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Towards Predicting the Analgesic Response to Ibuprofen Following Third-molar Extraction

Primary Purpose

Impacted Third Molar Tooth, Pain, Acute

Status
Completed
Phase
Phase 1
Locations
United States
Study Type
Interventional
Intervention
Ibuprofen
Acetaminophen
Placebo
Oxycodone
Sponsored by
University of Pennsylvania
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional other trial for Impacted Third Molar Tooth focused on measuring Non-steroidal anti-inflammatory drugs

Eligibility Criteria

18 Years - 64 Years (Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Men and women greater than 18 years of age requiring extraction of at least one impacted mandibular third molar tooth (at least 50% covered with bone).
  • Body mass index (BMI) between 18 and 30 kg/m2.
  • Absence of other major medical problems or contraindications to surgery or study drugs.
  • Has not used tobacco products, including smoking cessation nicotine-containing products (e.g., nicotine patch, nicotine gum), for at least the 3 months prior to screening.
  • Female subjects of child bearing potential must be using a medically acceptable method of contraception (oral contraception, Depo-Provera injection, IUD, condom with spermicide, diaphragm, cervical cap, progestin implant, abstinence, tubal ligation, oophorectomy, TAH) throughout the entire study period. All female subjects must consent to a urine pregnancy test at screening and a urine pregnancy test on the day of surgery, which must be negative at all time points.
  • Has not ingested caffeine-containing products within 12 hours of surgery.
  • All subjects must consent to a urine drug test at screening. Results must be negative. A positive result will be reported to the subject.
  • Does not consume more than 1 alcoholic beverage per day on average.
  • Subjects must reach a level of at least moderate pain within four hours of surgery completion, with a pain score greater than or equal to 4 on a 0-10 numerical pain scale
  • Subjects must be willing and able to complete safety and efficacy diaries.
  • An escort must be available to pick up the subject at the end of at the end of the surgical/dosing visit (Visit #2)
  • In the opinion of the investigators or research coordinators, subjects must be willing and able to understand and comply with study procedures, including completing safety and efficacy diaries at home.
  • Able and willing to provide written informed consent prior to any study procedures being performed.

Exclusion Criteria:

  • Female subjects who are pregnant or nursing a child.
  • Subjects who have received an investigational drug or used an experimental medical device within 30 days prior to screening, or who gave a blood donation of ≥ one pint within 8 weeks prior to screening.
  • Subjects who are sensitive or allergic to ibuprofen, acetaminophen, or their components.
  • Subjects who are sensitive or allergic to aspirin or other NSAIDs.
  • Subjects who are sensitive or allergic to oxycodone or other opioids (excluding nausea and constipation).
  • Presence of a serious medical condition (e.g. poorly controlled hypertension or diabetes, gastrointestinal disorders such as bleeding ulcer, coagulation or bleeding disorders, significantly impaired cardiac, renal, hepatic, respiratory, or thyroid function) that according to the investigator may interfere with interpretation of the study results or compromise the safety of a potential subject.
  • Acute local infection at the time of surgery that could confound post-surgical evaluation.
  • Use of any confounding prescription or non-prescription drug within 24 hours of the surgical procedure, including analgesics, sedating antihistamine, sedative, alcohol, or CNS/psychotropic agents (i.e. sleep aids, benzodiazepines, performance/attention enhancers, marijuana, anti-depressants). Hormonal contraceptives, hormone replacement therapy (including males taking testosterone as a hormone replacement to treat a documented low testosterone level), or thyroid replacement hormones are allowed. Individuals taking other/additional chronic stable medications can be considered on a case-by-case basis for inclusion in the study if agreed upon by judgment of the investigator.
  • Subjects who have taken NSAIDs, including acetaminophen, or other medications for pain, including aspirin or aspirin-containing products within 1 week of study drug administration.
  • Subjects who routinely consume high doses of antioxidant vitamins daily (vitamin C > 1000mg, Vitamin E > 400IU, Beta Carotene > 1000IU, Vitamin A > 5000IU, Selenium > 200mcg, Folic Acid > 1mg) during the 2 weeks prior to the start of the study.
  • Subjects with any abnormal laboratory value or physical finding that according to the investigator may interfere with interpretation of the study results, be indicative of an underlying disease state, or compromise the safety of a potential subject.
  • Subjects who have a history of abuse of narcotics, street drugs, prescription sleeping pills, based upon history and judgment of the Investigator.
  • Subjects who are unwilling to provide a blood sample for genetic analyses.
  • Employees of the principal investigator, sub-investigators, or relative of an employee who is directly involved in this study.

Sites / Locations

  • Institute for Translational Medicine and Therapeutics (ITMAT), University of Pennsylvania School of Medicine

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

Ibuprofen

Placebo

Arm Description

During the double-blind stage, subjects will receive blinded ibuprofen (400 mg by mouth) when pain is at least 4/10 following third molar extraction. During the open-label stage, all subjects will receive ibuprofen (400 mg by mouth) and acetaminophen (500 mg by mouth) to be taken every 4 hours around the clock for the first 2 days after third molar extraction and then as needed for pain up to 7 days after third molar extraction. Rescue medication (oxycodone 5 mg by mouth) will be available if additional analgesic is requested.

During the double-blind stage, subjects will receive blinded placebo when pain is at least 4/10 following third molar extraction. During the open-label stage, all subjects will receive ibuprofen (400 mg by mouth) and acetaminophen (500 mg by mouth) to be taken every 4 hours around the clock for the first 2 days after third molar extraction and then as needed for pain up to 7 days after third molar extraction. Rescue medication (oxycodone 5 mg by mouth) will be available if additional analgesic is requested.

Outcomes

Primary Outcome Measures

Analgesic response
Need for opioid rescue medication after administration of blinded study drug

Secondary Outcome Measures

Ibuprofen plasma concentrations
Assessed by measuring the amount of ibuprofen in plasma
Acetaminophen plasma concentrations
Assessed by measuring the amount of acetaminophen in plasma
Gene expression profiling
mRNA levels will be measured in peripheral blood mononuclear cells
COX-1 activity
COX-1 activity will be measured ex vivo using a whole blood assay and in vivo by quantifying concentrations of prostaglandin metabolites in urine.
COX-2 activity
COX-2 activity will be measured ex vivo using a whole blood assay and in vivo by quantifying concentrations of prostaglandin metabolites in urine.
DNA sequencing
Assessment of genetic variation
Urinary metabolomics
Assessed by measuring levels of metabolites in urine
Plasma metabolomics
Assessed by measuring levels of metabolites in plasma
Composition of the gut microbiome
Assessed by evaluating the microbes present in a stool sample
Composition of the oral microbiome
Assessed by evaluating the microbes present in an oral swab
Pain intensity score
Rating of pain from 0 (no pain) to 10 (worst imaginable pain)
Inflammatory mediator profiling
Assessment of cytokines in plasma
C-reactive protein
Assessment C-reactive protein in serum
Procalcitonin levels
Assessment of procalcitonin in serum
Complete blood count with differential
Assessment of proportions of red blood cells, white blood cells, and platelets in whole blood

Full Information

First Posted
March 22, 2019
Last Updated
April 15, 2022
Sponsor
University of Pennsylvania
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1. Study Identification

Unique Protocol Identification Number
NCT03893175
Brief Title
Towards Predicting the Analgesic Response to Ibuprofen Following Third-molar Extraction
Official Title
Towards Predicting the Analgesic Response to Ibuprofen Following Third-molar Extraction
Study Type
Interventional

2. Study Status

Record Verification Date
April 2022
Overall Recruitment Status
Completed
Study Start Date
May 10, 2019 (Actual)
Primary Completion Date
March 2, 2022 (Actual)
Study Completion Date
March 2, 2022 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Pennsylvania

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Product Manufactured in and Exported from the U.S.
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
This research study will evaluate inter-individual variability in the analgesic response to the non-steroidal anti-inflammatory drug (NSAID) ibuprofen after third molar extraction surgery. It will also investigate demographic, clinical, genetic, and environmental factors that cause this variability.
Detailed Description
The dramatic increase in opioid prescriptions over the past years has been linked to the concomitant rise in opioid addiction and to deaths from opioid abuse. Young adults' initial exposure to opioid analgesics is often following extraction of their impacted third molars, with an average of 5,000,000 cases in the USA per year. Over-prescribing of opioids for surgical pain, often 2-5 times more than patients actually use, further exacerbates this problem, as patients tend to save leftover pills rather than discard them. Up to 70% of individuals who become addicted to prescription opioids had access to leftover pills prescribed for others. This is particularly troubling as the odds of transitioning to heroin from prescription opioid abuse are much higher than other suspected gateway drugs, about 40 fold greater than non-gateway drug users. Heroin is now often laced with fentanyl derivatives making overdose and death more likely in even the most opioid tolerant individuals. Multiple studies have demonstrated that non-addicting nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac are effective in relieving pain after dental impaction surgery, being at least equally efficacious to optimal doses of immediate release opioid formulations combined with acetaminophen. However, these assessments of pain relief represent average scores and approximately 22% and 50% of individuals required additional opioid-containing rescue analgesics when ibuprofen and diclofenac were employed at FDA-approved dosages. A deeper understanding of the sources of variability in pain relief should allow improvements in the overall efficacy of NSAIDs by targeting treatment to those who are most likely to receive sufficient pain relief. Thus, optimizing pain therapy with NSAIDs by personalization would be expected to help limit the unnecessary prescription of highly addicting immediate release opioids. Moreover, these results may have applicability to other types of pain that are driven by inflammation.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Impacted Third Molar Tooth, Pain, Acute
Keywords
Non-steroidal anti-inflammatory drugs

7. Study Design

Primary Purpose
Other
Study Phase
Phase 1
Interventional Study Model
Parallel Assignment
Model Description
Subjects will be randomized to receive either ibuprofen or placebo after third molar extraction when pain intensity is at least 4/10. Four hours after the masked ibuprofen or placebo, all subjects will receive open-label ibuprofen + acetaminophen to be taken every 4 hours for the first 2 days and then as needed for up to 7 days after oral surgery. Oxycodone will be available as a rescue medication if additional analgesic is requested.
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Masking Description
Administration of ibuprofen vs. placebo will be masked.
Allocation
Randomized
Enrollment
86 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Ibuprofen
Arm Type
Experimental
Arm Description
During the double-blind stage, subjects will receive blinded ibuprofen (400 mg by mouth) when pain is at least 4/10 following third molar extraction. During the open-label stage, all subjects will receive ibuprofen (400 mg by mouth) and acetaminophen (500 mg by mouth) to be taken every 4 hours around the clock for the first 2 days after third molar extraction and then as needed for pain up to 7 days after third molar extraction. Rescue medication (oxycodone 5 mg by mouth) will be available if additional analgesic is requested.
Arm Title
Placebo
Arm Type
Placebo Comparator
Arm Description
During the double-blind stage, subjects will receive blinded placebo when pain is at least 4/10 following third molar extraction. During the open-label stage, all subjects will receive ibuprofen (400 mg by mouth) and acetaminophen (500 mg by mouth) to be taken every 4 hours around the clock for the first 2 days after third molar extraction and then as needed for pain up to 7 days after third molar extraction. Rescue medication (oxycodone 5 mg by mouth) will be available if additional analgesic is requested.
Intervention Type
Drug
Intervention Name(s)
Ibuprofen
Other Intervention Name(s)
Advil
Intervention Description
400 mg by mouth every 4 hours for 2 days after third molar extraction and then as needed for pain up to 7 days after third molar extraction
Intervention Type
Drug
Intervention Name(s)
Acetaminophen
Other Intervention Name(s)
Tylenol
Intervention Description
500 mg by mouth every 4 hours for 2 days after third molar extraction and then as needed for pain up to 7 days after third molar extraction
Intervention Type
Drug
Intervention Name(s)
Placebo
Intervention Description
By mouth
Intervention Type
Drug
Intervention Name(s)
Oxycodone
Intervention Description
5 mg by mouth every 6 hours as needed for pain
Primary Outcome Measure Information:
Title
Analgesic response
Description
Need for opioid rescue medication after administration of blinded study drug
Time Frame
Up to 4 hours after taking blinded ibuprofen or placebo
Secondary Outcome Measure Information:
Title
Ibuprofen plasma concentrations
Description
Assessed by measuring the amount of ibuprofen in plasma
Time Frame
Up to 7 days
Title
Acetaminophen plasma concentrations
Description
Assessed by measuring the amount of acetaminophen in plasma
Time Frame
Up to 7 days
Title
Gene expression profiling
Description
mRNA levels will be measured in peripheral blood mononuclear cells
Time Frame
Up to 7 days
Title
COX-1 activity
Description
COX-1 activity will be measured ex vivo using a whole blood assay and in vivo by quantifying concentrations of prostaglandin metabolites in urine.
Time Frame
Up to 7 days
Title
COX-2 activity
Description
COX-2 activity will be measured ex vivo using a whole blood assay and in vivo by quantifying concentrations of prostaglandin metabolites in urine.
Time Frame
Up to 7 days
Title
DNA sequencing
Description
Assessment of genetic variation
Time Frame
1 day
Title
Urinary metabolomics
Description
Assessed by measuring levels of metabolites in urine
Time Frame
Up to 7 days
Title
Plasma metabolomics
Description
Assessed by measuring levels of metabolites in plasma
Time Frame
Up to 7 days
Title
Composition of the gut microbiome
Description
Assessed by evaluating the microbes present in a stool sample
Time Frame
1 day
Title
Composition of the oral microbiome
Description
Assessed by evaluating the microbes present in an oral swab
Time Frame
1 day
Title
Pain intensity score
Description
Rating of pain from 0 (no pain) to 10 (worst imaginable pain)
Time Frame
Up to 7 days
Title
Inflammatory mediator profiling
Description
Assessment of cytokines in plasma
Time Frame
Up to 7 days
Title
C-reactive protein
Description
Assessment C-reactive protein in serum
Time Frame
Up to 7 days
Title
Procalcitonin levels
Description
Assessment of procalcitonin in serum
Time Frame
Up to 7 days
Title
Complete blood count with differential
Description
Assessment of proportions of red blood cells, white blood cells, and platelets in whole blood
Time Frame
Up to 7 days

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
64 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Men and women greater than 18 years of age requiring extraction of at least one impacted mandibular third molar tooth (at least 50% covered with bone). Body mass index (BMI) between 18 and 30 kg/m2. Absence of other major medical problems or contraindications to surgery or study drugs. Has not used tobacco products, including smoking cessation nicotine-containing products (e.g., nicotine patch, nicotine gum), for at least the 3 months prior to screening. Female subjects of child bearing potential must be using a medically acceptable method of contraception (oral contraception, Depo-Provera injection, IUD, condom with spermicide, diaphragm, cervical cap, progestin implant, abstinence, tubal ligation, oophorectomy, TAH) throughout the entire study period. All female subjects must consent to a urine pregnancy test at screening and a urine pregnancy test on the day of surgery, which must be negative at all time points. Has not ingested caffeine-containing products within 12 hours of surgery. All subjects must consent to a urine drug test at screening. Results must be negative. A positive result will be reported to the subject. Does not consume more than 1 alcoholic beverage per day on average. Subjects must reach a level of at least moderate pain within four hours of surgery completion, with a pain score greater than or equal to 4 on a 0-10 numerical pain scale Subjects must be willing and able to complete safety and efficacy diaries. An escort must be available to pick up the subject at the end of at the end of the surgical/dosing visit (Visit #2) In the opinion of the investigators or research coordinators, subjects must be willing and able to understand and comply with study procedures, including completing safety and efficacy diaries at home. Able and willing to provide written informed consent prior to any study procedures being performed. Exclusion Criteria: Female subjects who are pregnant or nursing a child. Subjects who have received an investigational drug or used an experimental medical device within 30 days prior to screening, or who gave a blood donation of ≥ one pint within 8 weeks prior to screening. Subjects who are sensitive or allergic to ibuprofen, acetaminophen, or their components. Subjects who are sensitive or allergic to aspirin or other NSAIDs. Subjects who are sensitive or allergic to oxycodone or other opioids (excluding nausea and constipation). Presence of a serious medical condition (e.g. poorly controlled hypertension or diabetes, gastrointestinal disorders such as bleeding ulcer, coagulation or bleeding disorders, significantly impaired cardiac, renal, hepatic, respiratory, or thyroid function) that according to the investigator may interfere with interpretation of the study results or compromise the safety of a potential subject. Acute local infection at the time of surgery that could confound post-surgical evaluation. Use of any confounding prescription or non-prescription drug within 24 hours of the surgical procedure, including analgesics, sedating antihistamine, sedative, alcohol, or CNS/psychotropic agents (i.e. sleep aids, benzodiazepines, performance/attention enhancers, marijuana, anti-depressants). Hormonal contraceptives, hormone replacement therapy (including males taking testosterone as a hormone replacement to treat a documented low testosterone level), or thyroid replacement hormones are allowed. Individuals taking other/additional chronic stable medications can be considered on a case-by-case basis for inclusion in the study if agreed upon by judgment of the investigator. Subjects who have taken NSAIDs, including acetaminophen, or other medications for pain, including aspirin or aspirin-containing products within 1 week of study drug administration. Subjects who routinely consume high doses of antioxidant vitamins daily (vitamin C > 1000mg, Vitamin E > 400IU, Beta Carotene > 1000IU, Vitamin A > 5000IU, Selenium > 200mcg, Folic Acid > 1mg) during the 2 weeks prior to the start of the study. Subjects with any abnormal laboratory value or physical finding that according to the investigator may interfere with interpretation of the study results, be indicative of an underlying disease state, or compromise the safety of a potential subject. Subjects who have a history of abuse of narcotics, street drugs, prescription sleeping pills, based upon history and judgment of the Investigator. Subjects who are unwilling to provide a blood sample for genetic analyses. Employees of the principal investigator, sub-investigators, or relative of an employee who is directly involved in this study.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Tilo Grosser, MD
Organizational Affiliation
University of Pennsylvania
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
Katherine N Theken, PharmD, PhD
Organizational Affiliation
University of Pennsylvania
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
Elliot V Hersh, DMD, MS, PhD
Organizational Affiliation
University of Pennsylvania
Official's Role
Principal Investigator
First Name & Middle Initial & Last Name & Degree
John Farrar, MD, PhD
Organizational Affiliation
University of Pennsylvania
Official's Role
Principal Investigator
Facility Information:
Facility Name
Institute for Translational Medicine and Therapeutics (ITMAT), University of Pennsylvania School of Medicine
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
17666691
Citation
Friedman JW. The prophylactic extraction of third molars: a public health hazard. Am J Public Health. 2007 Sep;97(9):1554-9. doi: 10.2105/AJPH.2006.100271. Epub 2007 Jul 31.
Results Reference
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PubMed Identifier
29602656
Citation
Gauger EM, Gauger EJ, Desai MJ, Lee DH. Opioid Use After Upper Extremity Surgery. J Hand Surg Am. 2018 May;43(5):470-479. doi: 10.1016/j.jhsa.2018.02.026. Epub 2018 Mar 27.
Results Reference
background
PubMed Identifier
27663358
Citation
Maughan BC, Hersh EV, Shofer FS, Wanner KJ, Archer E, Carrasco LR, Rhodes KV. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug Alcohol Depend. 2016 Nov 1;168:328-334. doi: 10.1016/j.drugalcdep.2016.08.016. Epub 2016 Sep 20.
Results Reference
background
PubMed Identifier
28697049
Citation
Thiels CA, Anderson SS, Ubl DS, Hanson KT, Bergquist WJ, Gray RJ, Gazelka HM, Cima RR, Habermann EB. Wide Variation and Overprescription of Opioids After Elective Surgery. Ann Surg. 2017 Oct;266(4):564-573. doi: 10.1097/SLA.0000000000002365.
Results Reference
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PubMed Identifier
28252892
Citation
Substance Abuse and Mental Health Services Administration (US); Office of the Surgeon General (US). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health [Internet]. Washington (DC): US Department of Health and Human Services; 2016 Nov. Available from http://www.ncbi.nlm.nih.gov/books/NBK424857/
Results Reference
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PubMed Identifier
26760086
Citation
Compton WM, Jones CM, Baldwin GT. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med. 2016 Jan 14;374(2):154-63. doi: 10.1056/NEJMra1508490. No abstract available.
Results Reference
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PubMed Identifier
6763202
Citation
Cooper SA, Engel J, Ladov M, Precheur H, Rosenheck A, Rauch D. Analgesic efficacy of an ibuprofen-codeine combination. Pharmacotherapy. 1982 May-Jun;2(3):162-7. doi: 10.1002/j.1875-9114.1982.tb04528.x.
Results Reference
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PubMed Identifier
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Citation
Hersh EV, Levin LM, Adamson D, Christensen S, Kiersch TA, Noveck R, Watson G 2nd, Lyon JA. Dose-ranging analgesic study of Prosorb diclofenac potassium in postsurgical dental pain. Clin Ther. 2004 Aug;26(8):1215-27. doi: 10.1016/s0149-2918(04)80033-x.
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PubMed Identifier
11117655
Citation
Hersh EV, Levin LM, Cooper SA, Doyle G, Waksman J, Wedell D, Hong D, Secreto SA. Ibuprofen liquigel for oral surgery pain. Clin Ther. 2000 Nov;22(11):1306-18. doi: 10.1016/s0149-2918(00)83027-1.
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Citation
Desjardins PJ, Black PM, Daniels S, Bird SR, Fitzgerald BJ, Petruschke RA, Tershakovec A, Chang DJ. A randomized controlled study comparing rofecoxib, diclofenac sodium, and placebo in post-bunionectomy pain. Curr Med Res Opin. 2004 Oct;20(10):1523-37. doi: 10.1185/030079904X3069.
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Towards Predicting the Analgesic Response to Ibuprofen Following Third-molar Extraction

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