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Background: The nephrotoxic effects of non-steroidal anti-inflammatory drugs (NSAIDs) are widely acknowledged. In particular, diclofenac is the most commonly prescribed NSAIDs, but no previous findings of electrolyte disturbances were reported following its administration., Case Report: We presented the case of a man who experienced significant weakness associated with severe deficiencies in potassium, calcium, and magnesium after misusing diclofenac because of severe back pain., Conclusions: This case emphasizes the need of awareness about the electrolyte imbalances and electrolyte disturbances associated with the misuse of diclofenac, which is a widely available drug. This is a case report which does not need a Clinical Trial Number., (© 2024. The Author(s).)

Background: It is crucial to identify patients at highest risk for opioid use disorder (OUD) and to address challenges in reducing opioid use. Reported nonsteroidal anti-inflammatory drug (NSAID) allergies may predispose to use of stronger pain medications and potentially to OUD., Objective: We sought to investigate the clinical impact of reported NSAID allergy on OUD in patients with chronic back pain., Methods: We conducted a retrospective study of adults receiving care at a tertiary health care system from January 1, 2013, to December 31, 2018. Back pain and OUD were identified using administrative data algorithms. We used propensity score matching and logistic regression to estimate the impact of self-reported NSAID adverse drug reactions (ADRs) on risk of OUD, adjusting for other relevant clinical information., Results: Of 47,114 patients with chronic back pain, 3,620 (7.7%) had a reported NSAID ADR. In an adjusted propensity score-matched analysis, patients with NSAID ADRs had higher odds (odds ratio, 1.34; 95% CI, 1.07-1.67) of developing OUD as compared with those without NSAID ADRs. Additional risk factors for OUD included younger age, male sex, Medicaid insurance, Medicare insurance, higher number of inpatient and outpatient visits in the previous year, and comorbid anxiety and depression. Patients with listed NSAID ADRs also had higher odds of a documented opioid prescription during the study period (odds ratio, 1.22; 95% CI, 1.11-1.34)., Conclusions: Adults with chronic back pain and reported NSAID ADRs are at a higher risk of developing OUD and receiving opioid analgesics, even after accounting for comorbidities and health care utilization. Allergy evaluation is critical for potential delabeling of patients with reported NSAID allergies and chronic pain., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Multifocal bone Langerhans cell histiocytosis (LCH) is usually treated with prednisolone and vinblastine. We present a case conservatively treated with indomethacin with good clinical and radiological response. A 7-year-old achondroplastic boy presented with worsening thoracic back pain and leg weakness. An admission MRI spine showed a pathological T1 vertebrae fracture with posterior soft tissue extension compressing and distorting the spinal cord. A CT guided biopsy revealed an LCH. Steroids were avoided to reduce osteopenia risk and further vertebral fragility. Considering the risk of a thoracic surgical approach in a child with this background, he was managed conservatively with indomethacin and a Sternal Occipital Mandibular Immobilizer (SOMI) Brace. Pain resolved completely within 6 months and the brace was discontinued. Serial follow-up scans showed progressive resolution of the pathological T1 fracture and complete resolution of the spinal cord compression., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

History: A 23 years old, previously healthy woman was admitted to our clinic with neutropenic fever to rule out acute leukemia. Upon admission the patient reported that a few days ago the carcass of a pig had fallen on her from above, so that she experienced strong back pain., Findings and Diagnosis: The blood count showed thrombocytopenia and marked neutropenia of 0.04G/L. Moreover, laboratory work up demonstrated increased C-reactive protein, procalcitonin as well as serum creatinine levels., Therapy and Course: Broad antiinfective therapy was initiated immediately. During the further course of disease the patient developed signs of acute cholecystitis, which was managed conservatively. Only after repeated specific investigation and after initially denying, the patient reported to have taken 1 g of metamizole as self-medication after her initial accident. All symptoms and laboratory parameters gradually improved and finally completely resolved to normal, and the patient could be released from hospital after seven days., Conclusions: In retrospect all signs and symptoms reported here can be interpreted as an infectious complication during an episode of agranulocytosis caused by a single dose of metamizole, underscoring the importance of carefully judging indication when using this otherwise highly useful substance., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Drug induced acute respiratory distress syndrome (ARDS) is a common clinical condition. Patients typically present with noncardiogenic pulmonary edema. Large number of ARDS cases reported induced by antineoplastic drugs and other drug intoxications. The pathophysiologic mechanisms of drug induced ARDS remains unknown. One of the postulated mechanisms of drug induced ARDS is anaphylaxis. We present a case of acute respiratory distress syndrome complicated by anaphylactic shock after use of two different nonsteroidal antiinflammatory drugs (NSAID). To the best of our knowledge, ARDS following normal doses of NSAID ingestion has not been reported previously. The case showed that ARDS may occur after ingestion of therapeutic doses of NSAID. NSAID ingestion should be considered in the differential diagnosis of patients with non-cardiogenic pulmonary edema., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Background: While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain., Methods: We searched MEDLINE, EMBASE, CINAHL, CENTRAL and LILACS for randomised controlled trials comparing the efficacy and safety of NSAIDs with placebo for spinal pain. Reviewers extracted data, assessed risk of bias and evaluated the quality of evidence using the Grade of Recommendations Assessment, Development and Evaluation approach. A between-group difference of 10 points (on a 0-100 scale) was used for pain and disability as the smallest worthwhile effect, as well as to calculate numbers needed to treat. Random-effects models were used to calculate mean differences or risk ratios with 95% CIs., Results: We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days., Conclusions: NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

The aim of this study was to compare the efficacy of elcatonin injections and oral nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with osteoporosis who have acute lumbar pain after experiencing new vertebral compression fractures. Two hundred twenty-eight Japanese female patients (mean age 77.3 years) with acute lumbar pain from osteoporotic vertebral fractures were randomly divided into two groups. Patients in one group were given an NSAID (NSAIDs group) and patients in the other group were given weekly intramuscular injections of 20 units of elcatonin (elcatonin group). All patients underwent follow-up examinations up to 6 weeks from the start of the trial. Outcome measures were the level of functional impairment according to the Japan Questionnaire for Osteoporotic Pain (JQ22), the Roland-Morris Disability Questionnaire (RDQ), and a visual analog scale (VAS) of pain intensity. Statistical analyses focused on (1) the time course of pain and functional level using linear mixed effects models to analyze the longitudinal data and (2) the effectiveness of elcatonin injection with mean difference values and 95 % confidence intervals. Significant differences were seen over time between the initial values and the postintervention values (4 and 6 weeks) in JQ22, RDQ, and VAS scores (effect size d > 0.4) in each group. The mean differences between the elcatonin group and the NSAIDs group in each measure at 4 and 6 weeks were -4.8 and -8.3 for the JQ22, -1.3 and -2.6 for the RDQ, and -11.3 and -11.5 for the VAS, shifted to elcatonin. Once weekly elcatonin injection was more effective than NSAIDs for treating acute lumbar pain and improving mobility in Japanese women with osteoporotic vertebral fractures.

Non-steroidal anti-inflammatory drugs (NSAIDs) are part of the treatment of patients with chronic nonspecific back pain (CBP). An analysis of the reasons for the absence of NSAIDs administration or cancellation of previously iniciated NSAIDs in patients with CBP was the goal of this study., Material and Methods: We analyzed the peculiarities of treatment of CBP in 250 patients at baseline and after 1 and 2 years. The features of drug therapy, the reasons for therapy cancellation were evaluated., Results and Conclusion: 52 (20.8%) of patients with CBP were not treated with NSAIDs, 38 (15.2%) recieved NSAIDs in 4 and > days per week, 44 (17.6%) - 3 and < days a week, 62 (24.8%) took NSAID in 7-14 day 2-5 times per year, 54 (21.6%) - in on-demand mode. Absence of NSAIDs administration in CBP was associated with older age, the presence of comorbidites, with non-alcoholic fatty liver disease and obesity. The cancelletion of previously initiated NSAID was equally associated with the resolution of pain and with the failure to respond to therapy, with the presence of obesity and with the intake of nonselective NSAIDs. Continuation of the initiated effective anti-inflammatory therapy was associated with the use of coxibs, complex treatment with the use of neirobion, with the presence of normal body weight, and with the achievement of a decrease in the severity of the pain syndrome even in the absence of its complete resolution. Increased adherence to treatment with NSAIDs in CBP patients can be achieved by increasing of its effectiveness through the use of NSAIDs (especially coxibs) with B group vitamins (B 1 , B 6 , B 12 ), by normalizing of BMI and effectively controlling liver function.

Objectives: The objectives of the study were to assess the 2 year BMD changes and their determinants in patients with early inflammatory back pain suggestive of axial spondyloarthritis (SpA) (DESIR cohort)., Methods: A total of 265 patients (54% male, mean age 34.4 years) had BMD measurements at baseline and at 2 years. Low BMD was defined as a Z score ≤-2 (at at least one site) and significant bone loss was defined by a decrease in BMD ≥0.03 g/cm(2). Clinical, biological and imaging parameters were assessed over 2 years., Results: Thirty-nine patients (14.7%) had low BMD at baseline; 112 patients (42.3%) had a 2 year significant bone loss. One hundred and eighty-seven (70.6%) used NSAIDs at baseline and 89 (33.6%) received anti-TNF therapy over 2 years. In anti-TNF users, BMD significantly increased at the lumbar spine and did not change at the hip site from baseline. In multivariate analysis, baseline use of NSAIDs [odds ratio (OR) 0.38, P = 0.006] had a protective effect on hip bone loss. In patients without anti-TNF treatments, baseline use of NSAIDs (OR 0.09, P = 0.006) and a 2 year increase in BMI (OR 0.55, P = 0.003) had protective effects on hip bone loss, whereas a 2 year increase in fat mass was associated with hip bone loss (OR 1.18, P = 0.046)., Conclusion: Among patients with symptoms suggestive of early axial SpA, 42.3% of patients have significant bone loss over 2 years. Anti-TNF therapy is protective against bone loss and baseline use of NSAIDs has a protective effect on hip bone loss., (© The Author 2015. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The article deals with various aspects of pain in degenerative diseases of the spine and with the actual problems of non-specific back pain. The data on the mechanisms of pain and analgesic treatment algorithms of the patients with radicular syndrome, and pharmacological and non-pharmacological therapies is provided. The effect of structural-modifying drugs in relief of nonspecific back pain was investigated and compared with a traditional nonsteroidal anti-inflammatory drug (NSAID) therapy in combination with B vitamins, without chondroprotectors. The study population was composed of 85 patients (42 men and 43 women) aged 38 to 68 years (mean age - (46,3±2,6) years) with chronic vertebral pain syndromes (VPS). For objectification assessment of pain, severity of pain, and evaluate the effectiveness of therapy we used the visual analog scale (VAS).The majority (88%) of the patients included in the study, complained of a moderately severe pain (from 40 to 70 mm on the VAS). Patients were divided into two groups. The first (primary) group consisted of 55 patients (30 men and 25 women). The following treatment was applied: all patients of the first group, in addition to the NSAID administered with hondroprotektror arbitrarily - Struktum 1000 mg twice a day or 300 mg Piaskledin once a day for 40-60 days.The second (control) group consisted of 30 patients (14 men, 16 women). Patients in the control group administered with a traditional NSAID therapy in combination with B vitamins, without chondroprotectors. The results of the study on the influence of drugs Piaskledin 300, Struktum for the relief of nonspecific back pain revealed that in the treatment of vertebral pain, a combination of non-steroidal anti-inflammatory drugs with structure-modifying agents could achieve rapid rehabilitation of patients with locomotor activity and improve quality of life in general.

Background: Although often considered to be lacking adequate evidence, nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in the management of neuropathic pain. Previous surveys found 18% to 47% of affected people reported using NSAIDs specifically for their neuropathic pain, although possibly not in the United Kingdom (UK)., Objectives: To assess the analgesic efficacy of oral NSAIDs for chronic neuropathic pain in adults, when compared to placebo or another active intervention, and the adverse events associated with its use in clinical trials., Search Methods: We searched CENTRAL, MEDLINE, and EMBASE from inception to 29 May 2015, together with reference lists of retrieved papers and reviews, and an online trials registry., Selection Criteria: We included randomised, double-blind studies of two weeks duration or longer, comparing any oral NSAID with placebo or another active treatment in chronic neuropathic pain., Data Collection and Analysis: Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality. We did not carry out any pooled analysis., Main Results: We included two studies involving 251 participants with chronic low back pain with a neuropathic component or postherpetic neuralgia; 209 of these participants were involved in a study of an experimental NSAID not used in clinical practice, and of the remaining 42, only 16 had neuropathic pain. This represented only third tier evidence, and was of very low quality. There was no indication of any significant pain reduction with NSAIDs. Adverse event rates were low, with insufficient events for any analysis., Authors' Conclusions: There is no evidence to support or refute the use of oral NSAIDs to treat neuropathic pain conditions.

The results of studying the pathogenetic features of back pain at vertebrogenic of Spine, and disorders of life of patients in relation to it. Application of therapy with the standard treatment and the complex medicine of the vitamins B.

Nicolau syndrome is a rare complication of intramuscular injection that leads to local ischemic necrosis of the skin and adipose tissue. In this paper, we discuss etiologies, risk factors, and treatment options for gluteal Nicolau syndrome referring to patients treated in our hospital. Our study includes 17 women who visited our clinic with symptoms of gluteal necrosis secondary to intramuscular injection. The following variables were taken into account: injection site, drug administered, frequency of injections, the person who administered the injections, needle size, and needle tip color. Magnetic resonance images obtained in the aftermath of intramuscular injection application were carefully analyzed for presence of necrosis, cyst formation and the thickness of the gluteal fat tissue layer. Drugs that had been received in intramuscular injection were exclusively non-steroidal anti-inflammatory drugs. Mean patient BMI was 41.8 (all patients were considered as obese), and mean gluteal fat thickness was 54 mm. Standard length of needles (3.8 cm) had been used in procedures. The wounds were treated with primary closure in 11 patients and with local flap therapy in 6 patients. The observed necrosis was a consequence of misplaced gluteal injection, where drugs were injected into the adipose tissue instead of the muscle due to the extreme thickness of the fat layer, on one hand, and the inappropriate length of standard needles, on the other hand. Intramuscular injection should be avoided in obese patients whenever possible: if it is necessary, proper injection technique should be used.

Aim: To evaluate the safety of etoricoxib in patients with acute nonspecific back pain associated with the high risk of cardiovascular events (CVE) in clinical practice., Subjects and Methods: The open prospective follow-up by a simple randomization method included 80 patients, including 49 women and 31 men (mean 60.8±4.7 years). The patients were randomized into 4 groups of 20 persons each: 1) etoricoxib 90 mg/day; 2) nimesulide 100 mg/day; 3) diclofenac 100 mg/day; 4) meloxicam 15 mg/day. The investigation lasted 90±4.5 days. The interim evaluation criteria (study points) were pain changes using a visual analog scale (VAS); blood pressure (BP) changes; diurnal BP rhythm; and changes in coagulation hemostatic parameters and blood biochemical markers. The primary evaluation criteria (study endpoints) were the incidence of CVE in the use of nonsteroidal anti-inflammatory drugs (NSAIDs)., Results: The patients with acute back pain were shown to have a high incidence of comorbidities during outpatient care. The administration of NSAIDs resulted in a significant reduction in the magnitude and intensity of pain syndrome according to VAS in all the groups just on day 3 of therapy with a more marked analgesia in patients receiving etoricoxib and diclofenac. All the groups exhibited an increase in average daily systolic and diastolic BP with the most favorable profile in Group 1 patients. The intake of etoricoxib and other NSAIDs provided no evidence for changes in hemostatic parameters and biochemical markers during 10 weeks. The safety of etoricoxib was comparable with that of NSAIDs in its effect on the plasma hemostatic system., Conclusion: Unlike nimesulide, diclofenac, and meloxicam, etoricoxib was characterized by a rapid steady-state analgesic effect with a less pronounced action on diurnal BP rhythm. Within 3 months after treatment, no acute CVE was recorded in the patients taking etoricoxib.

Transient reactive papulotranslucent acrokeratoderma (TRPA) is an unusual skin condition characterized by the rapid and transient development of symmetric, edematous white papules with eccrine duct prominence on the palms after exposure to water. We present the case of a 28-year-old woman diagnosed in our clinic with TRPA induced by the use of a non-steroidal anti-inflammatory drug. The possible pathophysiology and treatment options are discussed.

Background: Current restrictions in use of flupirtine-containing medicines for a maximum of 14 days endorsed by the European Medicines Agency were followed by uncertainty/ambiguity of its analgesic efficacy for the treatment of acute low/back pain., Methods: Post-hoc selection of patient-level data from non-interventional studies with flupirtine MR and diclofenac with respect to patient age (> or = 18 years), duration of treatment (14 +/- 2 days), indication (acute/subacute low/back pain) and first-line use. Primary endpoint: average 24-hr. pain intensity; secondary endpoints: pain-related disabilities in daily life, 30/50/70% response with respect to pain and pain-related restrictions, frequency of untoward side effects/treatment emergent adverse events., Results: 318/31 patients treated with flupirtine MR/diclofenac fulfilled the inclusion criteria for this subgroup analysis. Starting from comparable demographic and baseline characteristics both treatments were followed by significant effects (p < 0.001). Subgroup comparisons revealed superior effects for flupirtine MR vs. diclofenac for pain relief (p = 0.001), improvement of pain-related restrictions in daily life (p = 0.023), and gastrointestinal/overall tolerability (p < 0.001)., Conclusions: Even for short-term use in patients suffering from muscle-related acute low/back pain, flupirtine MR is superior effective and tolerated compared with the nsaid diclofenac.

Membranous nephropathy presents clinically as nephrotic syndrome, with subepithelial immune complex deposits seen on biopsy. Historically, in about three-quarters of membranous cases, no obvious etiologic agent or condition can be identified. More recently, serum antibodies to the phospholipase A2 receptor have been discovered in many patients with primary/idiopathic membranous nephropathy. About one-quarter of patients have membranous nephropathy as a manifestation of another systemic disorder, such as autoimmune conditions, infection, malignancy, toxin exposure, or drugs (classically gold or penicillamine). In this report, we present a case of recurrent nephrotic syndrome with biopsy-proven membranous nephropathy closely associated with use of the nonsteroidal anti-inflammatory drugs (NSAIDs) naproxen and piroxicam. Characterization of the immunoglobulin G (IgG) subclass profile of the deposits showed abundant IgG1, weak IgG4, and positive staining for phospholipase A2 receptor. This case serves to highlight membranous nephropathy as an under-recognized renal complication of NSAID use. Other kidney effects of NSAIDs, such as hemodynamic compromise, interstitial nephritis, and minimal change disease, are more broadly recognized., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Study Design: Multicenter, randomized, double-blind, placebo-controlled trial., Objective: To examine the safety and efficacy of three different doses of the tumor necrosis factor alpha (TNF-α) inhibitor etanercept versus placebo for the treatment of symptomatic lumbar disc herniation (LDH)., Summary of Background Data: TNF-α is considered to be a major cause of radicular leg pain associated with symptomatic LDH. Systemic administration of TNF-α inhibitors for sciatica has indicated a trend toward efficacy., Methods: Forty-nine subjects aged between 18 and 70 years, with persistent lumbosacral radicular pain secondary to LDH, and an average leg pain intensity of 5/10 or more were randomized to 1 of 4 groups: 0.5-mg, 2.5-mg, 12.5-mg etanercept, or placebo. Subjects received 2 transforaminal epidural injections, 2 weeks apart, and were assessed for efficacy up to 26 weeks after the second injection. The primary outcome measure was the change in mean daily worst leg pain (WLP). Secondary outcomes included average leg pain, worst back pain, average back pain, in-clinic pain, Oswestry Disability Index, patient global impression of change, and tolerability., Results: Forty-three of the 49 randomized patients completed the study. Patients receiving 0.5-mg etanercept showed a clinically and statistically significant (P< 0.1) reduction in mean daily WLP compared with the placebo cohort from 2 to 26 weeks for both the per protocol population (-5.13 vs. -1.95; P= 0.066) and the intention-to-treat population (-4.40 vs. -1.84; P= 0.058). Fifty percent of these subjects reported a 100% reduction in WLP 4 weeks post-treatment compared with 0% of subjects in the placebo cohort. Improvements in all secondary outcomes were also observed in the 0.5-mg etanercept cohort. The overall incidence of adverse events was similar in placebo and all etanercept cohorts., Conclusion: Two transforaminal injections of etanercept provided clinically significant reductions in mean daily WLP and worst back pain compared with placebo for subjects with symptomatic LDH. Epidural etanercept may offer patients with sciatica a safe and effective nonoperative treatment.

Objectives: To investigate the relationships between inflammation, nocturnal back pain and fatigue in ankylosing spondylitis (AS) and the impact of 12 weeks' etanercept treatment versus sulfasalazine or placebo., Methods: Data were combined from four clinical trials for patients with AS who received at least one dose of etanercept, sulfasalazine or placebo and had at least one postbaseline assessment value. Linear regression was performed (controlling for site, protocol and demographics), to explore the relationship between inflammation (C-reactive protein [CRP]), nocturnal back pain (visual analog scale [VAS] 0-100 mm) and fatigue (VAS 0-100 mm Bath AS Disease Activity Index fatigue item)., Results: Out of 1283 patients (etanercept, n = 867; sulfasalazine, n = 187; placebo, n = 229), improvement in nocturnal back pain was a significant predictor of improvement in fatigue. Significant correlations were found between nocturnal back pain and fatigue, but not CRP levels. Etanercept provided significantly greater pain/fatigue improvement than sulfasalazine or placebo. Improvements in nocturnal back pain and fatigue had weak relationships with improvement in inflammation (CRP level)., Conclusions: AS patients treated with etanercept demonstrated superior improvement in nocturnal back pain and fatigue versus sulfasalazine or placebo. Decrease in nocturnal back pain can improve fatigue. Assessing treatment response using CRP levels alone may be misleading without also examining patient-reported outcomes such as back pain and fatigue.

Hyponatremia (serum sodium level, <135 mmol/L) occasionally may develop in the course of treatment with nonsteroidal anti-inflammatory drugs, which are usually used in daily clinical practice. Nonsteroidal anti-inflammatory drugs diminish the normal inhibitory effect of prostaglandins on the activity of antidiuretic hormone and can therefore reduce free water excretion, leading to water retention and induction or exacerbation of hyponatremia. In this report, we present a case of hyponatremia in a 78-year-old man who had received meloxicam, a nonsteroidal anti-inflammatory drug.

A previously healthy 60-year-old man receiving aspirin for primary prevention of cardiovascular disease presented with hemoptysis after 1 week of treatment for his back pain with diclofenac. He had not suffered from any bleeding episode in the past and his family history was negative for hemorrhagic disorders. He had been a heavy smoker until his thirties, but had stopped smoking since then. After extensive workup, other pulmonary and nonpulmonary causes of hemoptysis were ruled out. Thus, in this case, because of the temporal relationship between exposure to the drug and the onset of symptoms, diclofenac was considered as the most probable cause of hemoptysis either alone or as a result of its pharmacodynamic interaction with aspirin. The adverse reaction was considered probable according to the Naranjo scale. Diclofenac treatment was discontinued and occasional use of acetaminophen for the back pain was recommended. Regular use of antiplatelet doses of aspirin was also discontinued., (Copyright © 2010 S. Karger AG, Basel.)

Intramuscular diclofenac is used extensively for pain relief in medical practice. Tissue necrosis is a rare but serious complication of intramuscular injections. The pathogenetic mechanism is still not completely understood. A case of tissue necrosis following self-administration of diclofenac inadvertently injected into an arterial perforator branch of the superficial femoral artery is reported, supporting a vascular pathogenesis., (Copyright (c) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Efficacy of different nonsteroid anti-inflammatory drugs (voltaren (diclofenac), movalis (meloxicam), nimesil (nimesulide) and xefocam (lornoxicam) in stopping the pain syndrome and normalization of motor activity was assessed in 140 patients with dorsalgia using the Visual Analogous Scale and the modified Waddel scale. Moreover, we suggest a method for calculating a treatment efficacy coefficient. The most effective drug in the treatment of back pain was xefocam (lornoxicam). Nimesil (nimesulide) was somewhat less effective. Other drugs did not reveal any significant effect. Xefocam was well-tolerated: adverse effects were rare compared to other drugs used in the study.

Reversible posterior leukoencephalopathy syndrome is a recently described disorder with typical radiologic findings in the posterior regions of the cerebral hemisphere and cerebellum. The symptoms include headache, nausea, vomiting, visual disturbances, focal neurologic deficits, and seizures. A 10-year-old male was hit on his back, resulting in backache. He was medicated with sodium diclofenate and mefenamic acid. The next day, he had edema and oliguria. By the third day, his blood pressure increased and he began to experience restlessness and worsening mental status. He then complained of headache and visual disturbances and had a seizure. A magnetic resonance imaging scan revealed abnormalities in the posterior regions of the cerebral hemisphere and cerebellum. The patient was treated with antiepileptics and calcium antagonists. His hypertension and seizures were well controlled. On the 22nd day, he was discharged without any neurologic or renal deficits. Reversible posterior leukoencephalopathy syndrome does not occur frequently in childhood, and this is the first case report of reversible posterior leukoencephalopathy syndrome related to nonsteroidal anti-inflammatory drugs. One should consider reversible posterior leukoencephalopathy syndrome as a side effect of nonsteroidal anti-inflammatory drug use in daily medical treatment.

Selective inhibitors of cyclooxygenase-2 have less gastroduodenal toxicity than non selective anti-inflammatory drugs. However, there is little information on their effect on the distal gut. A 91 year old woman presented with acute diarrhoea 5 weeks after beginning celecoxib treatment. Laboratory results showed an inflammatory syndrome and increased alanine aminotransferase (ALT) to 13 N. Endoscopic examination of the colon showed diffuse erythematous lesions of the sigmoid and of part of the right colon. No aetiology has been found for colitis or hepatitis. Diarrhea and blood test anomalies disappeared one week after celecoxib was stopped. The role of celecoxib in the etiology of colitis was considered plausible but not for liver damage. This report and a few other cases in the literature suggest that cyclooxygenase-2 selective non-steroidal anti-inflammatory drug inhibitor toxicity should be investigated in case of unexplained acute colitis.

Objective: This prospective, randomized, open-label, multicenter, community-based study was conducted to compare cyclobenzaprine 5 mg three times daily (TID) orally (CYC5) given for 7 days as monotherapy or in combination with ibuprofen 400 mg TID (CYC5/IBU400) or 800 mg TID (CYC5/IBU800) in adults with acute neck or back pain with muscle spasm., Study Design: Eligible patients were 18-65 years old, had cervical or thoracolumbar pain and spasm for < or = 14 days, and, aside from the prescribed study medications, discontinued treatment with all analgesics, anti-inflammatory agents, and skeletal muscle relaxants during the study period. Randomization was 1:1:1 to the three treatment groups. Treatment outcome was assessed after 3 and 7 days of therapy using five patient-rated scales: spasm, pain, patient global impression of change (PGIC), medication helpfulness, and Oswestry Disability Index (ODI)., Results: A total of 867 patients provided postbaseline data and were included in the intent-to-treat population (CYC5, n = 288; CYC5/IBU400, n = 286; CYC5/IBU800, n = 293). All three treatment groups demonstrated significant improvements from baseline in PGIC, spasm, pain, ODI, and medication helpfulness (p < 0.001 for all comparisons) after 3 and 7 days of therapy. There were no significant differences in mean PGIC among groups after 3 days of therapy (p = 0.65 for treatment effect) or after 7 days of therapy (primary endpoint; p = 0.41). A PGIC responder analysis of changes from baseline showed that 88% and 93% of patients reported at least mild improvement after 3 and 7 days of therapy, respectively. All three treatments were well tolerated, with no significant differences between treatments regarding the number of adverse events (AEs) reported or number of patients reporting AEs. The most common AEs in all groups were fatigue, somnolence, dizziness, sedation, and nausea. Limitations of this study include an unblinded design and possible introduction of bias into efficacy and safety results by use of a voluntary telephone reporting system., Conclusions: This randomized, community-based clinical trial demonstrated that combination therapy with cyclobenzaprine 5 mg TID plus ibuprofen was not superior to cyclobenzaprine 5 mg TID alone in adult patients with acute neck and back pain with muscle spasm. All treatments were well tolerated.

A 71-year-old patient with melena, abdominal and lower back pain was admitted to hospital under suspicion of upper gastrointestinal bleeding. He had mild anemia and an elevated C-reactive protein. Endoscopy and ultrasound failed to localize the source of bleeding. The patient died 2 1/2 days after admission on an exsanguinating hemorrhage. On pathologic examination a fistula between the small aortic aneurysm and duodenum and periaortic inflammation in contact with a spondylitis were found. When clinical presentation is subtle, with a herald bleeding followed by a period of grace, the diagnosis of aortoenteric fistula may be extremely difficult.

Objective: To assess the long-term benefits of medication, needle acupuncture, and spinal manipulation as exclusive and standardized treatment regimens in patients with chronic (>13 weeks) spinal pain syndromes., Study Design: Extended follow-up (>1 year) of a randomized clinical trial was conducted at the multidisciplinary spinal pain unit of Townsville's General Hospital between February 1999 and October 2001., Patients and Methods: Of the 115 patients originally randomized, 69 had exclusively been treated with the randomly allocated treatment during the 9-week treatment period (results at 9 weeks were reported earlier). These patients were followed up and assessed again 1 year after inception into the study reapplying the same instruments (ie, Oswestry Back Pain Index, Neck Disability Index, Short-Form-36, and Visual Analogue Scales). Questionnaires were obtained from 62 patients reflecting a retention proportion of 90%. The main analysis was restricted to 40 patients who had received exclusively the randomly allocated treatment for the whole observation period since randomization., Results: Comparisons of initial and extended follow-up questionnaires to assess absolute efficacy showed that only the application of spinal manipulation revealed broad-based long-term benefit: 5 of the 7 main outcome measures showed significant improvements compared with only 1 item in each of the acupuncture and the medication groups., Conclusions: In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.

Study Design: Secondary analysis of the 2000 Medical Expenditure Panel Survey (MEPS). OBJECTIVE.: To examine national prescription patterns of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants among individuals with back pain in the United States., Summary of Background Data: There is a lack of information on national prescription patterns of NSAIDs and muscle relaxants among individuals with back pain in the United States., Methods: Traditional NSAIDs, cyclooxygenase-2-specific (COX-2) inhibitors, and muscle relaxants were investigated. Individuals with back pain were stratified by socio-demographic characteristics and geographic regions. For each medication category, overall prescribing frequency was compared across different strata and individual drug prescription was analyzed., Results: Traditional NSAIDs, COX-2 inhibitors, and muscle relaxants, respectively, accounted for 16.3%, 10%, and 18.5% of total prescriptions for back pain in 2000. Among individual drugs, ibuprofen and naproxen accounted for most of the prescriptions for traditional NSAIDs (60%), whereas two thirds of the prescriptions for muscle relaxants were attributable to cyclobenzaprine, carisoprodol, and methocarbamol. Prescription of COX-2 inhibitors or muscle relaxants demonstrated wide variations across different regions. Several individual characteristics including age, race, and educational level were associated with the prescription of some of the medications., Conclusions: Neither traditional NSAIDs, nor COX-2 inhibitors, nor muscle relaxants dominated prescriptions for back pain. However, a small number of individual drugs were attributable to most of the prescriptions for traditional NSAIDs or muscle relaxants. The prescription of some of the medications demonstrated wide variations across different regions or different racial and educational groups. More studies are needed to understand the source of the variations and what constitutes optimal prescribing.

Objective: Documentation of the clinical results obtained utilizing perispinal etanercept off-label for treatment-refractory back and neck pain in a clinical practice setting., Research Design and Methods: The medical charts of all patients who were treated with etanercept for back or neck pain at a single private medical clinic in 2003 were reviewed retrospectively. Patients were treated if they had disc-related pain which was chronic, treatment-refractory, present every day for at least 8 h, and of moderate or severe intensity. Patients with active infection, demyelinating disease, uncontrolled diabetes, lymphoma or immunosuppression were excluded from treatment with etanercept. Etanercept 25 mg was administered by subcutaneous injection directly overlying the spine. Visual Analogue Scales (VAS, 0-10 cm) for intensity of pain, sensory disturbance, and weakness prior to and 20 min, 1 day, 1 week, 2 weeks, and 1 month after treatment were completed. Inclusion criteria for analysis required baseline and treatment VAS data., Main Outcome Measures: Before and after treatment VAS comparisons for intensity of pain, sensory disturbance, and weakness., Results: 143 charts out of 204 met the inclusion VAS criteria. The 143 patients had a mean age of 55.8 +/- 14, duration of pain of 9.8 +/- 11 years, and an initial Oswestry Disability Index of 42.8 +/- 18, with 83% having back pain, 61% sciatica, and 33% neck pain. 30% had previous spinal surgery, and 69% had previously received epidural steroid injections (mean 3.0 +/- 3). The patients received a mean of 2.3 +/- 0.7 doses of perispinal etanercept separated by a mean interval of 13.6 +/- 16.3 days. The mean VAS intensity of pain, sensory disturbance, and weakness were significantly reduced after perispinal etanercept at 20 min, 1 day, 1 week, 2 weeks, and 1 month with a p < 0.0001 at each time interval for the first dose in this patient population., Conclusions: Perispinal etanercept is a new treatment modality which can lead to significant clinical improvement in selected patients with chronic, treatment-refractory disc-related pain. Generalizability of the present study results is limited by the open-label, uncontrolled methodology employed. Based on this and other accumulating recent studies, etanercept may be useful for both acute and chronic disc-related pain. Further study of this new treatment modality utilizing double-blind placebo controlled methodology is indicated. NOTE: This treatment method is protected by multiple patents awarded to Edward Tobinick MD, including U. S. patents 6 015 557; 6 177 077; 6 419 944; 6 537 549 and Australian patent 758 523.

In regard to therapeutic effect of different medications used in dorsopathy treatment, non-steroid anti-inflammatory drugs rank first. Compounds selectively blocking COX-2 received special attention due to their minimal impact on COX-1 that provides good anti-inflammatory and analgesic effect with simultaneous dramatic reduction of ulcerogenic activity. One of the first drugs with such an action is Movalis (meloxicam). Thirty patients were divided into 2 groups, the first including 22 patients with vertebral diseases and musculotonic syndromes; patients of the second group (8) had a pain syndrome caused by disk herniation. During the first 3 days Movalis was administered in the form of injections (15 mg/day) and in the same doses in tablets for the following 20 days. After the treatment course, complete arrest of pain syndrome was observed in 33.3% patients, significant improvement--in 53.3% and insignificant effect--in 13.3%. Patients with reflex pain and musculotonic syndromes had a good analgesic effect after 3-day course of intramuscular injections, with the effect being mostly expressed in 8-10 days. Patients with diskogenic compressive radicular syndrome demonstrated a stable analgesic effect after a week of Movalis intake in tablet form. Movalis is well tolerated; side effects have occurred in 10 patients but they were minimal and did not lead to the change of medication dose or additional therapy.