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Ibuprofen improves survival and neurologic outcome after resuscitation from cardiac arrest.

Kuhn JE, Steimle CN, Zelenock GB, D'Alecy LG.

Post-ischemic inflammatory changes in the central nervous system (CNS) following cardiac arrest and resuscitation are potentially responsible for ultimate survival and much of the neurologic damage, producing greater morbidity and mortality in successfully resuscitated patients. This study was undertaken to assess the non-steroidal anti-inflammatory agent, ibuprofen, in a controlled and monitored experimental model of canine cardiac arrest and resuscitation. With the investigator blinded as to the intervention, eight of 21 dogs were randomly assigned to receive ibuprofen as an i.v. bolus (10 mg/kg) and a 6-h i.v. infusion (5 mg/kg per h). The other 13 dogs received an equivalent volume of 0.9% NaCl to serve as controls. No statistically significant differences between the two groups were detected in any pre-arrest variables. All 21 dogs were successfully resuscitated. At 24 h, dogs receiving ibuprofen exhibited 100% survival, while control dogs exhibited only 54% survival (P = 0.03). The majority of deaths for the control group occurred within the first 6 h. Neurologic deficit scores were assigned at 1, 2, 6 and 24 h after resuscitation. A general trend occurred such that dogs treated with ibuprofen improved over time, while the control dogs remained severely impaired. A significant difference in neurologic deficit score was detected at 6 h (P = 0.01). At 24 h the ibuprofen group exhibited minimal neurologic deficit (5.9 +/- 3.2), and the control group exhibited significantly more severe neurologic impairment (52.2 +/- 13.0, P = 0.01). These results suggest that ibuprofen may be helpful in the pharmacologic management of cardiac arrest as a means of increasing survival and decreasing neurologic impairment.

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Ibuprofen prevents thrombin-induced lung vascular injury: mechanism of effect.

Perlman MB, Johnson A, Malik AB.

We compared pulmonary vascular responses with thrombin-induced pulmonary microembolism in awake sheep pretreated with ibuprofen or meclofenamate. Control sheep with lung lymph fistulas (n = 6) were challenged with 80 U/kg of alpha-thrombin, the native enzyme. Two groups of similarly prepared sheep received the cyclooxygenase inhibitors, ibuprofen (n = 4) or meclofenamate (n = 4), before the thrombin challenge. Thrombin-induced pulmonary microembolism in control sheep increased pulmonary lymph flow and lymph protein clearance (lymph flow X lymph-to-plasma protein concentration ratio). These lymph changes were associated with sustained increases in mean pulmonary arterial pressure (Ppa) and pulmonary vascular resistance (PVR) and a decrease in circulating neutrophil count. The steady-state pulmonary hemodynamic and lymph responses to thrombin persisted after cyclooxygenase inhibition with meclofenamate, although the increases in pulmonary lymph flow and lymph protein clearance were delayed. In contrast, ibuprofen reduced pulmonary lymph flow, lymph protein clearance, Ppa, and PVR responses. Neutrophil count in control and meclofenamate groups remained below base line after thrombin, whereas neutrophil count returned to base line in the ibuprofen group within 90 min after thrombin. Ibuprofen resulted in a greater decrease in vitro neutrophil adherence to pulmonary endothelium induced by serum generated by clotting whole blood with alpha-thrombin as compared with meclofenamate. Results indicate that ibuprofen attenuates the increases in Ppa and PVR and markedly attenuates the increase in pulmonary transvascular protein clearance after thrombin. The protective effect of ibuprofen may be due to reduction of neutrophil sequestration in lung.

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Inhibition of human polymorphonuclear leukocyte functions by ibuprofen.

Nielsen VG, Webster RO.

We have found that pretreatment of human neutrophils with ibuprofen (0.10-1.0 mg/ml) results in an irreversible, concentration-dependent inhibition of superoxide anion generation and release of lysosomal enzymes (myeloperoxidase, lysozyme) stimulated by the synthetic peptide, N-formyl-methionyl-leucyl-phenylalanine (FMLP), the complement fragment C5a, and to a lesser extent by serum opsonized zymosan. Inhibition of granule exocytosis and oxygen radical generation at ibuprofen concentrations less than 5 mg/ml was not due to drug cytotoxicity since release of the cytoplasmic enzyme lactate dehydrogenase was not affected by ibuprofen. In contrast to neutrophil responses mediated by C5a or FMLP, ibuprofen did not inhibit either enzyme release or superoxide anion generation by neutrophils stimulated with phorbol myristate acetate. Ibuprofen did not function as an oxygen radical scavenger in a cell-free system in which superoxide anion was generated by the aerobic action of xanthine oxidase on hypoxanthine. Ibuprofen also inhibited in a concentration-dependent fashion both directed migration (chemotaxis) and stimulated random migration (chemokinesis) of neutrophils exposed to either FMLP or C5a. Inhibition of neutrophil adherence to plastic surfaces and bovine pulmonary artery endothelial cells was equally effective when the neutrophils were treated with ibuprofen before stimulation with FMLP or phorbol myristate acetate. The inhibitory effects of ibuprofen pretreatment of neutrophils could not be overcome by addition of prostaglandins E1 or E2 (0.3-300 nM). These results demonstrate that ibuprofen is capable of suppressing many functions thought to be important in neutrophil-mediated acute pulmonary inflammatory processes. Results of these experiments further suggest that ibuprofen may inhibit neutrophil functions by acting on cellular components separate from membrane receptors or by blockade of cyclo-oxygenase products which may be involved in these neutrophil functions.

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Low dose ibuprofen reverses the hemodynamic alterations of canine endotoxin shock.

Balk RA, Jacobs RF, Tryka AF, Walls RC, Bone RC.

Department of Medicine, University of Arkansas for Medical Sciences, Little Rock.

The dose response of the nonsteroidal anti-inflammatory drug, ibuprofen, was evaluated in order to determine the most efficacious dose in the treatment of canine endotoxin shock. Fifteen minutes after an infusion of Escherichia coli endotoxin, four groups of dogs were given a single iv dose of 1, 5, 10, or 20 mg/kg of ibuprofen. These groups were compared to endotoxin only and saline control groups. All ibuprofen doses significantly improved the systolic, diastolic, and mean systemic arterial BP. The improvement in systemic BP was accompanied by an increase in the systemic vascular resistance. Pulmonary vascular pressures and resistance also increased after ibuprofen administration. The lack of a dose response and the demonstrated beneficial effect of low dose ibuprofen in the reversal of the hypotension associated with experimental canine endotoxin shock lead us to recommend the use of low dose ibuprofen for future endotoxin and sepsis studies. Use of low dose ibuprofen might have less of an effect on renal perfusion and would therefore be more likely to produce the beneficial hemodynamic response without compromising renal function.

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Study of usage pattern of nonsteroidal anti-inflammatory drugs (NSAIDs) among different practice categories in Indian clinical setting.

Paul AD, Chauhan CK.

Department of Pharmacology and Clinical Pharmacology Unit, L.T.M. Medical College and L.T.M.G. Hospital, Sion, Mumbai, 400 022, India.

OBJECTIVE: The aim of the study was to evaluate the usage pattern of nonsteroidal anti-inflammatory drugs (NSAIDs) in diverse clinical practice settings in India. METHODS: The study was conducted in Mumbai city and its suburbs, involving 1,916 doctors from among general practice to specialist practice. The data were collected with the help of a semi-structured questionnaire and were analysed statistically to bring out differences in NSAID usage among different groups of prescribers. RESULTS: All the 1,916 doctors prescribed NSAIDs frequently with prescriptions ranging from 1 to 15 daily; they short-listed and prescribed only two to five NSAIDs from among a plethora of drugs available including fixed-dose combinations (FDCs). It is significant that FDCs were prescribed by more than 39% of doctors in all the categories, the highest prescribers being orthopaedic surgeons (76%) and lowest general practitioners (GPs; 39%). Apart from recommended usage, NSAIDs such as ibuprofen, diclofenac and aspirin were used for pelvic inflammatory disease, and indomethacin for pre-term labour and patent ductus arteriosus. Dosage variation, both in terms of dose and frequency of administration, has been observed for several NSAIDs in the GPs category as well as in the specialist categories-except that of paediatricians. In patients suffering from bronchial asthma, there has been significant use of aspirin and ibuprofen by GPs despite contra-indication for their use in such patients. Most prescribers perceived that NSAIDs are associated with mild gastrointestinal (GI) adverse events. Ibuprofen, a drug with reportedly better gastric tolerance, was perceived to cause GI adverse events, though to a lesser extent than aspirin; fewer prescribers perceived that diclofenac and piroxicam cause GI adverse events when compared with aspirin and ibuprofen. There were significant differences among the five practice categories with regard to preferences for NSAIDs. The first choice NSAIDs were ibuprofen, aspirin, diclofenac, paracetamol, piroxicam and ibuprofen+paracetamol FDC. CONCLUSIONS: This study has shown that there exist significant differences in the usage pattern and preferences of NSAIDs among different practice categories in India. The data have also revealed that there is a need for awareness programmes on rational prescribing of NSAIDs towards optimal therapeutics and improved patient care in India.

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The effect of the cytochrome P450 CYP2C8 polymorphism on the disposition of (R)-ibuprofen enantiomer in healthy subjects.

Martinez C, Garcia-Martin E, Blanco G, Gamito FJ, Ladero JM, Agundez JA.

Department of Pharmacology, Medical School, University of Extremadura, Avda. De Elvas s/n, E-06071 Badajoz, Spain.

AIMS: To study the effect of CYP2C8*3, the most common CYP2C8 variant allele on the dis-position of (R)-ibuprofen and the association of CYP2C8*3 with variant CYP2C9 alleles. METHODS: Three hundred and fifty-five randomly selected Spanish Caucasians were screened for the common CYP2C8 and CYP2C9 mutations. The pharmacokinetics of (R)-ibuprofen were studied in 25 individuals grouped into different CYP2C8 genotypes. RESULTS: The allele frequency of CYP2C8*3 (0.17) was found to be higher than that reported for other Caucasian populations (P = 0.0001). The frequencies of CYP2C9*2 and CYP2C9*3 were 0.19 (0.16-0.21) and 0.10 (0.08-0.12), respectively. An association between CYP2C8*3 and CYP2C9*2 alleles was observed, occurring together at a frequency 2.4-fold higher than expected for a random association of alleles (P = 0.0001). The presence of the CYP2C8*3 allele was found to influence the pharmacokinetics of (R)-ibuprofen in a gene-dose effect manner. Thus, after administration of 400 mg ibuprofen, the plasma half-life (95% confidence intervals) for individuals with genotypes CYP2C8*1/*1, CYP2C8*1/*3 and CYP2C8*3/*3, was 2.0 h (1.8-2.2), 4.2 h (1.9-6.5; P < 0.05) and 9.0 h (7.8-10.2; P < 0.002), respectively. A statistically significant trend with respect to the number of variant CYP2C8*3 alleles was also observed for the area under the concentration-time curve (P < 0.025), and drug clearance (P < 0.03). CONCLUSION: Polymorphism of the CYP2C8 gene was found to be common, with nearly 30% of the population studied carrying the variant CYP2C8*3 allele. The presence of the latter caused a significant effect on the disposition of (R)-ibuprofen. This suggests that a substantial proportion of Caucasian subjects may show alterations in the disposition of drugs that are CYP2C8 substrates.

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Beneficial effects of ibuprofen in oleic acid induced lung injury.

Fuhrman TM, Hollon MF, Reines HD, Olanoff LS, Halushka PV.

Metabolites of arachidonic acid, particularly thromboxanes, have been implicated as mediators of lung injury. The formation of thromboxane A2 can be decreased by glucocorticoid steroids by inhibiting the enzyme phospholipase A2 or by ibuprofen which inhibits fatty acid cyclooxygenase. This study was performed to determine if ibuprofen, methylprednisolone, or a combination of both could improve the pulmonary injury induced by oleic acid. Five groups of dogs were instrumented with pulmonary artery and extravascular lung water (EVLW) catheters and ventilated with 100% O2. Serial determinations of hemodynamic and pulmonary parameters were performed before and after oleic acid infusion. Plasma immunoreactive thromboxane B2 (iTxB2) and ibuprofen levels were also determined. Oleic acid rapidly induced a significant pulmonary injury as evidenced by hypoxemia and increases in extravascular lung water. Plasma iTxB2 rose significantly in the control group receiving only oleic acid. Pulmonary function and hemodynamic parameters were not changed by ibuprofen infusion alone. Ibuprofen attenuated the oleic acid induced hypoxemia and increased EVLW but did not significantly reduce plasma iTxB2. Methylprednisolone did not prevent the increase in plasma iTxB2 and was less effective than ibuprofen in preventing hypoxemia and increases in EVLW. The combination of ibuprofen and methylprednisolone did significantly inhibit the production of iTxB2, however in combination they protected less against the hypoxemia and increased EVLW than either agent alone. These results indicate that ibuprofen may have a protective effect in oleic acid induced lung injury that is not mediated through the inhibition of fatty acid cyclooxygenase. The results are also further evidence that thromboxane is probably not a pathogenetic factor in oleic acid induced lung injury.

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The actions of halothane, ibuprofen and BW755C on hypoxic pulmonary vasoconstriction.

Marshall C, Kim SD, Marshall BE.

The effect of halothane on the pressor responses to hypoxia (3% O2, 5% CO2, balance N2) and to Angiotensin II (Ang II) (0.2 microgram) has been compared in an in vitro perfused and ventilated rat lung preparation in the presence and absence of agents known to block the lipoxygenase (BW755C) and/or the cyclooxygenase (ibuprofen) pathways for arachidonic acid metabolism. Preliminary studies established the stability of the preparation (experiment 1) during two hours of observation and allowed estimation of (experiment 2) the concentration of BW755C that inhibited the HPV response by 50% (ED50 = 125 microM). In experiment 3, the rat lungs were subdivided into four groups: A, B, C, and D. Group A received the drug solvent, and B received 17 microM ibuprofen. Groups C and D received ibuprofen and, in addition, an ED50 dose of BW755C. The lungs were then tested for their response to hypoxia. In addition, groups C and D were tested for their response to 0.2 microgram Ang II. 0.5 MAC halothane was introduced into the ventilatory circuit of A, B, and D. Group C received no halothane. Responses to hypoxia and Ang II (groups C and D) were measured. Halothane was terminated and a further hypoxic response was tested in groups A and B. The results show, in group A, that the addition of halothane reduced the response to hypoxia from (mean +/- SE cm H2O) 13.4 +/- 1.56 to 6.5 +/- 1.28, a 50% reduction. The addition of ibuprofen in group B caused a 33% increase in the response, and the addition of halothane now caused only a 30% decrease.(ABSTRACT TRUNCATED AT 250 WORDS)

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