The Barriers to Deprescription in Older Patients: A Survey of Spanish Clinicians.

BACKGROUND AND OBJECTIVE: There are barriers to deprescription that hinder its implementation in clinical practice. The objective of this study was to analyse the main barriers and limitations of the deprescription process perceived by physicians who care for multipathological patients. MATERIALS AND METHODS: The "deprescription questionnaire of elderly patients" was adapted to an online format and sent to physicians in geriatrics. Question 1 is a reference to establish agreement or disagreement with this practice. The influence of different aspects of deprescription was analysed via the demographic characteristics of the clinicians and perceptions of the various barriers (questions 2-9) by means of bivariate analysis. Based on the latter, a multivariate model was carried out to demonstrate the relationship between barriers and the degree of deprescription agreement among respondents. RESULTS: Of the 72 respondents, 72.2% were in favour of deprescribing. Regarding the analyses, the demographic characteristics did not influence rankings. The deprescription of preventive drugs and consensus with patients were associated with a positive attitude towards deprescribing, while withdrawing drugs prescribed by other professionals, time constraints and patient reluctance emerged as possible barriers. The only factor independently associated with deprescribing was lack of time. CONCLUSIONS: Time was found to be the main barrier to deprescription. Training, the creation of multidisciplinary teams and integrated health systems are key facilitators.

Adherence and preference of intravenous zoledronic acid for osteoporosis versus other bisphosphonates.

OBJECTIVE: To evaluate adherence as well as patient preference and satisfaction of once-yearly intravenous zoledronic acid versus other bisphosphonates treatments. METHODS: In accordance with the PRISMA guidelines, a systematic literature search was conducted in PubMed, Cochrane Library and EMBASE databases, over the date range of 2000-2016. Following the PICO (Population, Interventions, Comparator, Outcomes) elements, eligibility criteria included: (1) participants: adults over 18 with osteoporosis and adults who were at high risk of developing low bone density as a result of chronic use of glucocorticoids; (2) intervention: adherence or patient preference/satisfaction of once-yearly zoledronic acid treatment; (3) comparator: other bisphosphonates; (4) outcome: data about adherence, persistence, compliance, preference and satisfaction criteria. Specific exclusion criteria were also applied. RESULTS: Adherence to zoledronate is only quantified in one study showing that mean proportion of days covered for zoledronic acid was greater than for ibandronate users. Three studies showed 100% of compliance to zoledronate treatment and only one study showed zoledronic acid provided the highest persistence rates. Once-yearly intravenous infusion of zoledronic acid was clearly preferred. Only one article indicated preference for schedules that were once monthly or less frequent and other preference results practically equal between once-yearly intravenous infusion or weekly oral. Although there is little evidence, adherence to osteoporosis treatment is improved with annual intravenous zoledronate regimen. Moreover, patients appear to have preference for less frequent dosing. Switching from oral to intravenous therapy, based on the opportunities offered by an integrated health management area, may allow obtaining better outcomes in adherence to osteoporosis treatment.

The flavonol-enriched Cistus albidus chloroform extract possesses in vivo anti-inflammatory and anti-nociceptive activity.

ETHNOPHARMACOLOGICAL RELEVANCE: Cistus albidus L. (Cistaceae) has been traditionally used to treat various inflammatory diseases, but no systematic studies on the anti-inflammatory and anti-nociceptive actions of C. albidus and its putative mechanism have been reported. We aimed to explore the anti-inflammatory and anti-nociceptive effects of this plant and to characterize its polyphenolic composition by liquid chromatography coupled to mass spectrometry (MS). MATERIALS AND METHODS: A chloroform extract derived from C. albidus leaves was obtained by solid-liquid and liquid-liquid extraction. The tail immersion test and acetic-acid-induced writhing test were used to evaluate the anti-nociceptive action, while the experimental λ-carrageenan-induced paw edema model was used to test the anti-inflammatory action. Changes in cyclooxygenase (COX)-2 and inducible nitric oxide synthase (iNOS) expression, as well as the role of mitogen-activated protein kinases (MAPKs) and the nuclear transcription factor kappa B (NF-kB) signaling pathways on lipopolysaccharide (LPS)-stimulated murine peritoneal macrophages were analyzed by western blotting. HPLC with diode array detection coupled to tandem mass spectrometry detection with electrospray ionization (HPLC-DAD-ESI-MS/MS) was performed to determine the phytochemical profile of the extract. RESULTS: Significant anti-nociceptive activity was observed both in the tail immersion (59.63% reduction at 120min) and in the acetic acid (65.94% inhibition) tests at 100mg/kg. The extract (50mg/kg) exhibited a substantial reduction in paw edema (51.6%) and significantly inhibited nitrite generation (72.62%) without affecting cell viability of LPS-stimulated murine peritoneal macrophages. These results were concomitant with a down-regulation of the pro-inflammatory enzymes COX-2 and iNOS in extract-treated macrophages and a decrease in p38 MAPK phosphorylation. HPLC-DAD-ESI-MS/MS analysis revealed that flavonols such as kaempferol and quercetin derivatives were potentially responsible for such effects. CONCLUSION: These results support the widespread use of C. albidus in popular medicine and indicate that this plant has therapeutic potential with analgesic and anti-inflammatory properties based on the presence of flavonol derivatives.

Dietary squalene supplementation improves DSS-induced acute colitis by downregulating p38 MAPK and NFkB signaling pathways.

SCOPE: Squalene is a polyunsaturated triterpene, which has exhibited anticancer and antioxidant activities among others. We investigated dietary squalene supplementation effect on an acute colitis model induced by dextran sulfate sodium (DSS) in C57BL/6 mice. METHODS AND RESULTS: Mice were fed from weaning with squalene at 0.02% and 0.1%. After 4 weeks, mice were exposed to 3% DSS for 5 days developing acute colitis. After DSS removal (5 days), colons were histological and biochemically processed. Our results showed that dietary squalene treatment exerts anti-inflammatory action in DSS-induced acute colitis. Western blot revealed that squalene downregulated COX-2 (where COX is cyclooxygenase) and inducible nitric oxide synthase system by inhibition of mitogen-activated protein kinase p38 and the nuclear factor-kappa B signaling pathways, preventing an increase in the cytokines levels. Under our experimental conditions, STAT3 and FOXP3 (where FOXP3 is forkhead box P3) were not modified and the transcriptional regulation of antioxidant and/or detoxifying enzymes, Nrf2 (where Nrf2 is nuclear factor (erythroid-derived 2)-like 2), was reduced in DSS-induced colitis. However, any change could be observed after squalene supplementation. CONCLUSION: Squalene was able to improve the oxidative events and returned proinflammatory proteins expression to basal levels probably through p38 mitogen-activated protein kinase and nuclear factor-kappa B signaling pathways. However, supplementary studies are needed in order to provide a basis for developing a new dietary supplementation strategy.

Dietary extra virgin olive oil polyphenols supplementation modulates DSS-induced chronic colitis in mice.

We evaluated the protective effect of dietary extra virgin olive oil (EVOO) polyphenol extract (PE) supplementation in the inflammatory response associated to chronic colitis model. Six-week-old mice were randomized in four dietary groups: standard diet (SD), EVOO diet and both enriched with PE (850 ppm) (SD+PE and EVOO+PE). After 30 days, animals that were exposed to dextran sodium sulfate (DSS) (3%) followed by 3 weeks of drinking water developed chronic colitis, which was evaluated by disease activity index (DAI) and histology. Cell proliferation was analyzed by immunohistochemical and changes in monocyte chemotactic protein (MCP)-1 and tumor necrosis factor (TNF)-α mRNA expression by quantitative real-time polymerase chain reaction. Colonic expression of inducible nitric oxide synthase (iNOS), cyclooxygenase (COX)-2, mitogen-activated protein kinases (MAPKs), IκBα inhibitory and peroxisome proliferator-activated receptor gamma (PPARγ) were determined by western blotting. SD-DSS group showed a significant increase of DAI, histological damage and cell proliferation, as well as an up-regulation of TNF-α, MCP-1, COX-2 and iNOS proteins. p38 and JNK MAPKs phosphorylation, IκBα degradation and PPARγ deactivation were also observed. However, in DSS-treated and EVOO+PE-fed mice, DAI and cell proliferation were significantly reduced, as well as MCP-1, TNF-α, COX-2 and iNOS expression levels. In addition, this dietary group, notably down-regulated JNK phosphorylation, prevented IκBα degradation and PPARγ deactivation. These results demonstrated, for the first time, that EVOO-PE supplementation possessed marked protective effects on experimental colitis through PPARγ up-regulation and nuclear transcription factor-kappa B and MAPK signaling pathway inhibition, decreasing the inflammatory cascade. We concluded that PE-enriched EVOO diet could be a beneficial functional food on ulcerative colitis.

Dietary supplementation of an ellagic acid-enriched pomegranate extract attenuates chronic colonic inflammation in rats.

Dietary polyphenols present in Punica granatum (pomegranate), such as ellagitannins and ellagic acid (EA) have shown to exert anti-inflammatory and antioxidant properties. This study was designed to evaluate the effects of a dietary EA-enriched pomegranate extract (PE) in a murine chronic model of Cronh's disease (CD). Colonic injury was induced by intracolonic instillation of trinitrobenzensulfonic acid (TNBS). Rats were fed with different diets during 30 days before TNBS instillation and 2 weeks before killing: (i) standard, (ii) PE 250 mg/kg/day, (iii) PE 500 mg/kg/day, (iv) EA 10 mg/kg/day and (v) EA 10 mg/kg/day enriched-PE 250 mg/kg/day. Inflammation response was assessed by histology and MPO activity and TNF-α production. Besides, colonic expressions of iNOS, COX-2, p38, JNK, pERK1/2 MAPKs, IKBα and nuclear p65 NF-κB were studied by western blotting. MPO activity and the TNF-α levels were significantly reduced in dietary fed rats when compared with TNBS group. Similarly, PE and an EA-enriched PE diets drastically decreased COX-2 and iNOS overexpression, reduced MAPKs phosporylation and prevented the nuclear NF-κB translocation. Dietary supplementation of EA contributes in the beneficial effect of PE in this experimental colitis model and may be a novel therapeutic strategy to manage inflammatory bowel disease (IBD).

Influence of extra virgin olive oil diet enriched with hydroxytyrosol in a chronic DSS colitis model.

PURPOSE: Recent epidemiological studies have shown that habitual consumption of extra virgin olive oil (EVOO), the characteristic culinary fat of the Mediterranean area, is effective in the prevention of diverse types of digestive disorders such as inflammatory bowel disease. Many of these benefits are, in addition to its high proportion of oleic acid, due to the high content of phenolic compounds. METHODS: Six-week-old mice were randomized into three dietary groups: standard, EVOO and hydroxytyrosol-enriched EVOO. After 30 days, mice that were exposed to 3% DSS for 5 days developed acute colitis that progressed to severe chronic inflammation during a regime of 21 days of water. RESULTS: Diets enriched with EVOO significantly attenuated the clinical and histological signs of damage, improving results from disease activity index and reducing about 50% the mortality caused by DSS. Moreover, hydroxytyrosol supplement showed better results. Cytokines study showed that TNF-α was maintained near to sham control and IL-10 levels were significantly improved in EVOO and EVOO plus hydroxytyrosol diet-DSS groups. In the same way, COX-2 and iNOS were downregulated, and the activation of p38 MAPK was reduced. We also observed a higher significant reduction in iNOS in hydroxytyrosol-enriched EVOO compared with EVOO alone. CONCLUSIONS: EVOO diets exerted a noteworthy beneficial effect in chronic DSS-induced colitis by cytokine modulation and COX-2 and iNOS reduction via downregulation of p38 MAPK. In addition to the beneficial effect by EVOO, supplementation of the diet with hydroxytyrosol may improve chronic colitis through iNOS downregulation plus its antioxidant capacity.

Chronic administration of Abarema cochliacarpos attenuates colonic inflammation in rats

Inflammatory bowel diseases are characterized by a chronic clinical course of relapse and remission associated with self-destructive inflammation of the gastrointestinal tract. Active extracts from plants have emerged as natural potential candidates for its treatment. Abarema cochliacarpos (Gomes) Barneby & Grimes, Fabaceae (Barbatimão), is a native medicinal plant in to Brazil. Previously we have demonstrated in an acute colitis model a marked protective effect of a butanolic extract, so we decided to assess its anti-inflammatory effect in a chronic ulcerative colitis model induced by trinitrobenzensulfonic acid (TNBS). Abarema cochliacarpos (150 mg/day, v.o.) was administered for fourteen consecutive days. This treatment decreased significantly macroscopic damage as compared with TNBS. Histological analysis showed that the extract improved the microscopic structure. Myeloperoxidase activity (MPO) was significantly decreased. Study of cytokines showed that TNF-α was diminished and IL-10 level was increased after Abarema cochliacarpos treatment. In order to elucidate inflammatory mechanisms, expression of cyclooxygenase (COX)-2 and nitric oxide synthase (iNOS) were studied showing a significant downregulation. In addition, there was reduction in the JNK and p-38 activation. Finally, IκB degradation was blocked by Abarema cochliacarpos treatment being consistent with an up-regulation of the NF-kappaB-binding activity. These results reinforce the anti-inflammatory effects described previously suggesting that Abarema cochliacarpos could provide a source for the search for new anti-inflammatory compounds useful in ulcerative colitis treatment.

Dietary supplementation of resveratrol attenuates chronic colonic inflammation in mice.

Ulcerative colitis is a nonspecific inflammatory disorder characterized by oxidative and nitrosative stress, leucocyte infiltration and upregulation of inflammatory mediators. Resveratrol is a polyphenolic compound found in grapes and wine, with multiple pharmacological actions, mainly anti-inflammatory, antioxidant, antitumour and immunomodulatory activities. The aim of this study was to investigate the effect of dietary resveratrol on chronic dextran sulphate sodium (DSS)-induced colitis. Six-week-old mice were randomized into two dietary groups: one standard diet and the other enriched with resveratrol at 20mg/kg of diet. After 30days, mice were exposed to 3% DSS for 5days developing acute colitis that progressed to severe chronic inflammation after 21days of water. Our results demonstrated that resveratrol group significantly attenuated the clinical signs such as loss of body weight, diarrhea and rectal bleeding improving results from disease activity index and inflammatory score. Moreover, the totality of resveratrol-fed animals survived and finished the treatment while animals fed with standard diet showed a mortality of 40%. Three weeks after DSS removal, the polyphenol caused substantial reductions of the rise of pro-inflammatory cytokines, TNF-alpha and IL-1beta and an increase of the anti-inflammatory cytokine IL-10. Also resveratrol reduced prostaglandin E synthase-1 (PGES-1), cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) proteins expression, via downregulation of p38, a mitogen-activated protein kinases (MAPK) signal pathway. We conclude that resveratrol diet represents a novel approach to the treatment of chronic intestinal inflammation.

Anti-inflammatory intestinal activity of Abarema cochliacarpos (Gomes) Barneby & Grimes in TNBS colitis model.

AIM OF THE STUDY: To assess the anti-inflammatory effect of butanolic fraction of methanolic extract from bark of Abarema cochliacarpos in acute ulcerative colitis model induced by intracolonic administration of trinitrobenzene sulfonic acid (TNBS) in Wistar rats. MATERIALS AND METHODS: Abarema cochliacarpos (100 and 150mg/kg/day) was administered by gavage 48, 24 and 1h prior to the induction of colitis with 10mg/kg of TNBS and, 24h later. RESULTS: Phytochemical studies by mass spectrometry (MS) and nuclear magnetic resonance spectroscopy (NMR) revealed that catechins were a major component into condensate class of tannins. Treatment with Abarema cochliacarpos decreased significantly macroscopic damage as compared with TNBS (p<0.05). Histological analysis showed that both doses of the extract improved the microscopic structure and preserved some areas of the colonic mucosa structure. In addition, myeloperoxidase activity (MPO), as a marker of neutrophil infiltration, was decreased in a dose-dependent way (p<0.01 and p<0.001 respectively), TNF-alpha level was also diminished with the highest dose of the extract (p<0.001) and, IL-10 level obtained no significant results. In order to elucidate some of the mechanisms, expression of inducible inflammatory enzymes, such as cyclooxygenase (COX)-2 and nitric oxide synthase (iNOS), were studied showing a significant reduction. Finally, the involvement of c-Jun N-terminal kinase (JNK) signalling demonstrated a reduction in the JNK activation with the highest dose (p<0.05 vs TNBS). CONCLUSIONS: We have shown for the first time that the extracts obtained from Abarema cochliacarpos bark possess active substances, which exert marked protective effects in acute experimental colitis, confirming and justifying, at least in part, the popular use of this plant to treat gastrointestinal diseases.

New mechanisms and therapeutic potential of curcumin for colorectal cancer.

Curcumin is a polyphenol derived from Curcuma longa. Over the last few years, a number of studies have provided evidence of its main pharmacological properties including chemosensitizing, radiosensitizing, wound healing activities, antimicrobial, antiviral, antifungical, immunomodulatory, antioxidant and anti-inflammatory. More recent data provide interesting insights into the effect of this compound on cancer chemoprevention and chemotherapy. In fact, preclinical studies have shown its ability to inhibit carcinogenesis in various types of cancer including colorectal cancer (CRC). Curcumin has the capacity of interact with multiple molecular targets affecting the multistep process of carcinogenesis. Also, curcumin is able to arrest the cell cycle, to inhibit the inflammatory response and the oxidative stress and to induce apoptosis in cancer cells. Likewise, it has been shown to possess marked antiangiogenic properties. Furthermore, curcumin potentiates the growth inhibitory effect of cyclo-oxygenase (COX)-2 inhibitors and traditional chemotherapy agents implicating another promising therapy regimen in the future treatment of CRC. However, its clinical advance has been hindered by its short biological half-life and low bioavailability after oral administration. This review is intended to provide the reader an update of the bioavailability and pharmacokinetics of curcumin and describes the recently identified molecular pathways responsible of its anticancer potential in CRC.