Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Introduction
NSAIDs are non-narcotic analgesics (An analgesic reduces or removes the sensation of pain), they are also anti-pyretic (fever) and anti-inflammatory. These effects are produced by the inhibition of the fatty acid cyclooxygenase (COX) which inhibits prostaglandin synthesis.
Because NSAIDs are non-narcotic they do not cause any largely noticeable effects on CNS (central nervous system) function. This makes them ineffective against normal nociceptive tests. These are tests designed to test pain responses in living organisms and they are specifically used in the testing of new analgesic drugs. Methods usually involve the applying of pressure to a specific point of the organism. NSAIDs only raise the pain threshold when pressure is applied to a swollen and inflamed joint (this is known as analgesia via peripheral mechanisms). Therefore NSAIDs are considered anti-inflammatory agents with a mild central analgesic effect (associated with anti-pyretic action). NSAIDs are therefore primarily used in the treatment of acute or chronic conditions producing mild-moderate pain, especially involving the musculo-skeletal system. Principal utilisation occurs in the horse and dog.
Another benefit of NSAIDs’ non-narcotic function is that, by having an unnoticeable effect on the CNS they can therefore be used as a pre-med drug, i.e. before general anaesthetic, without fear of overloading the CNS. The use of an analgesic before the introduction of pain means that a lower dose will be required later when pain is introduced (e.g. surgery) – thus reducing the chances of side effects associated with high doses. However, the type of NSAID must be selected for carefully as there may be a possibility of renal damage/toxicity. There are only a couple of NSAIDs which are believed to be renal safe.
Prostaglandins and Inflammation
NSAIDs work by inhibiting prostaglandin synthesis by targeting the COX enzyme. Prostaglandins activate the inflammatory response giving the production of pain and fever, they are produced when leukocytes reach a site of damaged tissue in an attempt to minimise tissue destruction.
Prostaglandins are involved in several other organs such as the gastrointestinal tract (inhibit acid synthesis and increase secretion of protective mucus), increase blood flow in kidneys, and leukotrienes which promote constriction of bronchi associated with asthma.
Question:
What is/are the precursor(s) of prostaglandins?
The answer may be found in the ‘Mechanisms of NSAID Action’ section.
Cyclooxygenase Enzymes (COX)
COX forms two isoforms, COX-1 and COX-2:
- COX-1 is often thought of as being the ‘good’ COX; this is due to its involvement in tissue homeostasis. It is required to keep the body ‘normal’ – primarily the synthesis of prostaglandins responsible for protection of the stomach lining. (Constitutive physiological).
- COX-2 therefore is thought of as the ‘bad’ COX; this is because it is produced during inflammation, by the inflammatory cells which have been activated by cytokines. (Inducible physiological).
- There is some evidence for a COX-3, a possible variation of COX-1 which is also associated with the inflammatory response. It has been found in the CNS and is affected by paracetamol.
Mechanism of NSAID Action
The primary action of NSAIDs is the inhibition of the COX enzyme, by inhibiting this enzyme the production of prostaglandins are also inhibited. The COX enzyme synthesised prostaglandins from fatty acids such as arachidonic acid.
Most NSAIDs inhibit both major forms of the COX enzyme, however all are still considered toxic. Newer drugs which are believed to be COX-2 specific (thereby not affecting the COX-1 enzyme and allowing prostaglandins associated with normal function to continue normal operation) are relatively safer in chronic use. There are fewer side effects which is what makes them be suited to prolonged periods of use. Examples: Merck’s rofecoxib and etoricoxib, Pfizer’s celecoxib and valdecoxib.
The NSAIDs selective for COX-2 are now however under scrutiny, due to reports of cardiovascular toxicity. These include strokes and myocardial infarctions. This has resulted in the withdrawal of certain COX-2 selective drugs such as rofecoxib. Further studies are suggesting that the cardiovascular toxicity of these COX-2 selective NSAIDs may actually not be much greater than ‘trusted’ NSAIDs such as ibuprofen. However, their toxicity still remains a point of research and discussion.
Other Actions of NSAIDs
Besides from the inhibition of the COX enzyme, other actions include:
- Inhibit superoxides (toxic) and free radicals
- Inhibit Bradykinin production (A Peptide which dilates blood vessels, lowering blood pressure)
- Stabilises lysosomes
- Inhibits metalloproteinases (Proteolytic enzymes whose catalytic mechanism involves a metal)
- Antagonises interleukin-1 (fever inducer and controlling factor of lymphocytes) and tumour necrosis factor (TNF – cytokine involved in the induction of inflammation and apoptosis, dysfunction of this factor is believed to be involved with the production of cancers.)
IC50
This is the half maximal inhibitory concentration (IC50). It is a measure of the effectiveness of a compound (typically a drug candidate) in inhibiting biological or biochemical function. This quantitative measure indicates how much of a particular drug is needed to inhibit a given biological process (or component of a process, i.e. an enzyme, cell, cell receptor or microorganism) by half. It is commonly used as a measure of antagonist drug potency in pharmacological research.
This can be related to inhibition of COX enzymes, we can use it to find out how many times a dose required to inhibit COX-1 we need to administer in order to inhibit COX-2, i.e. COX-2/COX-1, a lower ratio is better as it shows that the drug has a higher selectivity for COX-2 the ‘bad’ COX associated with inflammatory responses.
COX-1 Selective Drugs Amount times dose required to inhibit COX-2
- Aspirin 170
- Piroxicam 250
Less Selective COX-1 Drugs
- Paracetamol 7
- Ibuprofen 15
Equipotent
- Naproxen 1
COX-2 Selective Drugs
- Meloxicam <1
The Anti-Pyretic Effect of NSAIDs
NSAIDs do not affect normal body temperature only when pyrexia (fever) is present, do they alter temperature. Bacterial or endogenous (substances from within the body) pyrogens can act directly on the hypothalamus. Heat temperature is regulated in the hypothalamus by controlling temperature regulating peripheral mechanisms such as vasoconstriction/dilation, sweating, shivering and metabolic activity.
Pyrogens activate hypothalamic COX, increasing prostaglandin concentration. The effect of this is that the set body temperature (Average 37oC) is increased (Pyrexia is considered >38oC). NSAIDs counter this by inhibiting prostaglandin synthesis by the inhibition of COX enzymes. By doing this they have effectively blocked the action of the pyrogens on the CNS and return the raised set body temperature back down to normal levels (37oC).
Commonly Used NSAIDs
Some of the most commonly found NSAIDs and their properties:
Aspirin (Acetylsalicylic acid)
Aspirin is a potent anti-inflammatory drug with mild central analgesic and antipyretic actions. It is administered orally and readily absorbed from the stomach and small intestine, an acid drug is well absorbed in an acidic environment. It is metabolised by tissue /plasma esterases. Aspirin may also be used in low doses, daily to prevent platelet aggregation.
In a healthy body, thromboxane and prostacyclin (eicosanoids – fatty acid signalling molecules) are balanced. Aspirin however disrupts this balance in the favour of prostacyclin, inhibiting aggregation.
Aspirin irreversibly binds to platelet COX, however as platelets are produced every few days, the condition is not permanent, and this is why chronic dosing may be necessary.
Aspirin is toxic in cats due to their lack of the enzyme UDP-glucuronyl transferase, therefore when giving aspirin to cats the maximum stated dose is 25mg/kg daily (Compared to 25mg/kg 3-4 times a day in dogs) Toxicity effects may still appear even at lower doses e.g. vomiting, abdominal pain, anorexia and gastric ulceration.
Paracetamol
Paracetamol is a weak anti-inflammatory drug; however it does have a more potent central analgesia and anti-pyretic effects than aspirin (See IC50 table to see a smaller dose is required of paracetamol to inhibit COX-2, the COX enzyme responsible for inflammatory responses).
Due to paracetamol being well tolerated, producing less gastric irritation than aspirin and having much fewer side effects than aspirin, it has become a predominant household analgesic. Acute overdoses can cause fatal hepatic damage; early symptoms include anorexia, vomiting, diarrhoea and abdominal pain. It is the reactive metabolites of paracetamol latching onto -SH groups that cause hepatic toxicity.
The dog is more resistant to paracetamol toxicity than cats, an oral dose is recommended every 6 hours of 25-30mg/kg.
Phenylbutazone
Phenylbutazone is the most widely used NSAID in equine medicine; however it is extremely toxic in humans. It has a long t1/2 (half-life) of 70 hours and produces severe gastric ulceration and agranulocytosis. It can be administered orally and by intravenous injection. Due to the acidity of the drug, it is readily absorbed from the stomach/duodenum. Phenylbutazone metabolites are weak acids and therefore preferably excreted in alkaline urine. Training horses may have acidic urine, and so it is recommended not to take Phenylbutazone within 8 days of competition.
Half-life in dogs of Phenylbutazone has been recorded at 3-8 hours (however this may vary dependent on the dose). Phenylbutazone can inhibit the synthesis of prostaglandin in inflammatory exudates for 12-24 hours, with the response lasting for up to three days after the final dose in the course.
Signs of Phenylbutazone toxicity include inappetance and depression with weight loss and oedema. The oedema (fluid retention) is due to the decreased NaCl excretion.
Dosing of Phenylbutazone should not exceed:
- Day 1 – 4.4 mg/kg twice a day
- Day 2-4 – 2.2 mg/kg twice a day
- Day >5 – 2.2 mg/kg daily
Phenylbutazone is also administered in combination with other drugs for the treatment of musculoskeletal disorders e.g. Tomanol – Phenylbutazone and Isopyrin
Meclofenamic Acid (Arquel)
Meclofenamic acid is a potent anti-inflammatory, anti-pyretic analgesic. It is more potent than aspirin but similar in effect. As well as inhibiting COX enzymes it has found to be a prostaglandin antagonist, interacting with prostaglandin receptors. It therefore prevents the action of prostaglandin already present possibly exerting a more rapid reduction of inflammation.
Half-life is 6-8 hours; therapeutic levels are maintained with daily doses.
Unlike other NSAIDs onset of Meclofenamic acid is relatively slow, taking 36-96 hours for effects to begin
Prolonged administration in the horse may lead to anorexia, depression, ulceration of buccal mucosa, gastric haemorrhage or diarrhoea
Naproxen
Naproxen is a propionic acid derivative (like ibuprofen or Ketoprofen) with a tendency for reduced frequency of serious side effects at therapeutic doses. In the horse, half-life of the drug is 5 hours; double daily doses have been proven effective in soft-tissue inflammatory conditions such as myositis. In the dog however, half-life is much longer at around 70 hours, it is therefore recommended to avoid this NSAIDs due to excessive toxicity
Ketoprofen
Ketoprofen is a potent COX inhibitor which is also able to stabilise lysosomal membranes and is a Bradykinin antagonist. It is also reported to be an inhibitor of the lipoxygenase enzyme system (iron-containing enzymes which catalyse the dioxygenation [incorporation of two oxygen atoms] of some polyunsaturated fatty acids). It is around 50x more potent than Phenylbutazone, however this is not accompanied by an equivalent increase in toxicity. It is also suggested that it may be cartilage sparing, neither accelerating chondrocyte damage nor reducing proteoglycan production.
Carprofen
Carprofen is a potent anti-inflammatory drug, but is a weak inhibitor of COX. Its mode of action is not yet known but it significantly inhibits neutrophil migration. Due to weak inhibition of COX, toxicity of Carprofen its toxicity tends to be low.
Piroxicam
Piroxicam is a potent and long lasting anti-inflammatory drug. Its half-life of around 60 hours enables lower dosing (alternate days). A higher frequency of dosing will produce standard NSAID toxic effects (see below, section ‘Side Effects of NSAIDs’)
Meloxicam
Meloxicam is a similar drug, but with a shorter half-life (30-40 hours). It is thought to have greater potency for COX-2 than COX-1 therefore side-effects may be less. It is also thought to be chondroprotective (The slowing of degradation of articular cartilage)
Flunixin
Flunixin is a potent versatile anti-inflammatory drug with a short half-life in all species (2-8 hours). However its duration of action is relatively long (24-36 hours)
When to Use NSAIDs
- Mild to moderate inflammatory lesions and associated pain
- Acute inflammation and pain
- Joint inflammation and pain
- Suppression of pulmonary oedema
- Endotoxaemia
- Anti-thrombic
Side Effects of NSAIDs
- Gastric irritation and ulceration – This is a main side effect of chronic NSAID use, it occurs because when NSAIDs inhibit the COX-1 enzyme, COX-1 synthesises prostaglandins associated with inhibiting acid synthesis and increasing secretion of protective mucus. SO by inhibiting COX-1, the stomach becomes unprotected from the gastric acid causing irritation and possibly ulceration in chronic use.
- You can protect the gut by administering proton pump inhibitors (Losec), prostaglandin analogues (Misoprostol) or H2 receptor antagonists (Zantac)
- Vomiting and diarrhoea
- Hepatotoxicity
- Renal papillary necrosis, chronic nephritis
- Bone marrow disturbance
- Skin rashes
- Respiratory distress
