Use Of Nonsteroidal Anti-inflammatory Medications Research Articles

Interferon-β-1a for the Treatment of Steroid-Refractory Ulcerative Colitis: A Randomized, Double-Blind, Placebo-Controlled Trial

We performed a randomized, double-blind, placebo-controlled, multicenter trial to investigate the efficacy and safety of recombinant interferon-beta-1a (rIFN-beta-1a) in outpatients with active steroid-refractory ulcerative colitis. Ninety-one randomized patients subcutaneously received 3 MIU rIFN-beta-1a (group A, n = 32), 1 MIU rIFN-beta-1a (group B, n = 30), or placebo (group C, n = 29) 3 times a week over a period of 8 weeks in addition to standard therapy. An intention-to-treat analysis was performed to evaluate the efficacy and safety of treatment. In all 3 groups, the median prestudy clinical activity index (CAI) was 10. In 18 of 32 patients (56%) in group A, in 11 of 30 patients (36%) in group B, and in 10 of 29 patients (34%) in group C, a reduction of the CAI of 6 points or greater (response) was achieved (differences were not statistically significant). Complete response (reduction of CAI to < or =4) was achieved in 56%, 30%, and 38% of patients in groups A, B, and C, respectively. Compared with baseline, the median endoscopic index had been reduced by 5, 3, and 4 points in groups A, B, and C, respectively. Steroid reduction was 12 mg in group A, 6 mg in group B, and 10 mg in group C. Identical side effects occurred in all 3 groups. Seven serious adverse events were reported (1 in group A and 6 in group C). All were unrelated to therapy as judged by the investigating physicians. rIFN-beta-1a was safe but not significant, at the dosage and/or duration of treatment used, in steroid-refractory ulcerative colitis. Further studies are indicated.

Is Screening for Microalbuminuria Warranted in Children with Sickle Cell Hemoglobinopathies?.

Renal impairment occurs in adults and children with sickle cell disease. Microalbuminuria (MA) defined as albumin excretion >2.9 mg/dl in random urine sample or 30–300 mg in 24 hour urine collection is an early, sensitive indicator for glomerulopathy in both diabetes mellitus and sickle cell disease. Therefore, we conducted a universal screening in our patients (pts) with sickle cell hemoglobinopathies in order to identify the prevalence of MA and other indicators of early renal impairment. Children and young adults with hemoglobin SS, SC, Sβ+thalassemia and Sβ0thalassemia, ages 4–21 years (yrs), had urinalyses and random urine measurements for protein, microalbumin, and creatinine. All were in good state of health, free of pain, and without prior diagnosis of renal dysfunction when the samples were obtained. Serum electrolytes, creatinine, osmolality, and 24-hour urine collection for protein, microalbumin, β2-microglobulin, creatinine, and electrolytes were done in pts with abnormal urine samples. There were 101screened pts (53 males; 76 SS, 20 SC, 3Sβ0, and 2 Sβ +). Nineteen pts had MA detected by random urine. MA was confirmed in 24-hour samples in 46% of studied pts. In addition to MA, tubular proteinuria (increased β2-microglobulin) was detected in 1 pt, isolated hematuria in 3 and increased urine protein/creatinine (>0.2) in 4. From the MA+ pts, 15 had SS (19.7% of SS group) and 4 had SC (20% SC group). 25% of children 10 yrs of age or older had MA (mean± standard deviation MA 2.83±3.94), as compared to 6% of younger children (mean 1.21±0.80), (p=0.02). African Americans had lower incidence of MA (11.4%), compared to other children of Haitian (21.3%), Hispanic Caribbean (25%), and other Caribbean (28.5%) descent (p=not significant [NS]). There was no correlation between MA and history of stroke, acute chest syndrome/asthma, brief use of non-steroidal anti-inflammatory medications, hemoglobin or white cell values. From the subgroup of 16 pts on hydroxyurea, 11 were 10 yrs of age or older; of these, 5 (45.5%) had MA, compared to 21% of the same age non-treated group (p=NS). We analyzed the effect of age at onset of chronic transfusions and presence of MA. Six transfused pts had MA (age at start of transfusion 8.6–13.5 yrs, mean 11 yrs; mean MA 5.3±3.4), while there were 15 MA free pts (age 0.8–12.4 yrs, mean 7 yrs; mean MA 1.4±0.6), suggesting that early age at start of chronic transfusions may be protective for MA (p=0.0004). We conclude that: (1) urine screening of children with sickle cell hemoglobinopathies 10 yrs or older is recommended, (2) chronic transfusions starting at an early age may protect against MA, and (3) validity of random versus 24-hour urine collections in determining MA should be further investigated. Studies to further define the risk factors, prognosis, and intervention in children with sickle cell hemoglobinopathies are warranted.

Case Report: Pseudomembranous Collagenous Colitis

Pseumembranous colitis has usually been associated with Clostridium difficile colitis. We describe pseudomembrane formation in association with collagenous colitis in the absence of C. difficile or use of nonsteroidal antiinflammatory medications in two female patients. CASE REPORTS Case 1. A 58-year-old Caucasian female presented to an outside medical facility with the gradual onset of diarrhea consisting of 8‐11 daily bowel movements. A small bowel barium radiological contrast study (SBFT) was normal. The patient was treated with loperamide and, in addition, received lanazaprole for nausea. Colonoscopy was normal, although random biopsies were normal. Treatment was unsuccessful, and dehydration and weight loss ensued. The patient was hospitalized for 10 days and received treatment with intravenous corticosteroids, total parenteral nutrition (TPN), and mesalamine (Asacol; 1200 mg daily) by mouth. Upon discharge, she was prescribed prednisone on a tapering dose schedule and home TPN for 2 months. Serum antigliadin, antiendomyceal, and tissue transglutaminase antibodies were undetectable. Upon presentation to Northwestern, the patient noted a subjective lactose intolerance with diarrhea and flatulence, although she had discontinued lactose-containing foods without a change in her bowel habits. She noted that no specific foods seemed to trigger her diarrhea. There were no known medication allergies. Her medications included prednisone (20 mg/day), mesalamine (1200 mg/day), fluoxetine hydrochloride (Prozac; Lilly), pantoprazole sodium (Protonix; Wyeth), and montelukast sodium (Singular; Merck). When she had tapered her prednisone to 5‐10 mg/day, the diarrhea subjectively, significantly increased. She had not taken estrogens or nonsteroidal antiinflammatory (NSAID) medications. The patient also described occasional lower abdominal, crampy pain and occasional rectal bleeding. Surgical history included a cesarian section and foot surgery. The patient is a teacher. She abused tobacco and consumed 2‐3 glasses of wine weekly. There was no recent travel Preceding diarrheal development. Family history was unremarkable except that her mother died from pancreatic carcinoma.

Recommendations for treatment of hyponatraemia at endurance events.

This review focuses on possible pathophysiology of exercise-associated hyponatraemia and its implication on evaluation and treatment of collapsed athletes during endurance events. Rehydration guidelines and field care have traditionally been based on the belief that endurance events create a state of significant fluid deficit in athletes, which must be corrected by liberal hydration. Beliefs in the necessity of liberal hydration may have contributed to cases of hyponatraemia. Assumptions that fluid loss accounts for the entire weight loss during exercise and that fluid ingestion is the only source of water gain during exercise may lead to an overestimation of the degree of volume depletion and the amount of fluid needed for replacement. Increasing evidence suggests that hyponatraemic athletes are fluid overloaded; ingestion of large amount of hypotonic fluid in combination with inappropriate or inadequate physiological responses leads to excessive retention of free fluid. Risk factors include hot weather, female sex, slower finishing time, and possibly the use of nonsteroidal anti-inflammatory medications. Symptoms of hyponatraemia can be subtle and can mimic those of other exercise-related illnesses, thereby complicating its diagnosis and leading to possible inappropriate treatment. Most athletes who collapse at the finish line experience exercise-associated collapse, a benign and transient form of postural hypotension that can be treated simply by continued ambulation after finishing or elevation of legs while in a supine position for those who cannot walk. Care providers should consider the use of intravenous hydration with normal saline carefully since it is not needed by most collapsed athletes and may worsen the condition of patients with unsuspected hyponatraemia. Historic information and clinical signs of volume depletion should be elicited prior to its use. Most hyponatraemic athletes will recover uneventfully with careful observation while awaiting spontaneous diuresis. Use of hypertonic saline should be reserved for patients with severe symptoms. Moderate consumption of carbohydrate-electrolyte solution during exercise may allow the maintenance of adequate hydration and the prevention of hyponatraemia.

Family history of colon cancer: What does it mean and how is it useful?

Background Family history of colon cancer can be deconstructed into causal and noncausal explanations, which include genetic factors, environmental factors, gene–environment interactions, misclassification, and differences in screening. Methods We investigated some of these causal and noncausal explanations by using data from a case–control study of colon cancer conducted among African Americans and whites in North Carolina. We examined the relationship between family history and polymorphisms in four genes (N-acetyltransferase 1 and 2 [NAT1, NAT2], methylenetetrahydrofolate reductase, and peroxisome proliferator-activated receptor gamma [PPARG]), environmental risk factors, the joint distributions of these genes and environmental risk factors, and the prevalence of colon cancer screening. Results Participants with one or more first-degree relatives with colon cancer showed a slightly higher prevalence of at-risk genotypes for each locus, but results were statistically significant only for NAT2. Participants with a family history showed a higher prevalence of at-risk combinations of genotypes and environmental risk factors ( NAT2 and well-done red meat consumption; PPARG and nonsteroidal anti-inflammatory medication use). The sensitivity and predictive value of family history for identifying persons with at-risk genotypes or environmental risk factors was low. History of cancer screening was similar in those with and without a family history. Conclusions Our results suggest that family history of colon cancer may represent aggregation of some genetic polymorphisms and environmental risk factors. Although it is premature to use family history as a screening tool when testing for genetic polymorphisms, further research is needed to identify additional genes and environmental factors that may be associated with family history.

Selective outpatient management of upper gastrointestinal bleeding in the elderly.

We sought to determine whether elderly patients with upper gastrointestinal bleeding can be safely managed as outpatients. We were also interested in determining the etiology of bleeding peptic ulcer disease in this population. Eighty-four patients (65 yr of age and older) were studied during a 23-month period. Urgent outpatient endoscopy was performed and clinical as well as endoscopic criteria were applied to determine the need for hospital admission. Patients with endoscopic findings that indicated a low risk for rebleeding were not admitted if they lacked one major or three minor predefined clinical criteria. All enrollees were followed after discharge from the clinic or hospital for 4 wk with hematocrit determination and clinical assessments. The main outcome measures were the number of patients who met our predefined clinical and endoscopic criteria for outpatient versus inpatient care and the differences in the rebleeding rates in these two groups. Twenty-four (29%) patients were treated as outpatients; none rebled. In contrast, seven (12%) of the 60 inpatients had one or more rebleeding episodes (p = 0.002). Bleeding from peptic ulcer disease was associated with use of nonsteroidal antiinflammatory medications in 81% of patients. Selective outpatient management of elderly patients with upper gastrointestinal bleeding can be done safely and has the potential to lead to reduced health care expenditures. Over-the-counter nonsteroidal antiinflammatory drugs are the most frequent cause of bleeding peptic ulcer disease in this population.

Selective outpatient management of upper gastrointestinal bleeding in the elderly

OBJECTIVE: We sought to determine whether elderly patients with upper gastrointestinal bleeding can be safely managed as outpatients. We were also interested in determining the etiology of bleeding peptic ulcer disease in this population. METHODS: Eighty-four patients (65 yr of age and older) were studied during a 23-month period. Urgent outpatient endoscopy was performed and clinical as well as endoscopic criteria were applied to determine the need for hospital admission. Patients with endoscopic findings that indicated a low risk for rebleeding were not admitted if they lacked one major or three minor predefined clinical criteria. All enrollees were followed after discharge from the clinic or hospital for 4 wk with hematocrit determination and clinical assessments. The main outcome measures were the number of patients who met our predefined clinical and endoscopic criteria for outpatient versus inpatient care and the differences in the rebleeding rates in these two groups. RESULTS: Twenty-four (29%) patients were treated as outpatients; none rebled. In contrast, seven (12%) of the 60 inpatients had one or more rebleeding episodes ( p = 0.002). Bleeding from peptic ulcer disease was associated with use of nonsteroidal antiinflammatory medications in 81% of patients. CONCLUSIONS: Selective outpatient management of elderly patients with upper gastrointestinal bleeding can be done safely and has the potential to lead to reduced health care expenditures. Over-the-counter nonsteroidal antiinflammatory drugs are the most frequent cause of bleeding peptic ulcer disease in this population.

Use of Low-Dose Oral Prednisone to Prevent Paclitaxel-Induced Arthralgias and Myalgias

Objectives.The aim of this study was to examine the clinical utility of low-dose oral prednisone in preventing severe paclitaxel-associated arthralgias and myalgias.Methods.Patients treated with paclitaxel in the gynecologic oncology program of the Cleveland Clinic Foundation who developed arthralgias/myalgias which were uncontrolled through the use of nonsteroidal anti-inflammatory medications received low-dose oral prednisone (10 mg B.I.D. starting 24 h after the completion of chemotherapy and continuing for a total of 5 days) with their next paclitaxel course.Results.Of 46 patients meeting the criteria for treatment with the oral prednisone regimen (i.e., subjective feeling of unacceptable discomfort despite the use of nonsteroidal anti-inflammatory agents), 39 (85%) experienced substantial relief of symptoms. All but one of the responding patients requested continuation of the oral prednisone regimen with subsequent paclitaxel treatment cycles. There were no significant toxicities noted in any patient receiving prednisone.Conclusion.This low-dose oral prednisone regimen results in substantial improvement in the majority of patients experiencing significant paclitaxel-associated arthralgias/myalgias.

Antibacterial Treatment of Gastric Ulcers Associated withHelicobacter pylori

There is a strong association between infection with Helicobacter pylori and gastric ulcers that are unrelated to the use of nonsteroidal antiinflammatory medications. We studied the efficacy of antibacterial therapy without medication to suppress gastric acid for the treatment of patients with H. pylori infection and gastric ulcers unrelated to the use of nonsteroidal agents. Patients with gastric ulcers seen on endoscopy and with H. pylori infection confirmed by smear or culture were randomly assigned to receive either a one-week course of antibacterial agents (120 mg of bismuth subcitrate, 500 mg of tetracycline, and 400 mg of metronidazole, each given orally four times a day) or a four-week course of omeprazole (20 mg orally per day). Follow-up endoscopies were performed after five and nine weeks. The patients and their physicians were aware of the treatment assignments, but the endoscopists were not. A total of 100 patients were randomly assigned to treatment, and 85 completed the trial. At five weeks, H. pylori had been eradicated in 41 of the 45 patients in the antibacterial-treatment group (91.1 percent; 95 percent confidence interval, 82.9 to 99.3) and in 5 of the 40 in the omeprazole group (12.5 percent; 95 percent confidence interval, 2.3 to 22.7; P < 0.001). The gastric ulcers were healed in 38 of the patients treated with antibacterial drugs (84.4 percent; 95 percent confidence interval, 73.9 to 95.0) and in 29 of those treated with omeprazole (72.5 percent; 95 percent confidence interval, 58.6 to 86.4; P = 0.28). At nine weeks, ulcer healing was confirmed in 43 of the patients receiving antibacterial therapy and in 37 of those receiving omeprazole (P = 1.0). The mean (+/- SD) duration of pain during the first week of treatment was 1.9 +/- 2.6 days in the omeprazole group, as compared with 3.6 +/- 3.0 days in the antibacterial-treatment group (P = 0.004). One year after treatment, recurrent gastric ulcers were detected in 1 of 22 patients (4.5 percent) in the antibacterial-treatment group and in 12 of 23 (52.2 percent) in the omeprazole group (P = 0.001). H. pylori was detected in the 1 patient with a recurrent ulcer who had received antibacterial treatment and in 10 of the 12 patients with recurrent ulcers who had received omeprazole. In patients with H. pylori infection and gastric ulcers unrelated to the use of nonsteroidal antiinflammatory drugs, one week of antibacterial therapy without acid suppression heals the ulcers as well as omeprazole and reduces the rate of their recurrence.

The Use of Night Splints for Treatment of Recalcitrant Plantar Fasciitis

This study reports the results of the use of molded ankle foot orthosis night splints for the treatment of recalcitrant plantar fasciitis on 14 patients with a total of 18 symptomatic feet. All patients had symptoms for greater than 1 year and had previously undergone treatment with non-steroidal anti-inflammatory medicines, cortisone injections, shoe modifications, and physical therapy without resolution. All patients were provided with custom-molded polypropylene ankle foot orthoses in 5 degrees of dorsiflexion to be used as a night splint. With continued use of nonsteroidal anti-inflammatory medication, Tuli heel cups, Spenco liners, and general stretching exercises, successful resolution occurred in 11 patients in less than 4 months. There were three failures. It is felt that the use of night splints provides a useful, cost-effective adjunct to current therapeutic regimens of plantar fasciitis.

Preoperative nonsteroidal anti-inflammatory medication for the prevention of postoperative dental pain

It is predictable for patients to experience postoperative pain and inflammation. Until recently, therapeutic strategies for the management of these sequelae have been symptomatic rather than preventive. This article reviews prophylactic use of nonsteroidal anti-inflammatory medication for preventing postoperative discomfort, and includes recommendations on patient selection and medication regiment.

Perioperative Medical Care for Equine Abdominal Surgery

Rational perioperative management improves the success rate of abdominal surgery. Important aspects of management are discussed, including principles of fluid therapy, nutrition, intravenous catheterization, antimicrobial prophylaxis, and the use of nonsteroidal anti-inflammatory medication. Current advances in the area of immunotherapy are mentioned.

The carpal boss: an overview of radiographic evaluation.

The carpal boss, an unmovable bony protuberance, is located on the dorsum of the wrist at the base of the second and third metacarpals adjacent to the capitate and trapezoid bones. This bony prominence may represent degenerative osteophyte formation and/or the presence of an os styloideum, an accessory ossification center that occurs during embryonic development. When this condition is symptomatic, patients present with complaints of pain and limitation of motion of the affected hand. The symptoms of carpal boss may result from an overlying ganglion or bursitis, an exterior tendon slipping over this bony prominence, or from osteoarthritic changes at this site. Radiographically, the view that best profiles the separate os styloideum is a lateral view utilizing 30 degrees of supination and ulnar deviation of the wrist. Once a diagnosis has been made, treatment can range from the use of nonsteroidal antiinflammatory medication and limited use of the wrist to surgical excision of the anatomic abnormality.