"Medscape Medical News
March 19, 2013 -- People with low back pain may benefit from a hands-on treatment known as osteopathic manual therapy (OMT) more than they do from ultrasound therapy.
A new study suggests that OMT leads t"...
Mechanism of Action
The mechanism of action of carisoprodol in relieving discomfort associated with acute painful musculoskeletal conditions has not been clearly identified.
In animal studies, muscle relaxation induced by carisoprodol is associated with altered interneuronal activity in the spinal cord and in the descending reticular formation of the brain.
Carisoprodol is a centrally acting skeletal muscle relaxant that does not directly relax skeletal muscles.
A metabolite of carisoprodol, meprobamate, has anxiolytic and sedative properties. The degree to which these properties of meprobamate contribute to the safety and efficacy of SOMA is unknown.
The pharmacokinetics of carisoprodol and its metabolite meprobamate were studied in a crossover study of 24 healthy subjects (12 male and 12 female) who received single doses of 250 mg and 350 mg SOMA (see Table 2). The exposure of carisoprodol and meprobamate was dose proportional between the 250 mg and 350 mg doses. The Cmax of meprobamate was 2.5 ± 0.5 μg/mL (mean ± SD) after administration of a single 350 mg dose of SOMA, which is approximately 30% of the Cmax of meprobamate (approximately 8 μg/mL) after administration of a single 400 mg dose of meprobamate.
Table 2: Pharmacokinetic Parameters of Carisoprodol
and Meprobamate (Mean ± SD, n=24)
|250 mg SOMA||350 mg SOMA|
|Cmax (μg/mL)||1.2 ± 0.5||1.8 ± 1.0|
|AUCinf (μg*hr/mL)||4.5 ± 3.1||7.0 ± 5.0|
|Tmax (hr)||1.5 ± 0.8||1.7 ± 0.8|
|T½ (hr)||1.7 ± 0.5||2.0 ± 0.5|
|Cmax (μg/mL)||1.8 ± 0.3||2.5 ± 0.5|
|AUCinf (μg*hr/mL)||32 ± 6.2||46 ± 9.0|
|Tmax (hr)||3.6 ± 1.7||4.5 ± 1.9|
|T½ (hr)||9.7 ± 1.7||9.6 ± 1.5|
Absolute bioavailability of carisoprodol has not been determined. The mean time to peak plasma concentrations (Tmax) of carisoprodol was approximately 1.5 to 2 hours. Co-administration of a high-fat meal with SOMA (350 mg tablet) had no effect on the pharmacokinetics of carisoprodol. Therefore, SOMA may be administered with or without food.
The major pathway of carisoprodol metabolism is via the liver by cytochrome enzyme CYP2C19 to form meprobamate. This enzyme exhibits genetic polymorphism (see Patients with Reduced CYP2C19 Activity below).
Carisoprodol is eliminated by both renal and non-renal routes with a terminal elimination half-life of approximately 2 hours. The half-life of meprobamate is approximately 10 hours.
Exposure of carisoprodol is higher in female than in male subjects (approximately 30-50% on a weight adjusted basis). Overall exposure of meprobamate is comparable between female and male subjects.
Patients with Reduced CYP2C19 Activity
SOMA should be used with caution in patients with reduced CYP2C19 activity. Published studies indicate that patients who are poor CYP2C19 metabolizers have a 4-fold increase in exposure to carisoprodol, and concomitant 50% reduced exposure to meprobamate compared to normal CYP2C19 metabolizers. The prevalence of poor metabolizers in Caucasians and African Americans is approximately 3-5% and in Asians is approximately 15-20%.
The safety and efficacy of SOMA for the relief of acute, idiopathic mechanical low back pain was evaluated in two, 7-day, double blind, randomized, multicenter, placebo controlled, U.S. trials (Studies 1 and 2). Patients had to be 18 to 65 years old and had to have acute back pain ( ≤ 3 days of duration) to be included in the trials. Patients with chronic back pain; at increased risk for vertebral fracture (e.g., history of osteoporosis); with a history of spinal pathology (e.g., herniated nucleus pulposis, spondylolisthesis or spinal stenosis); with inflammatory back pain, or with evidence of a neurologic deficit were excluded from participation. Concomitant use of analgesics (e.g., acetaminophen, NSAIDs, tramadol, opioid agonists), other muscle relaxants, botulinum toxin, sedatives (e.g., barbiturates, benzodiazepines, promethazine hydrochloride), and anti-epileptic drugs was prohibited.
In Study 1, patients were randomized to one of three treatment groups (i.e., SOMA 250 mg, SOMA 350 mg, or placebo) and in Study 2 patients were randomized to two treatment groups (i.e., SOMA 250 mg or placebo). In both studies, patients received study medication three times a day and at bedtime for seven days.
The primary endpoints were the relief from starting backache and the global impression of change, as reported by patients, on Study Day 3. Both endpoints were scored on a 5-point rating scale from 0 (worst outcome) to 4 (best outcome) in both studies. The primary statistical comparison was between the SOMA 250 mg and placebo groups in both studies.
The proportion of patients who used concomitant acetaminophen, NSAIDs, tramadol, opioid agonists, other muscle relaxants, and benzodiazepines was similar in the treatment groups.
The results for the primary efficacy evaluations in the acute, low back pain studies are presented in Table 3.
Table 3: Results of the Primary Efficacy Endpointsa in
Studies 1 and 2
|Study||Parameter||Placebo||SOMA 250 mg||SOMA 350 mg|
|1||Number of Patients||n=269||n=264||n=273|
|Relief from Starting Backache, Mean (SE)b||1.4 (0.1)||1.8 (0.1)||1.8 (0.1)|
|Difference between SOMA and Placebo, Mean (SE)b (95% CI)||0.4 (0.2, 0.5)||0.4 (0.2, 0.6)|
|Global Impression of Change, Mean (SE)b||1.9 (0.1)||2.2 (0.1)||2.2 (0.1)|
|Difference between SOMA and Placebo, Mean (SE)b (95% CI)||0.2 (0.1, 0.4)||0.3 (0.1, 0.4)|
|2||Number of Patients||n=278||n=269|
|Relief from Starting Backache, Mean (SE)b||1.1 (0.1)||1.8 (0.1)|
|Difference between SOMA and Placebo, Mean (SE)b (95% CI)||0.7 (0.5, 0.9)|
|Global Impression of Change, Mean (SE)b||1.7 (0.1)||2.2 (0.1)|
|Difference between SOMA and Placebo, Mean (SE)b (95% CI)||0.5 (0.4, 0.7)|
|a The primary efficacy endpoints (Relief from
Starting Backache and Global Impression of Change) were assessed by the
patients on Study Day 3. These endpoints were scored on a 5-point rating scale
from 0 (worst outcome) to 4 (best outcome).
b Mean is the least squared mean and SE is the standard error of the mean. The ANOVA model was used for the primary statistical comparison between the SOMA 250 mg and placebo groups.
Patients treated with SOMA experienced improvement in function as measured by the Roland-Morris Disability Questionnaire (RMDQ) score on Days 3 and 7.
Last reviewed on RxList: 3/1/2013
This monograph has been modified to include the generic and brand name in many instances.
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