2013 http://informahealthcare.com/drt ISSN: 1061-186X (print), 1029-2330 (electronic) J Drug Target, 2013; 21(6): 551–563 ! 2013 Informa UK Ltd. DOI: 10.3109/1061186X.2013.776054 ORIGINAL ARTICLE Pharmaceutical and medical aspects of hyaluronic acid–ketorolac combination therapy in osteoarthritis treatment: radiographic imaging and bone mineral density Alia A. Badawi 1 , Hanan M. El-Laithy 1 , Demiana I. Nesseem 2 , and Shereen S. El-Husseney 2 1 Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt and 2 National Organization of Drug Control and Research, Cairo, Egypt Abstract The objective of this study was to formulate novel painless combined hyaluronic acid (HA)– ketorolac (KT) membrane for the management of osteoarthritis with rapid analgesic onset, thus avoiding HA frequent invasive intra-articular injections and KT gastrointestinal complaints associated with all non-steroidal anti-inflammatory drugs. HA was chemically crosslinked with carbodiimide/glutaraldehyde to yield membrane of low water content. Different in vitro aspects (mechanical properties, water content and in vitro release) were studied leading to an optimized soft, flexible K8 HA membrane containing 30 mg KT that achieved the desired balance of excellent elasticity and low water content. Moreover, a successful retardation of KT release rate was achieved (82%) after 48 h with favored initial fast drug release in the first hour (32.7%) to attain rapid analgesic effect. The clinical assessments in arthritic rats revealed apparent improvement in joint space narrowing, highest increase in bone mineral density at the proximal tibia and distal femur joints with the absence of osteophytosis only in animal group treated with combined HA–KT membrane. Application of K8 membrane was able to preserve KT plasma concentration above its minimum effective concentration for 48 h therefore, would able to replace six commercial tablets each of 10 mg KT. Keywords Bone mineral density, Freund’s complete adjuvant, hyaluronic acid, ketorolac tromethamine, osteoarthritis, radiography History Received 30 November 2012 Revised 1 February 2013 Accepted 9 February 2013 Published online 22 May 2013 Introduction Osteoarthritis (OA) is a common, progressive joint disease characterized by destruction of articular cartilage, which may affect several joints especially weight-bearing joints such as knee [1] leading to chronic pain and functional restrictions [2]. The disease process of OA is characterized by progressive erosion of articular cartilage, leading to joint space nar- rowing, subchondral sclerosis, synovial inflammation and marginal osteophyte formation [3]. The primary goal of therapeutic management of OA is pain relief and prevention of secondary functional disability and joint damage [1]. Recently, increasing interest has been given to the use of hyaluronic acid (HA) in the treatment of OA because of its safety and efficacy [4–6]. HA is a high molecular weight linear polysaccharide. It is an important component of synovial fluid and extracellular matrix of articular cartil- age, contributing to the elasticity and viscosity of syn- ovial fluid [7]. HA could restore the rheological and anti-inflammatory effects of synovial fluid, which are lost in OA by scavenging prostaglandin, metalloproteinase and other bioactive molecules, thus reducing the level of inflam- matory mediators [8]. However, injected HA is cleared from joints in less than a day [9] because of its degradation in vivo by hyaluronidase (HAase), so it does not exert a long lasting reaction [10]. A useful approach to solve this problem could be through the preparation of chemically crosslinked HA membrane that shows an increased resistance towards degradation by HAase and so, increasing biological activity resulting in an increased half-life of 1.5–9 d [11]. Chemical modification of HA can produce more mechanically and chemically robust material that still retains its biocompatibil- ity and biodegradability [10]. This biocompatible material crosslinks and gels in minutes and swells from a flexible dry membrane to a flexible porous hydrogel in seconds [12]. Although HA appears to be effective in improving function and pain caused by knee OA, it is a slow-acting symptom modifying agent, lacking rapid analgesic effects. Therefore, the clinical use of its marketed commonly used formulation implies the necessity of frequent administration of intra- articular (IA) HA injections for several times [13]. This frequent invasive dosing together with common side-effects to injectables HA that include bruising at the injection site, redness, slight pain, swelling and bacterial infections resulted in inconvenient poor patient compliance [14]. Address for correspondence: Hanan M. El Laithy, Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, 11562, Cairo, Egypt. Tel.: +20 122 312 40 34. E-mail: [email protected]; [email protected]Journal of Drug Targeting Downloaded from informahealthcare.com by Chinese University of Hong Kong on 03/28/14 For personal use only.
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J Drug Target, 2013; 21(6): 551–563! 2013 Informa UK Ltd. DOI: 10.3109/1061186X.2013.776054
ORIGINAL ARTICLE
Pharmaceutical and medical aspects of hyaluronic acid–ketorolaccombination therapy in osteoarthritis treatment: radiographic imagingand bone mineral density
Alia A. Badawi1, Hanan M. El-Laithy1, Demiana I. Nesseem2, and Shereen S. El-Husseney2
1Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt and 2National Organization of Drug
Control and Research, Cairo, Egypt
Abstract
The objective of this study was to formulate novel painless combined hyaluronic acid (HA)–ketorolac (KT) membrane for the management of osteoarthritis with rapid analgesic onset, thusavoiding HA frequent invasive intra-articular injections and KT gastrointestinal complaintsassociated with all non-steroidal anti-inflammatory drugs. HA was chemically crosslinked withcarbodiimide/glutaraldehyde to yield membrane of low water content. Different in vitro aspects(mechanical properties, water content and in vitro release) were studied leading to anoptimized soft, flexible K8 HA membrane containing 30 mg KT that achieved the desiredbalance of excellent elasticity and low water content. Moreover, a successful retardation of KTrelease rate was achieved (82%) after 48 h with favored initial fast drug release in the first hour(32.7%) to attain rapid analgesic effect. The clinical assessments in arthritic rats revealedapparent improvement in joint space narrowing, highest increase in bone mineral density atthe proximal tibia and distal femur joints with the absence of osteophytosis only in animalgroup treated with combined HA–KT membrane. Application of K8 membrane was able topreserve KT plasma concentration above its minimum effective concentration for 48 htherefore, would able to replace six commercial tablets each of 10 mg KT.
Keywords
Bone mineral density, Freund’s completeadjuvant, hyaluronic acid, ketorolactromethamine, osteoarthritis, radiography
History
Received 30 November 2012Revised 1 February 2013Accepted 9 February 2013Published online 22 May 2013
Introduction
Osteoarthritis (OA) is a common, progressive joint disease
characterized by destruction of articular cartilage, which may
affect several joints especially weight-bearing joints such
as knee [1] leading to chronic pain and functional restrictions
[2]. The disease process of OA is characterized by progressive
erosion of articular cartilage, leading to joint space nar-
rowing, subchondral sclerosis, synovial inflammation and
marginal osteophyte formation [3]. The primary goal of
therapeutic management of OA is pain relief and prevention
of secondary functional disability and joint damage [1].
Recently, increasing interest has been given to the use
of hyaluronic acid (HA) in the treatment of OA because
of its safety and efficacy [4–6]. HA is a high molecular
weight linear polysaccharide. It is an important component
of synovial fluid and extracellular matrix of articular cartil-
age, contributing to the elasticity and viscosity of syn-
ovial fluid [7]. HA could restore the rheological and
anti-inflammatory effects of synovial fluid, which are lost
in OA by scavenging prostaglandin, metalloproteinase and
other bioactive molecules, thus reducing the level of inflam-
matory mediators [8]. However, injected HA is cleared from
joints in less than a day [9] because of its degradation in vivo
by hyaluronidase (HAase), so it does not exert a long lasting
reaction [10]. A useful approach to solve this problem could
be through the preparation of chemically crosslinked HA
membrane that shows an increased resistance towards
degradation by HAase and so, increasing biological activity
resulting in an increased half-life of 1.5–9 d [11]. Chemical
modification of HA can produce more mechanically and
chemically robust material that still retains its biocompatibil-
ity and biodegradability [10]. This biocompatible material
crosslinks and gels in minutes and swells from a flexible dry
membrane to a flexible porous hydrogel in seconds [12].
Although HA appears to be effective in improving function
and pain caused by knee OA, it is a slow-acting symptom
the clinical use of its marketed commonly used formulation
implies the necessity of frequent administration of intra-
articular (IA) HA injections for several times [13]. This
frequent invasive dosing together with common side-effects
to injectables HA that include bruising at the injection site,
redness, slight pain, swelling and bacterial infections resulted
in inconvenient poor patient compliance [14].
Address for correspondence: Hanan M. El Laithy, Department ofPharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, CairoUniversity, 11562, Cairo, Egypt. Tel.: +20 122 312 40 34. E-mail:[email protected]; [email protected]
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It was suggested that HA and corticosteroids might act
synergistically. Although corticosteroids have been widely
used, due to their powerful and rapid effects on OA pain,
adverse systemic effects such as hyperglycemia in diabetic
patients, secondary adrenal insufficiency and Cushing’s
syndrome have been reported [15]. Moreover, adverse local
effects such as articular infection, loss of elasticity and
cartilage breakdown have been also mentioned [16].
For these reasons, non-steroidal anti-inflammatory drugs
(NSAIDs) instead of corticosteroids could be considered for
rapid analgesic onset in knee OA. Ketorolac tromethamine
(KT) has been widely used as a powerful analgesic NSAID.
KT is a non-selective cyclooxygenase (COX) inhibitor having
several mechanisms of action including inhibition of prosta-
glandin synthesis, modulator effect on opioid receptors, and
nitric oxide synthesis [17]. Clinical studies have shown that
a single dose of KT is more effective than that of morphine,
pethidine and pentazocine in severe to moderate post
operative pain [18] and has been found to be effective
in the treatment of trauma-related pain and pain associated
with cancer [19]. Thus, KT was chosen to be used rather than
corticosteroids in the present study.
Based on these considerations and to overcome all these
problems, the current work has aimed to improve HA therapy
in knee OA by developing novel combined controlled
membrane therapy containing both HA and KT. In this way,
easy, painless and continuous HA–KT delivery through
skin into the blood stream could be ensured thus producing
stable plasma concentrations over a long period avoiding
invasive frequent IA injections of HA and KT gastrointestinal
complaints associated with all NSAIDs such as bleeding,
perforation and peptic ulceration. Additional objective was
to examine the effects of the developed membranes on rat
adjuvant-induced arthritis using Freund’s complete adjuvant
(FCA), where combined treatment with HA and KT was
compared with HA treatment alone with the aid of radiog-
raphy, bone mineral density (BMD) and histopathology.
Materials and methods
Materials and animals
HA sodium salt from streptococcus equi sp.,
Polyvinylpyrrolidone (PVP) and ethyl cellulose (EC) were
purchased from Sigma-Aldrich (Steinheim, Germany).
revealed values of n50.5 which assures Fickian diffusion
combined mechanism of KT release partially through a
swollen membrane and partially through water-filled pores
[34,67].
Therefore, based on the good mechanical properties and
higher KT released after 48 h, two optimized formulae K8 and
K9 were further progressed to clinical animal study.
Animal experiments
OA is a chronic inflammatory disease involving the release of
several mediators like cytokines and prostaglandin that induce
inflammation due to infiltration of the injured tissues by
immune cells [42]. FCA-induced arthritis in rats is commonly
Figure 6. X-ray radiograph of right knee joint showing radiographic changes in rats’ femur and tibia. (a) Control rat showing normal femoro-tibial jointspace with no marginal osteophytosis. (b) FCA-induced rat showing: (1) minute marginal osteophytosis, (2) femoro-tibial joint space narrowingat femoro-tibial articulation, (3) subchondral bone sclerosis. (c) Animal group treated with plain HA showing rather normalized joint space andno definite evidence of osteophytosis. (d) Animal group treated with K8 showing: (4) smoothness in femoral condyle, (5) restoration of joint space.(e) Animal group treated with K9 showing less improved subchondral cartilage than K8 with no definite evidence of osteophytosis.
Figure 7. (a) BMD level of femoral and tibial bone of different rat groups. (b) DEXA scan of rat knee (tibia and femur) after treatment with K8.
0
20
40
60
80
100
3 6 9 12 15 18 21 24 27
Time (day)
%E
dem
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in r
atkn
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K8 K9 Plain
Figure 5. %Edema inhibition of rat knee joint.
DOI: 10.3109/1061186X.2013.776054 HA–KT combination therapy in osteoarthritis treatment 559
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used to study the clinical and pathological changes character-
izing OA including tenderness, edema, joint swelling, cartil-
age destruction and erosion of the underlying bone due to
decreased concentration of endogenous HA, a major compo-
nent of synovial fluid [41,68,69]. Figure 4(b) reveals that,
inflammation signs including paw redness as well as
progressive swelling around the right knee joints and the
plantar paw region started to appear on the right hind paw
3 d after FCA injection in all induced groups. The anti-
inflammatory response was significantly higher and quick in
groups IV and V treated with KT containing membranes K8
and K9 compared to group III treated with KT free plain HA
membrane. After 27 d of treatment completion, the inflam-
mation signs were relatively disappeared in HA–KT mem-
brane treated animals (Figure 4c) while knee joint and paw
plantar side of animals treated with plain HA membranes,
although partially ameliorated, still showed evident swelling
(Figure 4d).
In order to evaluate the anti-inflammatory effect of KT
during OA treatment, the %edema reduction of right knee
joint swelling was measured. It was clear from Figure 5 that,
%edema reduction 12 d post treatment was 51% and 49% for
K8 and K9, respectively, compared to 29% reduction for plain
HA group. This significant reduction in joint swelling was
attributable mainly to addition of KT, a powerful non-
selective COX inhibitor, to HA membrane and its unique
advantage in inhibition of prostaglandin synthesis at sites of
inflammation thus, initiating rapid relief of pain associated
with this inflammatory stimulus [70]. Therefore, it should be
pointed out that, the developed KT-based HA membrane
combination was thought to be an effective treatment of
arthritis as it is intended to minimize the associated inflam-
mation, tenderness, swelling and to decelerate the progress
of arthritic symptoms as well. Previous reports [71–73]
suggested that, HA alone lacks rapid anti-inflammatory effect
and has weaker activity against edema in inflammatory
animal model while addition of KT might synergize HA
therapeutic effectiveness in OA by enhancing HA accumula-
tion in the joints and controlling inflammation [13].
� Although radiography in OA relies on destruction of
articular cartilage, yet, signs of cartilage damage in the
arthritic rats’ knee joints could not be unequivocally
Figure 8. (a) Histopathology photomicrograph of knee joint of control rat showing normal intact cartilage with normal synovium containing noinflammatory cells and normal chondrocytes (arrow). Hematoxylin and eosin, original magnification¼ 40X. (b) Histopathology photomicrograph ofknee joint of FCA-induced rat showing synovial membrane with mild edema and irregular surface (arrow). Hematoxylin and eosin, originalmagnification¼ 40X. (c) Histopathology photomicrograph of knee joint of FCA-induced rat showing subchondral bone with fragmented trabaculae(arrow) with predominance of bone marrow elements (arrowhead) and osteoids (double arrow). Hematoxylin and eosin, original magnification¼ 40X.(d). Histopathology photomicrograph of articular cartilage from femoro-tibial knee joint of plain HA group showing synovial membrane (arrow) withmild edema (double arrowhead), many intact chondrocytes (arrowhead). Hematoxylin and eosin, original magnification¼ 40X. (e) Histopathologyphotomicrograph of knee joint of K8 group showing femoro-tibial joint with intact chondrocytes (arrowhead), intact synovial membrane (arrow).Hematoxylin and eosin, original magnification¼ 40X. (f) Histopathology photomicrograph of knee joint of K8 group showing intact chondrocytesin subchondral cartilage (arrowhead), well-preserve bony trabeculae (arrow). Hematoxylin and eosin, original magnification¼ 40X.
560 A. A. Badawi et al. J Drug Target, 2013; 21(6): 551–563
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detected due to the small size of rat joints [74]. Only
early effects of OA pathogenesis showed mild cartilage
alterations detected by the presence of bone erosions,
femoro-tibial joint space narrowing and increased sub-
patellar opacity with minute marginal osteophytosis
(Figure 6b) relative to normal rats (Figure 6a). At the
end of the treatment period, X-rays of all treated animals
with and without KT were normalized to a great extent
with apparent improvement of joint space narrowing and
absence of osteophytosis evidence (Figure 6c and d).
These detected improvements supported and confirmed
the potent anti-arthritic effect of HA in the presence or
absence of KT. For better assessment of subtle differ-
ences between formulations, BMD was measured using
DEXA scan. Figure 7 revealed that the mean BMD at the
proximal tibia and distal femur of normal control rats was
0.12� 0.005 and 0.13� 0.003 g/cm2, respectively. After
20 d of FCA induction, a significant decrease (p50.05)
of 26.9% and 43.5% was observed (0.097� 0.017 and
0.091� 0.03 g/cm2). This decrease in BMD suggesting
a successful establishment of OA that was associated
with thinning and loss of bone trabeculae induced by
cytokines or chemical mediators released from inflamed
joints into the adjacent bone [75,76]. Although HA
reported to decrease bone turnover and increased BMD
by increasing osteoblasts formation, therefore regulating
bone mineralization contributing to the overall bone
restoration progression. Nevertheless, application of
KT-containing HA membranes K8, K9 demonstrated
highest increase in BMD of rat tibia and femur (19.3%
and 28.7%, respectively for K8 and 16.5% and 25.75%
for K9) compared to (11.9% and 21.2%) KT-free plain
HA membranes. This might confirm the role of KT in
enhancing accumulation of more HA in the joints [13].
� Histopathological studies showed that the animals of
group I was apparently normal with well-organized intact
cartilage and bone microstructure in femero-tibial joints.
No infiltration of inflammatory cell nor edema were seen
(Figure 8a). However, tissues of FCA-injected animals
(arthritic group II) showed many inflammatory signs
including infiltration of inflammatory cells around bone
DOI: 10.3109/1061186X.2013.776054 HA–KT combination therapy in osteoarthritis treatment 561
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efficacy than conventional treatment with HA alone. The
coupling serves to protect joints from cartilage erosion
with apparent improvement of joint space narrowing, and
significant rapid analgesic onset due to KT powerful anti-
inflammatory role. The superior performance of the devel-
oped cross linked HA membrane containing 30 mg KT was
able to preserve KT plasma concentration over the MEC for
48 h and would be able to replace six commercial tablets
(three tablets per day) each of 10 mg KT.
Acknowledgements
The authors wish to acknowledge the superb efforts of
Dr Mohammed Shaker, Dr Rokia Elbanna, National Research
Center, biological anthropology department, as well as to
Dr Elias Makkar, an orthopedic surgeon for their valuable
support in performing radiographic and DEXA analysis.
Great appreciation to Dr Sahar Drwish, National Organization
of Drug Control and Research, histology department for her
technical assistance in histological analysis.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
References
1. Ozturk C, Atamaz F, Hepguler S, et al. The safety and efficacyof intraarticular hyaluronan wit/without corticosteroid in kneeosteoarthritis: 1 year, single-blind, randomized study. RheumatolInt 2006;26:314–19.
2. Lorenz H, Richter W. Osteoarthritis: cellular and molecularchanges in degenerating cartilage. Prog Histochem Cytochem2006;40:135–63.
3. Sun SF, Chou YJ, Hsu CW, et al. Efficacy of intra-articularhyaluronic acid in patients with osteoarthritis of the ankle: aprospective study. Osteoarthritis Cartilage 2006;14:867–74.
4. Bannuru RR Natov NS, Obadan IE, et al. Therapeutic trajectory ofhyaluronic acid versus corticosteroids in the treatment of kneeosteoarthritis: a systematic review and meta-analysis. ArthritisRheum 2009;61:1704–11.
5. Kim SB, Kwon DR, Kwak H, et al. Additive effects of intra-articular injection of growth hormone and hyaluronic acid in rabbitmodel of collagenase-induced osteoarthritis. J Korean Med Sci2010;2:776–80.
6. Foti C, Cisari C, Carda S, et al. A prospective observational studyof the clinical efficacy and safety of intra-articular sodiumhyaluronate in synovial joints with osteoarthritis. Eur J PhysRehabil Med 2011;47:407–15.
7. Sun SF, Chou YJ, Hsu CW, Chen WL. Hyaluronic acid as atreatment for ankle osteoarthritis. Curr Rev Musculoskelet Med2009;2:78–82.
8. Hakshur K, Benhar I, Bar-Ziv Y, et al. The effect of hyaluronaninjections into human knees on the number of bone and cartilagewear particles captured by bio-ferrography. Acta Biomater 2011;7:848–57.
9. Juni P, Reichenbach S, Trelle S, et al. Efficacy and safety of intra-articular hylan or hyaluronic acids for osteoarthritis of the knee: aRandomized Controlled Trial. Arthritis Rheum 2007;56:3610–19.
10. Pitarresi G, Palumbo FS, Tripodo G, et al. Preparation andcharacterization of new hydrogels based on hyaluronic acid and a,b-polyaspartyl hydrazide. Eur Poly 2007;43:3953–62.
11. Brown MB, Jones SA. Hyaluronic acid: a unique topical vehicle forthe localized delivery of drugs to the skin. J Eur Acad DermatolVenereol 2005;19:308–18.
12. Luo Y, Kirker KR, Prestwich GD. Cross-linked hyaluronic acidhydrogel films: new biomaterials for drug delivery. J ControlRelease 2000;69:169–84.
13. Lee SC, Rha DW, Chang WH. Rapid analgesic onset ofintraarticular hyaluronic acid with ketorolac in osteoarthritisof the knee. J Back Musculoskelet Rehabil 2011;24:31–8.
14. Van Dyke S, Hays GP, Caglia AE, Caglia M. Severe acute localreactions to a hyaluronic acid-derived dermal filler. J Clin AesthetDermatol 2010;3:32–35.
15. Shapiro PS, Rohde RS, Froimson MI, et al. The effect oflocal corticosteroid or ketorolac exposure on histologic andbiomechanical properties of rabbit tendon and cartilage. Hand(NY) 2007;2:165–72.
16. Desai A, Ramankutty S, Board T, Raut V. Does intraarticularsteroid infiltration increase the rate of infection in subsequent totalknee replacements? Knee 2009;16:262–4.
17. Galan-Herrera JF, Poo JL, Maya-Barrios JA, et al. Bioavailabilityof two sublingual formulations of ketorolac tromethamine 30 mg:a randomized, open-label, single-dose, two-period crossover com-parison in healthy Mexican adult volunteers. Clin Ther 2008;30:1667–74.
18. El-Setouhy DA, El-Ashmony SM. Ketorolac trometamol topicalformulations: release behavior, physical characterization, skinpermeation, efficacy and gastric safety. J Pharm Pharmacol 2010;62:25–34.
19. Angeles Gonzalez-Fernandez M. Appropriateness of ketorolac usein a trauma hospital. Rev Calid Asist 2009;24:115–23.
20. Collins MN, Birkinshaw C. Comparison of the effectiveness of fourdifferent crosslinking agents with hyaluronic acid hydrogel filmsfor tissue-culture applications. J Appl Polymer Sci 2007;104:3183–91.
21. Tomihata K, Ikada Y. Crosslinking of hyaluronic acid withglutaraldehyde. J Polym Sci A Polym Chem 1997;35:3553–9.
22. Jinghua C, Jingtao C, Zheng X, Qisheng G. Characteristic ofhyaluronic acid derivative films crosslinked by polyethylene glycolof low water content. J Med Coll PLA 2008;23:15–19.
23. Merrett K, Liu W, Mitra D, et al. Synthetic neoglycopolymer-recombinant human collagen hybrids as biomimetic crosslinkingagents in corneal tissue engineering. Biomaterials 2009;30:5403–8.
24. Shivaraj A, Panner Selvam R, Tamiz Mani T, Sivakumar T. Designand evaluation of transdermal drug delivery of ketotifen fumarate.Int J Pharm Biomed Res 2010;1:42–7.
25. Peh K, Khan T, Ch’ng H. Mechanical, bioadhesive strengthand biological evaluations of chitosan films for wound dressing.J Pharm Pharm Sci 2000;3:303–11.
26. Claudia Cristiano MZ, Fayad SJ, Porto LC, Soldi V. Protein-basedfilms cross-linked with 1-ethyl-3-(3-dimethylamino-propyl) carbo-diimide hydrochloride (EDC): effects of the cross-linker and filmcomposition on the permeation rate of p-hydroxyacetanilide as amodel drug. J Braz Chem Soc 2010;21:340–48.
27. Kerch G, Korkhov V. Effect of storage time and temperature onstructure, mechanical and barrier properties of chitosan-basedfilms. Eur Food Res Techno 2011;232:17–22.
28. Tiwary AK, Sapra B, Jain S. Innovations in transdermal drugdelivery: formulations and techniques. Recent Pat Drug DelivFormul 2007;1:23–36.
29. Saei K, Pongpaibul Y, Viernstein H, Okonogi S. Factorsinfluencing drug dissolution characteristics from hydrophilicpolymer matrix tablet. Sci Pharm 2007;75:147–63.
30. Tanabe M, Watanabe M, Yanagi M, et al. Controlled indomethacinrelease from mucoadhesive film: in vitro and clinical evaluations.Yakugaku Zasshi 2008;128:1673–9.
31. Zhang J, Liu M, Jin H, et al. In vitro enhancement of lactate esterson the percutaneous penetration of drugs with different lipophili-city. AAPS PharmSciTech 2010;11:894–903.
32. Higuchi T. Mechanism of sustained-action medication. Theoreticalanalysis of rate of release of solid drugs dispersed in solid matrices.J Pharm Sci 1963;52:1145–9.
33. Ritger PL, Peppas NA. A simple equation for description of soluterelease II. Fickian and anomalous release from swellable devices.J Control Release 1987;5:37–42.
34. Peppas NA. Analysis of Fickian and non-Fickian drug release frompolymers. Pharm Acta Helve 1985;60:110–11.
35. Lara MG, Bentley MV, Collet JH. In vitro drug release mechanismand drug loading studies of cubic phase gels. Int J Pharm 2005;293:241–50.
36. Dhaneshwar S, Patel V, Patil D, Meena G. Studies on synthe-sis, stability, release and pharmacodynamic profile of a
562 A. A. Badawi et al. J Drug Target, 2013; 21(6): 551–563
Jour
nal o
f D
rug
Tar
getin
g D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y C
hine
se U
nive
rsity
of
Hon
g K
ong
on 0
3/28
/14
For
pers
onal
use
onl
y.
novel diacerein-thymol prodrug. Bioorg Med Chem Lett 2013;23:55–61.
37. Włodarski KH, Dickson GR. Evaluation of locally inducedosteoarthritis by the complete and incomplete Freund’s adjuvantin mice. The application of DEXA measurements. Folia Biol(Praha) 2002;48:192–9.
38. Richard EF, Marilyn JB, Peggy JD, Alicia ZK. Anesthesia andanalgesia in laboratory animals. Copyright Elsevier Inc; June 2008.
39. Brahn E. Animal models of rheumatoid arthritis. Clues to etiologyand treatment. Clin Orthop Relat Res 1991;265:42–53.
40. Kumar VL, Roy S, Sehgal R, Padhy BM. A comparative study onthe efficacy of rofecoxib in monoarticular arthritis induced by latexof Calotropis procera and Freund’s Complete Adjuvant.Inflammopharmacology 2006;14:17–21.
41. Patil KR, Patil CR, Jadhav RB, et al. Anti-arthritic activity ofBartogenic acid isolated from fruits of Barringtonia racemosaRoxb. (Lecythidaceae). Evid Based Complement Alternat Med2011;2:1–7.
42. Kilimozhi D, Parthasarathy V, Amuthavalli N. Effect ofClerodendrum phlomidis on adjuvant induced arthritis in rats – aradiographic densitometric analysis. Int J PharmTech Res 2009;1:1434–41.
43. Arora P, Mukherjee B. Design, development, physicochemical,in vitro and in vivo evaluation of transdermal patches containingdiclofenac diethyl ammonium salts. J Pharm Sci 2002;91:2076–89.
44. Multani NK, Kaur H, Chahal A. Impact of sporting activities onbone mineral density. J Exercise Sci Physiotherapy 2011;7:103–9.
45. Rzonca SO, Suva LG, Gaddy D, et al. Bone is a target for theantidiabetic compound rosiglitazone. Endocrinology 2004;145:401–6.
46. Al-saffar FJ, Ganabadi S, Fakurazi S, et al. Chondroprotectiveeffect of Zerumbone on monosodium iodoacetate induced osteo-arthritis in rats. J Applied Sci 2010;10:248–60.
47. Young JJ, Cheng KM, Tsou TL, et al. Preparation of cross-linkedhyaluronic acid film using 2-chloro-1-methylpyridinium iodide orwater-soluble 1-ethyl-(3,3-dimethylaminopropyl) carbodiimide.J Biomater Sci Polym Ed 2004;15:767–80.
48. Park SN, Park JC, Kim HO, et al. Characterization of porouscollagen/hyaluronic acid scaffold modified by 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide cross-linking. Biomaterials2002;23:1205–12.
49. Collins MN, Birkinshaw C. Physical properties of crosslinkedhyaluronic acid hydrogels. J Mater Sci Mater Med 2008;19:3335–43.
50. Everaerts F, Torrianni M, Hendriks M, Feijen J. Quantificationof carboxyl groups in carbodiimide cross-linked collagen sponge.J Biomed Mater Res 2007;83:1176–83.
51. Parida UK, Nayak AK, Binhani BK, Nayak PL. Synthesis andcharacterization of chitosan-polyvinyl alcohol blended with cloisite30B for controlled release of the anticancer drug curcumin.J Biomater Nanobiotech 2011;2:414–25.
52. Jeon O, Song SJ, Lee KJ, et al. Mechanical properties anddegradation behaviors of hyaluronic acid hydrogels cross-linked atvarious cross-linking densities. Carbohydr Polym 2007;70:251–7.
53. Ammar HO, Ghorab M, El-Nahhas SA, Kamel R. Polymeric matrixsystem for prolonged delivery of tramadol hydrochloride, Part I:physicochemical evaluation. AAPS Pharm Sci Tech 2009;10:1065–70.
54. Lee MW, Chen HJ, Tsao SW. Preparation, characterization andbiological properties of Gellan gum films with 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide cross-linker. CarbohydrPolym 2010;82:920–6.
55. Park SK, Bae DH, Rhee KC. Soy protein biopolymers cross-linkedwith glutaraldehyde. J Am Oil Chem Soc 2000;77:879–84.
56. Powell HM, Boyce ST. EDC cross-linking improves skin substitutestrength and stability. Biomaterials 2006;27:5821–7.
57. Olde Damink LH, Dijkstra PJ, Van Luyn MJ, et al. Cross-linking ofdermal sheep collagen using a water-soluble carbodiimide.Biomaterials 1996;17:765–73.
58. Angele P, Abke J, Kujat R, et al. Influence of different collagenspecies on physico-chemical properties of crosslinked collagenmatrices. Biomaterials 2004;25:2831–41.
59. Alanazi FK, Abdel Rahman AA, Mahrous GM, Alsarra IA.Formulation and physicochemical characterization of buccoadhe-sive films containing ketorolac. J Drug Del Sci 2007;17:183–92.
60. Lemmouchi Y, Murariu M, Margarida Dos Santos A, et al.Plasticization of poly (lactide) with blends of tributyl citrate andlow molecular weight poly (d, l-lactide)-b-poly (ethylene glycol)copolymers. Eur Polymer J 2009;45:2839–48.
61. Jachowicz J, McMullen R. Mechanical analysis of elasticity andflexibility of virgin and polymer-treated hair fiber assemblies.J Cosmet Sci 2002;53:345–61.
62. Patel VM, Prajapati BG, Patel MM. Design and characterization ofchitosan-containing mucoadhesive buccal patches of propranololhydrochloride. Acta Pharm 2007;57:61–72.
64. Antesh KJ, Bhattacharya A, Pankaj VA. Formulation and in vitroevaluation of sustained release matrix tablets of metoprololsuccinate using hydrophilic polymers. Int J PharmTech Res 2009;1:972–77.
65. Dash S, Murthy PN, Nath L, Chowdhury P. Kinetic modeling ondrug release from controlled drug delivery systems. Acta Pol Pharm2010;67:217–23.
66. Ganesh S, Radhakrishnan M, Ravi M, et al. In vitro evaluation ofthe effect of combination of hydrophilic and hydrophobic polymerson controlled release zidovudine matrix tablets. Indian J Pharm Sci2008;70:461–65.
67. Yassin AB, Alsarra IA, Al-Mohizea AM. Chitosan beads as a newgastroretentive system of verapamil. Sci Pharm 2006;74:175–88.
68. Khaled KA, Sarhan HA, Ibrahim MA, et al. Prednisolone-loadedPLGA microspheres, in vitro characterization and in vivo applica-tion in adjuvant-induced arthritis in mice. AAPS PharmSci Tech2010;11:859–69.
69. Ando A, Hagiwara Y, Chimoto E, et al. Intra-articular injection ofhyaluronan diminishes loss of chondrocytes in a rat immobilized-knee model. Tohoku J Exp Med 2008;215:321–31.
70. Zhang Y, Shaffer A, Portanova J, et al. Inhibition ofcyclooxygenase-2 rapidly reverses inflammatory hyperalgesiaand prostaglandin E2 production. J Pharmacol Exp Ther 1997;283:1069–75.
71. Campo GM, Avenoso A, Campo S, et al. Efficacy of treatment withglycosaminoglycans on experimental collagen-induced arthritis inrats. Arthritis Res Ther 2003;5:R122–31.
72. Petrella RJ. Hyaluronic acid for the treatment of knee osteoarthritis:long-term outcomes from a naturalistic primary care experience.Am J Phys Med Rehabil 2005;84:278–83.
73. Chou LW, Wang J, Chang PL, Hsieh YL. Hyaluronan modulatesaccumulation of hypoxia-inducible factor-1 alpha, inducible nitricoxide synthase, and matrix metalloproteinase-3 in the synovium ofrat adjuvant-induced arthritis model. Arthritis Res Ther 2011;13:R90–102.
74. Kinne RW, Meyer P, Grunder W, et al. Rat antigen-inducedarthritis: cartilage alterations assessed with iodine-123-antileuko-proteinase. J Nucl Med 1998;39:1638–45.
75. Goldring SRMB. Bone and cartilage in osteoarthritis: is what’s bestfor one good or bad for the other? Arthritis Res Ther 2010;12:143–4.
76. Okazaki A, Koshino T, Saito T, Takagi T. Osseous tissue reactionaround hydroxyapatite block implanted into proximal metaphysis oftibia of rat with collagen-induced arthritis. Biomaterials 2000;21:483–7.
77. Cohen MN, Christians U, Henthorn T, et al. Pharmacokinetics ofsingle-dose intravenous ketorolac in infants aged 2–11 months.Anesth Analg 2011;112:655–60.
DOI: 10.3109/1061186X.2013.776054 HA–KT combination therapy in osteoarthritis treatment 563