal plasma flow and the glomerular filtration rate were not altered after 28 days in control subjects, whereas effective renal plasma flow, but not glomerular filtration rate, was lower after 1 month in subjects with renal disease. None of these changes are likely to be of major clinical significance.