Oral NSAIDs promising on paper, but CF clinicians wary

Cystic fibrosis

25 Apr 2016

The release of a Cochrane review showing high dose oral NSAIDs can slow the progression of lung damage in people with cystic fibrosis is unlikely to change clinical practice, says a leading Australian respiratory physician and researcher.

Associate Professor Sarath Ranganathan, director of Respiratory and Sleep Medicine at the Royal Children’s Hospital in Melbourne, and principal fellow at Melbourne University’s Department of Paediatrics, said non-steroidal anti-inflammatory drugs still posed too much risk of significant side effects.

“There is no information to say the benefits outweigh the risks of using these drugs,” he said.

The review looked at randomized controlled trials, published and unpublished, to address the hypothesis that as pulmonary damage in CF may occur as a consequence of inflammation, prolonged use of NSAIDs may prevent progressive pulmonary deterioration and respiratory morbidity.

“In one trial, long-term use of high-dose ibuprofen was associated with reduced intravenous antibiotic usage, improved nutritional and radiological pulmonary status,” the authors reported.

“No major adverse effects were reported, but the power of the trials to identify clinically important differences in the incidence of adverse effects was low.”

The authors went on to conclude: “High-dose ibuprofen can slow the progression of lung disease in people with cystic fibrosis, especially in children, which suggests that strategies to modulate lung inflammation can be beneficial for people with cystic fibrosis.”

While Professor Ranganathan said the review presented no real new data on the use of NSAIDs to reduce inflammation in patients with CF, it did provide a “useful summary” of all the data collected so far.

And that amounts to only a handful of studies, he said.

“I don’t think there’s a massive body of evidence, even in this Cochrane Review,” he told the limbic.

“I think we’ve known about the potential role of NSAIDs for some time, but not many people have taken up their use because of all the side effects.”

Some of these include gastritis, gastrointestinal bleeding, and negative effects on renal function.

Professor Ranganathan said NSAIDs were not commonly used for this purpose in young patients with CF and he thought it was unlikely that CF specialists would be likely to change their practice based on the Cochrane Review.

However he did say that the concept of using anti-inflammatories to slow the progression of lung disease in CF patients was definitely “logical” and there were already studies underway looking at how these could work when started in very young patients.

These are not NSAIDs, but different types of anti-inflammatories, he said.

“I think we need a really good trial of anti-inflammatories (including NSAIDs and other drug types) to understand whether there is long-term benefit without high risk of harm,” he said.

Associate Professor Peter Middleton, a respiratory specialist at Westmead Hospital and Clinical Associate Professor with University of Sydney, said the potential benefits of NSAID use seemed to be limited to children.

He said NSAIDs were rarely used in adult CF patients and the Cochrane Review would be unlikely to change that. Gastritis, gastrointestinal bleeding, and even renal failure in CF patients had been linked with the use of NSAIDs, he said.

“For adults there’s less benefits and more toxicity,” he said.

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