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Lornoxicam: a modern analgesic in the treatment of chronic pain syndrome

Correct and timely use of etiotropic or pathogenetic treatment can eliminate pain in most cases. Nevertheless, there are situations in which symptomatic pain therapy is indicated: with severe pain requiring immediate treatment, or in cases where the cause of pain cannot be eliminated [6]. Many acute and chronic diseases, medical interventions and injuries are associated with pain requiring the use of analgesics [1]. In clinical and outpatient practice, non-narcotic analgesics (painkillers) are widely used, which are separated from the group of non-steroidal anti-inflammatory drugs (NSAIDs) into a separate group, since the anti-inflammatory effect of most of these drugs is relatively weak. NSAIDs have an analgesic effect, which is combined with an antipyretic effect.

Non-narcotic analgesics include lornoxicam, ketorolac, paracetamol and metamizole sodium. The analgesic or analgesic effect of these drugs, like all NSAIDs, is due to the suppression of cyclooxygenase (COX) activity and a decrease in the production of prostaglandins E2 and F2α, which increase the sensitivity of nociceptors both during inflammation and tissue damage. A more pronounced analgesic than anti-inflammatory effect is possessed by those NSAIDs that, due to their chemical structure, are neutral, accumulate less in inflammatory tissue, penetrate the blood-brain barrier more quickly and suppress COX in the central nervous system, and also affect the thalamic centers of pain sensitivity (Table 1) [6, 7].

An NSAID with a pronounced analgesic effect is lornoxicam (Xefocam®, Takeda Pharmaceuticals LLC). Lornoxicam belongs to the oxicam class of NSAIDs and is a potent, balanced COX-1/COX-2 inhibitor. Unlike other members of the oxicam class, lornoxicam has a short half-life (approximately 4 hours), which reduces the risk of accumulation when taking multiple doses. Xefocam® has a powerful analgesic effect comparable to that of opioids. The drug is used in the treatment of acute pain from mild to moderately severe, to eliminate pain in renal colic, neurological diseases, injuries, in cancer patients, in the postoperative period, as well as in algodismenorrhea, lumbar ischialgia. In terms of analgesic activity, lornoxicam is superior to most NSAIDs, such as diclofenac, ketorolac and many others. To the same extent, unlike other analgesics, it also has a strong anti-inflammatory effect. Lornoxicam equally blocks COX-1 and COX-2, while in its ability to block COX it is superior to other drugs from the oxicam group. The anti-pain effect of the drug is due to both a violation of the generation of pain impulses and a weakening of the perception of pain. There is evidence that when administered parenterally, lornoxicam can increase the concentration of endogenous opioids, thereby activating the antinociceptive system. In addition, lornoxicam inhibits the release of oxygen free radicals from activated leukocytes. The drug does not affect opioid receptors and does not have a sedative or anxiolytic effect. In addition, it should be noted that in elderly patients with preserved liver and kidney function, no dose adjustment is required, which is also convenient for the physician prescribing the drug [6–21].

Ksefokam® is available in 3 forms (tablets Xefokam® and Xefokam® Rapid, Ksefokam® lyophilisate for injection), which is convenient from the point of view of choosing a therapeutic agent, since all therapeutic forms of the drug Xefokam® have relatively the same effect when switching from injection to oral form does not require dose adjustment. The presence of a parenteral form of lornoxicam is of particular value in the postoperative period. Xefocam® provides effective treatment of postoperative pain and demonstrates clinical effectiveness in abdominal, gynecological and orthopedic surgeries. When treating postoperative pain after abdominal surgery with Xefocam® for injection (iv), morphine consumption and the incidence of vomiting are reduced compared to tenoxicam. Xefocam® Rapid has faster absorption compared to standard Xefocam® tablets, which contributes to the rapid onset of the analgesic effect. Good tolerability due to safe pharmacokinetics (short half-life, inactive metabolites, absence of hepatotoxic action and accumulation of the drug in the body), as well as the “drug safety” of the drug, allow the drug to be widely and without complications used for the treatment of patients at risk: the elderly, obese, dysfunction of the liver (hepatitis) and kidneys, weakened patients, etc. [8–10, 19–25].

Lornoxicam is distinguished by its pronounced anti-inflammatory and analgesic effect and can be widely used in the practice of doctors of various specialties. A powerful balanced suppression of the activity of both COX isoenzymes, as well as stimulation of the production of endogenous dynorphin and endorphin, makes lornoxicam one of the most effective and safe modern analgesics for the relief of BS of any intensity and localization. Indications for the use of lornoxicam are short-term treatment of BS of various origins, symptomatic treatment of rheumatic diseases (rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, articular syndrome with exacerbation of gout, rheumatic soft tissue lesions) [6, 7, 19–21, 26].

The analgesic efficacy of lornoxicam (Xefocam®) was demonstrated in 3 meta-analyses, including 13 placebo-controlled studies evaluating various formulations and dosages ranging from 2 to 32 mg. Five studies assessed pain after surgical extraction of the 3rd molar. Five studies were conducted in patients with pain following major surgery (3 included general surgery, 1 included knee surgery, 1 included postpartum pain due to episiotomy). Three studies included patients with low back pain (1 with acute sciatica and 2 with chronic low back pain). For comparison, the meta-analysis included data obtained from the use of competitive drugs (acetylsalicylic acid, ibuprofen, naproxen, pethidine, diclofenac, tramadol, ketorolac and morphine). The results of the analysis showed that relatively small doses of Xefocam® have an effectiveness comparable to that of high doses of ketorolac and ibuprofen and medium doses of morphine, and have greater potency than low doses of acetylsalicylic acid, naproxen and ibuprofen. For example, the following ratios can be given: lornoxicam 4 mg tablets are equivalent in effectiveness to acetylsalicylic acid 650 mg and ibuprofen 200 mg, Xefocam® 8 mg tablets correspond to ibuprofen 400–800 mg and ketorolac 10 mg, for postoperative pain intravenous injections of lornoxicam 8– 16 mg is equivalent in effectiveness to morphine 20 mg, pethidine 100 mg and tramadol 50 mg. Moreover, unlike narcotic analgesics, lornoxicam does not have an effect on respiratory function, sedative, or psychomotor effects, and it is less likely to cause dyspepsia [26–31].

Of great interest is the ability of lornoxicam in chronic inflammatory arthropathy to quickly penetrate into the perivascular space, including synovial fluid, while other NSAIDs act mainly in the area of the inflamed synovium. Several foreign studies have shown the effectiveness of lornoxicam against BS in patients with OA. Thus, in a 4-week, double-blind, placebo-controlled, multicenter study involving 160 patients with hip and knee OA, it was shown that lornoxicam at a daily dose of 8 and 12 mg significantly reduced pain and improved joint function compared with placebo (5-5 mg each). Likert scale) – a dose of 12 mg was significantly more effective than 8 mg [17].

In a comparative study, the effectiveness of lornoxicam at a dose of 12 and 16 mg/day and diclofenac at a dose of 150 mg/day after 12 weeks. evaluated in 135 patients suffering from hip or knee OA. In all 3 comparison groups, after therapy, the functional status of patients with OA significantly improved (p<0.05 for paired assessment of effectiveness). Overall, 46% of patients across all treatment groups reported improvement in their disease, with pain relief rates (PAR) ranging from 42% to 48%. After 12 weeks When using lornoxicam at a dose of 16 mg/day, a significantly larger number of patients and doctors rated its effect as “good”, “very good” and “excellent” compared to the effect of diclofenac 150 mg/day and lornoxicam 12 mg/day [35].

Another comparative study (25-day multicenter) assessed the effectiveness of lornoxicam 16 mg/day and the selective COX-2 inhibitor rofecoxib 25 mg/day in 2520 patients with OA. During therapy with lornoxicam, there was a significant decrease in pain at night, during movement and at rest compared with the effect of therapy with a selective COX-2 inhibitor (p<0.01 in all cases). Although this was a non-randomized, double-blind clinical trial, the results are of interest due to the large number of participants. Overall, 40.9% of subjects rated the effectiveness of lornoxicam therapy as “excellent,” while in the comparison group only 20.1% of patients with OA reported an excellent result. Thus, lornoxicam therapy was significantly more effective against BS in patients with OA compared to therapy with a selective COX-2 inhibitor [18].

An overview of studies that evaluated the use of lornoxicam (Xefocam®) in RA or OA is presented in Table 2.

During a 3-week double-blind multicenter study involving 316 patients, the effectiveness of standard Xefocam® tablets at a daily dose of 12 mg and diclofenac at a daily dose of 150 mg was compared in RA. For all clinical parameters assessed (Ritchey joint index, duration and severity of morning stiffness, severity of pain and number of painful joints), there was a significant improvement in indicators compared to baseline indicators from the first week of treatment onwards (in all groups p<0.01 relative to baseline indicators on the 3rd week of the study). There were no significant differences between the 2 drugs. According to doctors, therapy with Xefocam® was assessed well and satisfactorily in 75% of patients compared to 69% of those who took diclofenac (Fig. 1) [15].

In a 12-week, prospective, randomized, multicenter, double-blind, parallel-group study in patients with RA, the effectiveness of the following drugs was compared: standard Xefocam® 4 mg tablets three times a day, standard Xefocam® tablets 8 mg twice a day, and 500 mg naproxen 2 rubles/day After 12 weeks. patients could continue treatment over the next 40 weeks, while they took Xefocam® either at the same dose or according to one of two therapeutic regimens for using the drug Xefocam®. The primary objective of the study was to examine changes in grip strength after 12 weeks. treatment. On average, changes in the strength of morning stiffness in the group of patients taking standard Xefocam® tablets at a dose of 4 mg 3 times a day and standard Xefocam® tablets at a dose of 8 mg 2 times a day were similar to those taking naproxen in the initial 12-12 days. week study period, as well as in those taking standard Xefocam® tablets at a dose of 4 mg 3 times / day and 8 mg 2 times / day during the subsequent 40-week study period. Improvements in mean scores for all parameters, including Ritchie joint index, subjective pain rating, functional status, disease progression, and PAR, were similar across treatment regimens. Lornoxicam has proven its effectiveness in reducing pain and inflammation in RA, which was confirmed by the results of assessing all significant clinical parameters [16].

A review of the clinical safety data for lornoxicam shows that its safety profile is comparable to that of other traditional NSAIDs. In addition, it should be noted that in the pooled analysis, Xefocam® was significantly better tolerated than other comparator drugs. Although Xefocam® did not increase the risk of side effects in patients over 65 years of age, the drug should nevertheless be prescribed with caution, taking into account the fact that gastrointestinal side effects are particularly difficult to tolerate in this age group. The favorable safety profile of Xefocam® is a consequence of the fact that the drug is a balanced COX-1/COX-2 inhibitor and has a relatively short half-life compared to that of other NSAIDs [36].

Conclusion

Analgesics play an important role in the treatment of chronic BS. Choosing an effective and safe drug is an urgent task for specialists. Lornoxicam (Xefocam®) is an NSAID with powerful analgesic activity. The analgesic effect of lornoxicam exceeds that of many other NSAIDs and is comparable in strength to narcotic analgesics. The safety of Xefocam® has been clinically proven and confirmed in studies.

Lornoxicam is a modern analgesic that provides sufficient effect for pain of any intensity, and its widespread use both in outpatient clinics, emergency rooms, and in multidisciplinary hospitals is justified from the standpoint of evidence-based medicine. The availability of various dosage forms of the drug Xefokam® - tablets Xefokam® and Xefokam® Rapid, as well as Xefokam® for injections - determine the convenience for both the specialist and the patient.