1
|
Rodrigues de Almeida A, Jaime Bezerra Mendonça Junior F, Tavares Dantas A, Eduarda de Oliveira Gonçalves M, Chêne C, Jeljeli M, Chouzenoux S, Thomas M, David de Azevedo Valadares L, Andreza Bezerra Correia M, Ângela da Silva Alves W, Carvalho Lira E, Doridot L, Jesus Barreto de Melo Rêgo M, Cristiny Pereira M, Luzia Branco Pinto Duarte A, Saes Parra Abdalla D, Nicco C, Batteux F, Galdino da Rocha Pitta M. IBPA a mutual prodrug of ibuprofen and acetaminophen alleviates inflammation, immune dysregulation and fibrosis in preclinical models of systemic sclerosis. Int Immunopharmacol 2024; 136:112344. [PMID: 38833846 DOI: 10.1016/j.intimp.2024.112344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/06/2024]
Abstract
Systemic sclerosis (SSc) is a devastating autoimmune illness with a wide range of clinical symptoms, including vascular abnormalities, inflammation, and persistent and progressive fibrosis. The disease's complicated pathophysiology makes it difficult to develop effective therapies, necessitating research into novel therapeutic options. Molecular hybridization is a strategy that can be used to develop new drugs that act on two or multiple targets and represents an interesting option to be explored for the treatment of complex diseases. We aimed to evaluate the effects of a hybrid mutual prodrug of ibuprofen and acetaminophen (IBPA) in peripheral blood mononuclear cells (PBMC) isolated from SSc patients, and in an in vivo model of SSc induced in BALB/c mice by intradermal injections of hypochlorous acid (HOCl) for 6 weeks. The mice were treated at the same time with daily intraperitoneal injections of IBPA (40 mg/kg). Pulmonary and skin fibrosis as well as immune responses were evaluated. IBPA significantly decreased the release of cytokines in PBMC culture supernatants from SSc patients after stimulation with phytohemagglutinin-M (IL-2, IL-4, IL-6, IL-10, IL-13, IL-17A, TNF and IFN-γ).In HOCl-induced SSc, IBPA treatment prevented dermal and pulmonary fibrosis, in addition to reducing CD4 + T and B cells activation and reversing the M2 polarization of macrophages in spleen cells, and inhibiting IFN-γ secretion in splenocyte cultures. These results show the anti-inflammatory and antifibrotic effects of IBPA in SSc and highlight the therapeutic potential of this mutual prodrug, providing support for future studies.
Collapse
Affiliation(s)
- Anderson Rodrigues de Almeida
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil; Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | - Francisco Jaime Bezerra Mendonça Junior
- Laboratório de Síntese e Vetorização de Moléculas, Departamento de Ciências Biológicas, Centro de Ciências Biológicas e Sociais Aplicadas, Universidade Estadual da Paraíba, João Pessoa, PB, Brazil
| | - Andréa Tavares Dantas
- Serviço de Reumatologia, Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Maria Eduarda de Oliveira Gonçalves
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Charlotte Chêne
- Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | - Mohamed Jeljeli
- Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | | | - Marine Thomas
- Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | | | - Maria Andreza Bezerra Correia
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | | | - Eduardo Carvalho Lira
- Departamento de Fisiologia e Farmacologia, Centro de Biociências, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Ludivine Doridot
- Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | - Moacyr Jesus Barreto de Melo Rêgo
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Michelly Cristiny Pereira
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil; Departamento de Fisiologia e Farmacologia, Centro de Biociências, Universidade Federal de Pernambuco, Recife, PE, Brazil.
| | | | - Dulcineia Saes Parra Abdalla
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carole Nicco
- Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | - Frédéric Batteux
- Université Paris Cité, Institut Cochin, Inserm, CNRS, Paris, France
| | - Maira Galdino da Rocha Pitta
- Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil
| |
Collapse
|
2
|
Nikitas J, Yanagawa J, Sacks S, Hui EK, Lee A, Deng J, Abtin F, Suh R, Lee JM, Toste P, Burt BM, Revels SL, Cameron RB, Moghanaki D. Pathophysiology and Management of Chest Wall Pain after Surgical and Non-Surgical Local Therapies for Lung Cancer. JTO Clin Res Rep 2024; 5:100690. [PMID: 39077624 PMCID: PMC11284817 DOI: 10.1016/j.jtocrr.2024.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/18/2024] [Accepted: 05/08/2024] [Indexed: 07/31/2024] Open
Abstract
Chest wall pain syndromes can emerge following local therapies for lung cancer and can adversely affect patients' quality-of-life. This can occur after lung surgery, radiation therapy, or percutaneous image-guided thermal ablation. This review describes the multifactorial pathophysiology of chest wall pain syndromes that develop following surgical and non-surgical local therapies for lung cancer and summarizes evidence-based management strategies for inflammatory, neuropathic, myofascial, and osseous pain. It discusses a step-wise approach to treating chest wall pain that begins with non-opioid oral analgesics and includes additional pharmacologic treatments as clinically indicated, such as anticonvulsants, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, and various topical treatments. For myofascial pain, physical medicine techniques, such as acupuncture, trigger point injections, deep tissue massage, and intercostal myofascial release can also offer pain relief. For severe or refractory cases, opioid analgesics, intercostal nerve blocks, or intercostal nerve ablations may be indicated. Fortunately, palliation of treatment-related chest wall pain syndromes can be managed by most clinical providers, regardless of the type of local therapy utilized for a patient's lung cancer treatment. In cases where a patient's pain fails to respond to initial medical management, clinicians can consider referring to a pain specialist who can tailor a more specific pharmacologic approach or perform a procedural intervention to relieve pain.
Collapse
Affiliation(s)
- John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Jane Yanagawa
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Sandra Sacks
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, California
| | - Edward K. Hui
- Center for East-West Medicine, University of California, Los Angeles, Los Angeles, California
| | - Alan Lee
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Jie Deng
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Fereidoun Abtin
- Thoracic Imaging and Intervention, Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, California
| | - Robert Suh
- Thoracic Imaging and Intervention, Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, California
| | - Jay M. Lee
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Paul Toste
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Bryan M. Burt
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Sha’Shonda L. Revels
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Robert B. Cameron
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Drew Moghanaki
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| |
Collapse
|
3
|
Palya M, Chevere JM, Drum M, Fowler S, Nusstein J, Reader A, Ni A. Pain Reduction of Ibuprofen Sodium Dihydrate Alone and in Combination with Acetaminophen in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation. J Endod 2024; 50:881-888. [PMID: 38657900 DOI: 10.1016/j.joen.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Most pain studies have been based on a postsurgical, third molar model using ibuprofen (IBU)/acetaminophen (APAP). Studies have found quicker onset of pain relief with a newer formulation of IBU - ibuprofen sodium dihydrate (ISD). The purpose of this study was to compare pain reduction of ISD/APAP to ISD in an acute endodontic pain model of untreated patients experiencing moderate to severe pain with symptomatic apical periodontitis. METHODS AND MATERIALS In this double-blind randomized study, 64 adult emergency patients in acute moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and symptomatic apical periodontitis participated. Each patient randomly received either one dose of 768 mg ISD/1000 mg APAP or one dose of 768 mg ISD. Pain intensity scores were recorded every 15 minutes over 240 minutes using the Heft-Parker VAS along with time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief also recorded. The data were analyzed statistically. RESULTS Both ISD and ISD/APAP groups showed a progressive decrease in pain from baseline to 120 minutes after medication administration. Afterward, a relative plateau was seen in the patients' pain. There was no difference in the VAS scores between the ISD and ISD/APAP at any given time point, time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief. CONCLUSIONS The addition of APAP to ISD for pain control in an untreated endodontic pain model did not differ significantly from ISD alone.
Collapse
Affiliation(s)
- Morgan Palya
- Former Graduate Student in Endodontics, Division of Endodontics, The Ohio State University, Pittsburg, Pennsylvania
| | - Janine Matos Chevere
- Former Graduate Student in Endodontics, Division of Endodontics, The Ohio State University, Holland and Muskegon, Michigan
| | - Melissa Drum
- Professor and Graduate Program Director, Division of Endodontics, The Ohio State University, Columbus, Ohio
| | - Sara Fowler
- Associate Professor and Predoctoral Director, Division of Endodontics, The Ohio State University, Columbus, Ohio
| | - John Nusstein
- Professor and Chair, Division of Endodontics, The Ohio State University, Columbus, Ohio
| | - Al Reader
- Emeritus Professor, Division of Endodontics, The Ohio State University, Columbus, Ohio.
| | - Andy Ni
- Assistant Professor, Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio
| |
Collapse
|
4
|
Welle K, Colorafi K, Daratha K. Opioid and Nerve Block Administration in Knee Arthroplasty: An Observational Retrospective Evaluation. Pain Manag Nurs 2023; 24:542-548. [PMID: 37271628 DOI: 10.1016/j.pmn.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/20/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023]
Abstract
AIMS Increasing opioid-related adverse events and deaths have amplified interest in non-opioid analgesic options. Peripheral nerve blocks (PNBs) are useful in pain management, especially in minimally invasive day surgeries. This evaluation sought to examine patterns of opioid use among adult patients undergoing total knee arthroplasty, stratified by use of PNBs. DESIGN A retrospective, observational design. SETTINGS A large tertiary medical center and community hospital in the Inland Northwest. PARTICIPANTS/SUBJECTS A dataset of 8,493 adult patients undergoing elective total knee arthroplasty, 3,432 of which received a PNB while 5,061 did not. METHODS A deidentified dataset was obtained to evaluate: (a) opioid use frequency, (b) average morphine milligram equivalents (MMEs) administered, (c) independent factors associated with opioid administration, and (d) time to first opioid administered in adults undergoing total knee arthroplasty while in the recovery room, stratified by use of PNBs. RESULTS When controlling for general anesthesia, opioid use frequency was reduced when PNBs were administered (p < .05). The amount of MMEs consumed was 15 mg less in the group receiving a PNB (p < .001). In a linear regression model, PNBs reduced the MMEs consumed by 5 mg (p = .014). Time-to-first opioid was increased in patients receiving general anesthesia and PNBs with a hazards ratio of 0.70 (p < .001). CONCLUSIONS Peripheral nerve blocks are an opioid-sparing technique in adult patients undergoing total knee arthroplasty. CLINICAL IMPLICATIONS The results confirm best practices regarding opioid-sparing PNBs. Postoperative opioids are appropriate, but regimens incorporating PNB administration for total knee arthroplasty help reduce opioid use.
Collapse
Affiliation(s)
- Kelsey Welle
- School of Nursing and Human Physiology, Gonzaga University
| | - Karen Colorafi
- School of Nursing and Human Physiology, Gonzaga University.
| | | |
Collapse
|
5
|
Qin M, Ye G, Xin J, Li M, Sui X, Sun Y, Fu Q, He Z. Comparison of in vivo behaviors of intramuscularly long-acting celecoxib nanosuspensions with different particle sizes for the postoperative pain treatment. Int J Pharm 2023; 636:122793. [PMID: 36870401 DOI: 10.1016/j.ijpharm.2023.122793] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/18/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Celecoxib (CXB) has a good analgesic effect on postoperative acute pain, but clinically its compliance is compromised because of frequent administration. Therefore, the development of injectable celecoxib nanosuspensions (CXB-NS) for long-acting analgesic effects is highly desirable. However, how the particle size affects the in vivo behaviors of CXB-NS remains unclear. Herein, CXB-NS with different sizes were prepared by the wet-milling method. Following intramuscular (i.m.) injection in rats (50 mg/kg), all CXB-NS achieved sustained systemic exposure and long-acting analgesic effects. More importantly, CXB-NS showed size-dependent pharmacokinetic profiles and analgesic effects, and the smallest CXB-NS (about 0.5 μm) had the highest Cmax, T1/2, and AUC0-240h and the strongest analgesic effects on incision pain. Therefore, small sizes are preferred for long action by i.m. injection, and the CXB-NS developed in this study were alternative formulations for the treatment of postoperative acute pain.
Collapse
Affiliation(s)
- Mengdi Qin
- Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Genyang Ye
- Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Jinghan Xin
- Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Mo Li
- Liaoning Institute for Drug Control, No. 7, Chongshan West Road, Shenyang 110016, China
| | - Xiaofan Sui
- Liaoning Institute for Drug Control, No. 7, Chongshan West Road, Shenyang 110016, China
| | - Yichi Sun
- Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Qiang Fu
- Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China.
| | - Zhonggui He
- Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China.
| |
Collapse
|
6
|
Fritsch G, Steltzer H, Oberladstaetter D, Zeller C, Prossinger H. Artificial intelligence algorithms predict the efficacy of analgesic cocktails prescribed after orthopedic surgery. PLoS One 2023; 18:e0280995. [PMID: 36730239 PMCID: PMC9894442 DOI: 10.1371/journal.pone.0280995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/30/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Mixtures ('cocktails') of various analgesics are more effective in controlling post-operative pain because of potential synergetic effects. Few studies have investigated such effects in large combinations of analgesics and no studies have determined the probabilities of effectiveness. METHODS We used one-hot encoding of the categorical variables reported pain levels and the administered cocktails (from a total of eight analgesics) and then applied an unsupervised neural network and then the unsupervised DBSCAN algorithm to detect clusters of cocktails. We used Bayesian statistics to classify the effectiveness of these cocktails. RESULTS Of the 61 different cocktails administered to 750 patients, we found that four combinations of three to four analgesics were by far the most effective. All these cocktails contained Metamizole and Paracetamol; three contained Hydromorphone and two contained Diclofenac and one Diclofenac-Orphenadrine. The ML probability that these cocktails decreased pain levels ranged from 0.965 to 0.981. Choice of a most effective cocktail involves choosing the optimum in a 4-dimensional parameter space: maximum probability of efficacy, confidence interval about maximum probability, fraction of patients with increase in pain levels, relative number of patients with successful pain level decrease. CONCLUSIONS We observed that administering one analgesic or at most two is not effective. We found no statistical indicators that interactions between analgesics in the most effective cocktails decreased their effectiveness. Pairs of most effective cocktails differed by the addition of only one analgesic (Diclofenac-Orphenadrine for one pair and Hydromorphone for the other). We conclude that the listed cocktails are to be recommended.
Collapse
Affiliation(s)
- Gerhard Fritsch
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Hospital Salzburg, Salzburg, Austria
- Paracelsus Medical University, Salzburg, Austria
- * E-mail:
| | - Heinz Steltzer
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Meidling, Austria
- Sigmund Freud University Vienna, Austria
| | - Daniel Oberladstaetter
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Hospital Salzburg, Salzburg, Austria
| | | | - Hermann Prossinger
- Department of Evolutionary Biology, University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Zangrilli J, Gouda N, Voskerijian A, Wang ML, Beredjiklian PK, Rivlin M. A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study. Hand (N Y) 2022; 17:1187-1193. [PMID: 33356569 PMCID: PMC9608278 DOI: 10.1177/1558944720975146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively. METHODS Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain. RESULTS From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing. CONCLUSIONS The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.
Collapse
Affiliation(s)
- Julian Zangrilli
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Nura Gouda
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Armen Voskerijian
- Jefferson Surgery Center at The Navy Yard, Philadelphia, PA, USA
- United Anesthesia Services, P.C., Bryn Mawr, PA, USA
| | - Mark L. Wang
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | | |
Collapse
|
8
|
Teoh L, McCullough M, Taing MW. Efficacy of oxycodone for postoperative dental pain: A systematic review and meta-analysis. J Dent 2022; 125:104254. [PMID: 35977697 DOI: 10.1016/j.jdent.2022.104254] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/25/2022] [Accepted: 08/13/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Dental pain is a commonly managed presentation in medicine and dentistry, where oxycodone is often prescribed. The aim of this systematic review and meta-analysis was to determine and quantify the effectiveness of oxycodone for acute dental pain. DATA Randomised controlled trials, controlled trials and comparative studies were included involving patients >12 years, where oxycodone was trialled for dental pain. SOURCES Three databases were searched: Medline Ovid, Embase Ovid and Web of Science. Two authors independently screened title and abstracts for relevance, extracted data and performed bias assessments. STUDY SELECTION Of 148 potentially relevant studies, 13 articles met the inclusion criteria for the systematic review and of the 13, nine studies were included in the meta-analysis. All studies were single-dose analgesia for surgical third molar extractions. CONCLUSIONS Oxycodone produced more effective analgesia in combination with paracetamol. In the meta-analysis, monotherapy etoricoxib and rofecoxib showed significant pain relief compared to combination oxycodone/paracetamol (SPID6 mean difference=-2.13, CI=-3.29, -0.98; TOTPAR6 mean difference=-2.98, CI=-4.90, -1.06). Non-steroidal anti-inflammatory drugs (NSAIDs) were more effective than oxycodone/paracetamol combinations, however, the evidence would become weak in a future study with a similar patient setting due to substantial statistical heterogeneity (SPID6 and TOTPAR6 prediction interval -4.471, 0.207 and -7.28, 1.32 respectively). CLINICAL SIGNIFICANCE Non-steroidal anti-inflammatory drugs were superior than oxycodone/paracetamol combinations, although some patient populations may experience similar effects to the combined oxycodone/paracetamol combination.
Collapse
Affiliation(s)
- Leanne Teoh
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia.
| | - Michael McCullough
- Melbourne Dental School, The University of Melbourne, Carlton, Victoria, Australia
| | - Meng-Wong Taing
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
| |
Collapse
|
9
|
Chen HY, Wang ZN, Zhang WY, Zhu T. Advances in the clinical application of oxycodone in the perioperative period. World J Clin Cases 2022; 10:5156-5164. [PMID: 35812649 PMCID: PMC9210879 DOI: 10.12998/wjcc.v10.i16.5156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/29/2022] [Accepted: 04/03/2022] [Indexed: 02/06/2023] Open
Abstract
To review the research progress of pure opioid receptor agonist oxycodone. The research progress of oxycodone in terms of pharmacokinetics, pharmacodynamics, adverse reactions, clinical application, combined medication and new progress in clinical application was summarized by referring to the literature. Oxycodone is a semi-synthetic thebaine derivative of opioid alkaloids, and is a pure opioid μ and κ receptor agonist. The main action sites are the central nervous system and visceral smooth muscle. Due to its advantages of low adverse reactions, good analgesic effects, and a wide range of safe doses, the drug has been widely used in the control of acute and chronic postoperative pain, as well as malignant and non-malignant pain. Since the end of the 20th century, researchers have begun to formulate antipyretic analgesics, opioid receptor agonists, opioid receptor antagonists, dopamine receptor antagonists and other drugs with oxycodone in different proportions to enhance the analgesic effect. At the same time, it can reduce the dosage of oxycodone and reduce its adverse reactions, so as to achieve the purpose of limiting opioid abuse. With the continuous research on the efficacy and safety of oxycodone in the perioperative period at home and abroad, oxycodone has become the only dual-opioid potent analgesic that can be used in clinical work.
Collapse
Affiliation(s)
- Hong-Yang Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Ning Wang
- Department of Anesthesiology, West China School of Clinical Medicine, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei-Yi Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
10
|
Veloso C, Videira RA, Andrade PB, Cardoso C, Vitorino C. In vivo methodologies to assist preclinical development of topical fixed-dose combinations for pain management. Int J Pharm 2022; 616:121530. [PMID: 35121043 DOI: 10.1016/j.ijpharm.2022.121530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 11/24/2022]
Abstract
The combination in a fixed dose of two or more active pharmaceutical ingredients in the same pharmaceutical dosage form is an approach that has been used successfully in the treatment of several pathologies, including pain. In the preclinical development of a topical fixed-dose combination product with analgesic and anti-inflammatory activities for pain management, the main objective is to establish the nature of the interaction between the different active pharmaceutical ingredients while obtaining data on the medicinal product safety and efficacy. Despite the improvement of in vitro assays, animal models remain a fundamental strategy to characterise the interaction, efficacy and safety of active pharmaceutical ingredients at the physiological level, which cannot be reached by in vitro assays. Thus, the main goal of this review is to systematise the available animal models to evaluate the efficacy and safety of a new fixed-dose combination product for topical administration indicated for pain management. Particular emphasis is given to animal models that are accepted for regulatory purposes.
Collapse
Affiliation(s)
- Cláudia Veloso
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Chemistry Center, Department of Chemistry, University of Coimbra, Rua Larga, 3004-535 Coimbra, Portugal
| | - Romeu A Videira
- REQUIMTE/LAQV, Laboratório de Farmacognosia, Departamento de Química, Faculdade de Farmácia, Universidade do Porto, R. Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal.
| | - Paula B Andrade
- REQUIMTE/LAQV, Laboratório de Farmacognosia, Departamento de Química, Faculdade de Farmácia, Universidade do Porto, R. Jorge Viterbo Ferreira, n° 228, 4050-313 Porto, Portugal
| | - Catarina Cardoso
- Laboratórios Basi, Parque Industrial Manuel Lourenço Ferreira, lote 15, 3450-232 Mortágua, Portugal
| | - Carla Vitorino
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Chemistry Center, Department of Chemistry, University of Coimbra, Rua Larga, 3004-535 Coimbra, Portugal.
| |
Collapse
|
11
|
Gusso D, Cruz FF, Fritsch PM, da Silva Gobbo MO, Morrone FB, Bonan CD. Pannexin channel 1, P2X7 receptors, and Dimethyl Sulfoxide mediate pain responses in zebrafish. Behav Brain Res 2022; 423:113786. [DOI: 10.1016/j.bbr.2022.113786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 12/15/2022]
|
12
|
Massaly N, Markovic T, Creed M, Al-Hasani R, Cahill CM, Moron JA. Pain, negative affective states and opioid-based analgesics: Safer pain therapies to dampen addiction. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 157:31-68. [PMID: 33648672 DOI: 10.1016/bs.irn.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Across centuries and civilizations opioids have been used to relieve pain. In our modern societies, opioid-based analgesics remain one of the most efficient treatments for acute pain. However, the long-term use of opioids can lead to the development of analgesic tolerance, opioid-induced hyperalgesia, opioid use disorders, and overdose, which can ultimately produce respiratory depressant effects with fatal consequences. In addition to the nociceptive sensory component of pain, negative affective states arising from persistent pain represent a risk factor for developing an opioid use disorder. Several studies have indicated that the increase in prescribed opioid analgesics since the 1990s represents the root of our current opioid epidemic. In this review, we will present our current knowledge on the endogenous opioid system within the pain neuroaxis and the plastic changes occurring in this system that may underlie the occurrence of pain-induced negative affect leading to misuse and abuse of opioid medications. Dissecting the allostatic neuronal changes occurring during pain is the most promising avenue to uncover novel targets for the development of safer pain medications. We will discuss this along with current and potential approaches to treat pain-induced negative affective states that lead to drug misuse. Moreover, this chapter will provide a discussion on potential avenues to reduce the abuse potential of new analgesic drugs and highlight a basis for future research and drug development based on recent advances in this field.
Collapse
Affiliation(s)
- Nicolas Massaly
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States; Washington University in St Louis, Pain Center, St. Louis, MO, United States; Washington University in St Louis, School of Medicine, St. Louis, MO, United States.
| | - Tamara Markovic
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States; Washington University in St Louis, Pain Center, St. Louis, MO, United States; Washington University in St Louis, School of Medicine, St. Louis, MO, United States
| | - Meaghan Creed
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States; Washington University in St Louis, Pain Center, St. Louis, MO, United States; Washington University in St Louis, School of Medicine, St. Louis, MO, United States; Department of Neuroscience, Washington University in St. Louis, St. Louis, MO, United States; Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Ream Al-Hasani
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States; Washington University in St Louis, Pain Center, St. Louis, MO, United States; Washington University in St Louis, School of Medicine, St. Louis, MO, United States; Department of Pharmaceutical and Administrative Sciences, St. Louis College of Pharmacy, St. Louis, MO, United States; Center for Clinical Pharmacology, St. Louis College of Pharmacy and Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Catherine M Cahill
- Department of Psychiatry and Biobehavioural Sciences, University of California, Los Angeles, CA, United States; Shirley and Stefan Hatos Center for Neuropharmacology, University of California Los Angeles, Los Angeles, CA, United States; Jane & Terry Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, United States
| | - Jose A Moron
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States; Washington University in St Louis, Pain Center, St. Louis, MO, United States; Washington University in St Louis, School of Medicine, St. Louis, MO, United States; Department of Neuroscience, Washington University in St. Louis, St. Louis, MO, United States; Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
| |
Collapse
|
13
|
Hickey T, Abelleira A, Acampora G, Becker WC, Falker CG, Nazario M, Weimer MB. Perioperative Buprenorphine Management: A Multidisciplinary Approach. Med Clin North Am 2022; 106:169-185. [PMID: 34823729 DOI: 10.1016/j.mcna.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Buprenorphine formulations (including buprenorphine/naloxone) are effective treatments of pain and opioid use disorder (OUD). Historically, perioperative management of patients prescribed buprenorphine involved abstinence from buprenorphine sufficient to allow for unrestricted mu-opioid receptor availability to full agonist opioid (FAO) treatment. Evidence is mounting that a multimodal analgesic strategy, including simultaneous administration of buprenorphine and FAO, nonopioid adjuncts such as acetaminophen and nonsteroidal anti-inflammatory drugs, and regional anesthesia, is a safe and effective perioperative strategy for the patient prescribed long-term buprenorphine treatment of OUD. This strategy will likely simplify management and more seamlessly provide continuous buprenorphine treatment of OUD after hospital discharge.
Collapse
MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Aged
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/pharmacology
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Buprenorphine/administration & dosage
- Buprenorphine/pharmacology
- Buprenorphine/therapeutic use
- Combined Modality Therapy/methods
- Drug Compounding/methods
- Female
- Humans
- Interdisciplinary Communication
- Male
- Opiate Substitution Treatment/methods
- Opioid-Related Disorders/drug therapy
- Pain/drug therapy
- Pain Management/methods
- Pain, Postoperative/prevention & control
- Perioperative Care/methods
- Receptors, Opioid, mu/drug effects
Collapse
Affiliation(s)
- Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Anesthesiology, Yale School of Medicine, 950 Campbell Avenue, West Haven, CT 06516, USA.
| | - Audrey Abelleira
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System; Program in Addiction Medicine, Yale School of Medicine
| | - Caroline G Falker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Mitchell Nazario
- National PBM Clinical Program Manager, VHA Pharmacy Benefits Management (12PBM), 1st Avenue - 1 Block North of Cermak (Building 37), Hines, IL 60141, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Yale School of Medicine; Yale School of Public Health
| |
Collapse
|
14
|
Analgesic effectiveness and safety of celecoxib versus non-opioid active controls after third molar surgery: A meta-analytical evaluation. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:e1-e9. [PMID: 34192584 DOI: 10.1016/j.jormas.2021.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 06/24/2021] [Indexed: 01/10/2023]
Abstract
The aim of this meta-analysis was to assess the analgesic efficacy and adverse effects of celecoxib compared to non-opioid drugs after third molar surgery. A search in PubMed and Google Scholar was performed to identify clinical trials, and then, the Cochrane Collaboration's toll for assessing risk of bias tool was used to evaluate the quality of all clinical trials. Studies without any high-risk of bias were included in the statistical analysis. The data extraction included the pain intensity measured by the visual analogue scale (VAS), the number of patients using rescue analgesics and adverse effects of gastric (nausea and vomiting), and nervous (dizziness and headache) systems. Data were analyzed using the Review Manager Software 5.3 for Windows and the Risk Reduction Calculator. The visual analog scale, total pain relief, and the number of patients who needed rescue analgesics showed statistical significance. Moreover, celecoxib had a lower frequency of nausea and vomiting compared with ibuprofen. In conclusion, celecoxib was more effective than acetaminophen and ibuprofen for pain control after third molar surgery.
Collapse
|
15
|
Veloso C, Cardoso C, Vitorino C. Topical Fixed-Dose Combinations: A Way of Progress for Pain Management? J Pharm Sci 2021; 110:3345-3361. [PMID: 34102201 DOI: 10.1016/j.xphs.2021.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 12/17/2022]
Abstract
Pain, a severe public health problem, can affect patient quality of life when inadequately controlled. Considering that pain pathophysiological mechanisms are complex, combining active pharmaceutical ingredients (APIs) with multiple and synergistic mechanisms of action represents a potentially more effective therapeutic approach than conventional monotherapy treatments. In turn, topical drug delivery has clear advantages over other routes of administration, such as high levels of efficacy, better safety profile and great patient compliance. In this context, the combination of two or more APIs in a single dosage form - fixed-dose combination product (FDC) - for topical administration may represent a promising therapeutic option in the field of pain management. Considering the above mentioned, the purpose of this manuscript is to address an overview of some general aspects regarding pain management and FDCs, as well as the regulatory environment that has to be taken into consideration during their development. Special emphasis will be given to fixed-dose combinations for topical administration with analgesic and/or anti-inflammatory activity. Market drivers of the topical FDC currently approved are ultimately pointed out, and new opportunities in pain management highlighted.
Collapse
Affiliation(s)
- Cláudia Veloso
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Chemistry Center, Department of Chemistry, University of Coimbra, Rua Larga, 3004-535 Coimbra, Portugal
| | - Catarina Cardoso
- Laboratórios Basi, Parque Industrial Manuel Lourenço Ferreira, lote 15, 3450-232 Mortágua, Portugal
| | - Carla Vitorino
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Chemistry Center, Department of Chemistry, University of Coimbra, Rua Larga, 3004-535 Coimbra, Portugal; Center for Neurosciences and Cell Biology (CNC), University of Coimbra, Rua Larga, Faculty of Medicine, Pólo I, 1st floor, 3004-504 Coimbra, Portugal.
| |
Collapse
|
16
|
McNicol ED, Ferguson MC, Schumann R. Single-dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 5:CD013263. [PMID: 33998669 PMCID: PMC8127532 DOI: 10.1002/14651858.cd013263.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative pain is common and may be severe. Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous ketorolac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 20 April 2020. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA Randomized double-blind trials that compared a single postoperative dose of intravenous ketorolac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period. Our secondary outcomes were time to and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related or opioid-related AEs. For subgroup analysis, we planned to analyze different doses of parenteral ketorolac separately and to analyze results based on the type of surgery performed. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, involving 1905 participants undergoing various surgeries (pelvic/abdominal, dental, and orthopedic), with 17 to 83 participants receiving intravenous ketorolac in each study. Mean study population ages ranged from 22.5 years to 67.4 years. Most studies administered a dose of ketorolac of 30 mg; one study assessed 15 mg, and another administered 60 mg. Most studies had an unclear risk of bias for some domains, particularly allocation concealment and blinding, and a high risk of bias due to small sample size. The overall certainty of evidence for each outcome ranged from very low to moderate. Reasons for downgrading certainty included serious study limitations, inconsistency and imprecision. Ketorolac versus placebo Very low-certainty evidence from eight studies (658 participants) suggests that ketorolac results in a large increase in the number of participants achieving at least 50% pain relief over four hours compared to placebo, but the evidence is very uncertain (risk ratio (RR) 2.81, 95% confidence interval (CI) 1.80 to 4.37). The number needed to treat for one additional participant to benefit (NNTB) was 2.4 (95% CI 1.8 to 3.7). Low-certainty evidence from 10 studies (914 participants) demonstrates that ketorolac may result in a large increase in the number of participants achieving at least 50% pain relief over six hours compared to placebo (RR 3.26, 95% CI 1.93 to 5.51). The NNTB was 2.5 (95% CI 1.9 to 3.7). Among secondary outcomes, for time to rescue medication, moderate-certainty evidence comparing intravenous ketorolac versus placebo demonstrated a mean median of 271 minutes for ketorolac versus 104 minutes for placebo (6 studies, 633 participants). For the number of participants using rescue medication, very low-certainty evidence from five studies (417 participants) compared ketorolac with placebo. The RR was 0.60 (95% CI 0.36 to 1.00), that is, it did not demonstrate a difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with placebo (74% versus 65%; 8 studies, 810 participants; RR 1.09, 95% CI 1.00 to 1.19; number needed to treat for an additional harmful event (NNTH) 16.7, 95% CI 8.3 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from eight studies (703 participants) did not demonstrate a difference in rates between ketorolac and placebo (RR 0.62, 95% CI 0.13 to 3.03). Ketorolac versus NSAIDs Ketorolac was compared to parecoxib in four studies and diclofenac in two studies. For our primary outcome, over both four and six hours there was no evidence of a difference between intravenous ketorolac and another NSAID (low-certainty and moderate-certainty evidence, respectively). Over four hours, four studies (337 participants) produced an RR of 1.04 (95% CI 0.89 to 1.21) and over six hours, six studies (603 participants) produced an RR of 1.06 (95% CI 0.95 to 1.19). For time to rescue medication, low-certainty evidence from four studies (427 participants) suggested that participants receiving ketorolac waited an extra 35 minutes (mean median 331 minutes versus 296 minutes). For the number of participants using rescue medication, very low-certainty evidence from three studies (260 participants) compared ketorolac with another NSAID. The RR was 0.90 (95% CI 0.58 to 1.40), that is, there may be little or no difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with another NSAID (76% versus 68%, 5 studies, 516 participants; RR 1.11, 95% CI 1.00 to 1.23; NNTH 12.5, 95% CI 6.7 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from five studies (530 participants) did not demonstrate a difference in rates between ketorolac and another NSAID (RR 3.18, 95% CI 0.13 to 76.99). Only one of the five studies reported a single serious AE. AUTHORS' CONCLUSIONS The amount and certainty of evidence for the use of intravenous ketorolac as a treatment for postoperative pain varies across efficacy and safety outcomes and amongst comparators, from very low to moderate. The available evidence indicates that postoperative intravenous ketorolac administration may offer substantial pain relief for most patients, but further research may impact this estimate. Adverse events appear to occur at a slightly higher rate in comparison to placebo and to other NSAIDs. Insufficient information is available to assess whether intravenous ketorolac has a different rate of gastrointestinal or surgical-site bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was a lack of studies in cardiovascular surgeries and in elderly populations who may be at increased risk for adverse events.
Collapse
Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| |
Collapse
|
17
|
Neighbors CP, Noller MW, Avillion MP, Neighbors JW, Spaw MC, Biello AR, Theler JM, Camacho M. Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative. Mil Med 2021; 187:e154-e159. [PMID: 33394014 DOI: 10.1093/milmed/usaa484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/18/2020] [Accepted: 10/29/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP). MATERIALS AND METHODS Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider. RESULTS Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates. CONCLUSIONS The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.
Collapse
Affiliation(s)
| | - Michael W Noller
- Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | | | | | | | | | | | | |
Collapse
|
18
|
McEntee KM, Crawford KD, Wilson MD, Ponzini MD, Wu BT, Nejad BM, Waetjen LE. Postoperative Opioid Prescribing and Consumption after Hysterectomy: A Prospective Cohort Study. J Minim Invasive Gynecol 2020; 28:1013-1021. [PMID: 33152533 DOI: 10.1016/j.jmig.2020.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To examine opioid prescribing and consumption patterns after hysterectomy and identify factors associated with postoperative opioid consumption. DESIGN Prospective cohort study. SETTING Single university medical center. PATIENTS Women undergoing hysterectomy for benign, nonobstetric indications. INTERVENTIONS Participant preoperative and surgical characteristics were obtained through chart review and patient report of baseline pain score. During the third postoperative week, participants completed a telephone interview, including a direct count of remaining opioid pills and assessment of satisfaction with pain management. We assessed factors associated with opioid consumption in oral morphine equivalents (OME) using a linear regression model. MEASUREMENTS AND MAIN RESULTS Of the 129 participants, 113 (88%) completed the postoperative survey after hysterectomy: 16 vaginal, 43 robotic-assisted, 42 conventional laparoscopic, and 12 abdominal hysterectomies. The median amount of opioid prescribed was 150 OME (interquartile range [IQR] 113-200), while the median amount consumed was 75 (IQR 10-135), reflecting an average consumption of about 50% of the prescription. Opioid prescription size was associated with consumption; for every additional oral morphine equivalent prescribed, on average, an additional 0.5 was consumed (p <.001). If the indication for hysterectomy was related to pain, participants consumed 25.3 additional OME (p = .04). The amount of opioid prescribed was inversely correlated with pain management satisfaction; every additional point on a 1 through 5 Likert scale of increasing satisfaction was associated with 44 fewer OME prescribed (standard error 9 OME, p <.001). For the 1464 total unused pills among the 104 participants with leftover opioids, only 20% reported an Food and Drug Administration -compliant opioid disposal plan. CONCLUSION Gynecologic surgeons can respond to the opioid epidemic by reducing excess opioid pills after hysterectomy by providing both the smallest effective prescription size and concrete resources for safe opioid disposal. These actions may contribute to a reduction in opioid use disorder cases or overdose deaths.
Collapse
Affiliation(s)
- Kelli M McEntee
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento (Drs. McEntee, Crawford, Wu, Nejad, and Waetjen).
| | - Kaitlin D Crawford
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento (Drs. McEntee, Crawford, Wu, Nejad, and Waetjen)
| | - Machelle D Wilson
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis Health, Davis (Dr. Wilson and Mr. Ponzini), California
| | - Matthew D Ponzini
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis Health, Davis (Dr. Wilson and Mr. Ponzini), California
| | - Brenda T Wu
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento (Drs. McEntee, Crawford, Wu, Nejad, and Waetjen)
| | - Bahareh M Nejad
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento (Drs. McEntee, Crawford, Wu, Nejad, and Waetjen)
| | - L Elaine Waetjen
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento (Drs. McEntee, Crawford, Wu, Nejad, and Waetjen)
| |
Collapse
|
19
|
Stamos A, Drum M, Reader A, Nusstein J, Fowler S, Beck M. An Evaluation of Ibuprofen Versus Ibuprofen/Acetaminophen for Postoperative Endodontic Pain in Patients With Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis. Anesth Prog 2020; 66:192-201. [PMID: 31891295 DOI: 10.2344/anpr-66-03-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The purpose of this investigation was to compare ibuprofen versus an ibuprofen/acetaminophen combination for postoperative pain control in a patient model specific to teeth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis. One hundred and two patients presenting with moderate to severe pain from a maxillary or mandibular posterior tooth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis were included. Following local anesthetic administration, complete endodontic cleaning and shaping was performed. Patients were randomly assigned to receive identically appearing tablets of ibuprofen 200 mg or a combination of ibuprofen 200 mg/acetaminophen 216.7 mg with instructions to take 3 tablets every 6 hours as needed for pain. Patients were also given a prescription for an escape medication to take if the study medications did not adequately control their pain. A 4-day diary was used to record pain ratings and medication use. Moderate to severe pain was experienced by 59-61% of the patients on postoperative day 1 and 50-57% of the patients on day 2, with the pain ratings decreasing over the next 2 days. There were no statistically significant differences between the 2 groups in postoperative pain, percussion pain, or medication use. There was no difference between ibuprofen and the combination of ibuprofen/acetaminophen in the reduction of postoperative pain following endodontic debridement in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.
Collapse
Affiliation(s)
- Alex Stamos
- Former Graduate Student in Endodontics, The Ohio State University
| | - Melissa Drum
- Professor and Graduate Program Director, Division of Endodontics, The Ohio State University
| | - Al Reader
- Emeritus Professor, Division of Endodontics, The Ohio State University
| | - John Nusstein
- Professor and Chair, Division of Endodontics, The Ohio State University
| | - Sara Fowler
- Assistant Professor and Predoctoral Director, Division of Endodontics, The Ohio State University
| | - Mike Beck
- Emeritus Associate Professor, Division of Biosciences, The Ohio State University
| |
Collapse
|
20
|
Persing S, Manahan M, Rosson G. Enhanced Recovery After Surgery Pathways in Breast Reconstruction. Clin Plast Surg 2020; 47:221-243. [DOI: 10.1016/j.cps.2019.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
21
|
Farooqi OA, Bruhn WE, Lecholop MK, Velasquez-Plata D, Maloney JG, Rizwi S, Templeton RB, Goerig A, Hezkial C, Novince CM, Zieman MT, Lotesto AMN, Makary MA. Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus. Int J Oral Maxillofac Surg 2020; 49:397-402. [PMID: 31611048 PMCID: PMC8771805 DOI: 10.1016/j.ijom.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/13/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023]
Abstract
One in 16 patients prescribed opioids after a surgical procedure will become a long-term user. The lack of procedure-specific guidelines after common dental procedures contributes to the opioid overprescribing problem. We convened a multidisciplinary panel to develop consensus recommendations for opioid prescribing after common dental procedures. We used a three-step modified Delphi method to develop a consensus recommendation for outpatient opioid prescribing for 14 common dental procedures. The multi-institution, multidisciplinary panel represented seven relevant stakeholder groups (oral surgeons, periodontists, endodontists, general dentists, general surgeons, oral surgery residents, and oral surgery patients). The panel determined the minimum and maximum number of opioid tablets a clinician should consider prescribing. For all 14 surgical procedures, ibuprofen was recommended as initial therapy. The maximum number of opioid tablets recommended varied by procedure (overall median = 5 tablets, range = 0-15 tablets). Zero opioid tablets were recommended as the maximum number for six of 14 (43%) procedures, one to 10 opioid tablets was the maximum for four of 14 (27%) procedures, and 11-15 tablets was the maximum for four of 14 (27%) procedures. Procedure-specific prescribing recommendations may help provide guidance to clinicians and help address the opioid overprescribing problem.
Collapse
Affiliation(s)
- O A Farooqi
- Department of Veteran Affairs, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - W E Bruhn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M K Lecholop
- Department of Oral and Maxillofacial Surgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - S Rizwi
- Dow International Medical College, Dow University of Health Sciences
| | | | - A Goerig
- Department of Orofacial Pain, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - C Hezkial
- Department of Orofacial Pain, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - C M Novince
- Department of Oral and Maxillofacial Surgery, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - M T Zieman
- Department of Oral and Maxillofacial Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - A M N Lotesto
- Department of Oral and Maxillofacial Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - M A Makary
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
22
|
Fiala C, Agostini A, Bombas T, Cameron S, Lertxundi R, Lubusky M, Parachini M, Saya L, Trumbic B, Gemzell Danielsson K. Management of pain associated with up-to-9-weeks medical termination of pregnancy (MToP) using mifepristone–misoprostol regimens: expert consensus based on a systematic literature review. J OBSTET GYNAECOL 2019; 40:591-601. [DOI: 10.1080/01443615.2019.1634027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- C. Fiala
- Gynmed Clinic, Vienna, Austria
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - A. Agostini
- Obstetric and Gynecology Department, La Conception Hospital, Marseille, France
| | - T. Bombas
- Obstetric Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - S. Cameron
- Chalmers Centre, NHS Lothian, Edinburgh, Scotland
| | | | - M. Lubusky
- Department of Obstetrics and Gynaecology, Palacky University Hospital, Olomouc, Czech Republic
| | | | - L. Saya
- Altius Pharma CS, Paris, France
| | | | - K. Gemzell Danielsson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynaecology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
23
|
Postoperative pain management in the era of ERAS: An overview. Best Pract Res Clin Anaesthesiol 2019; 33:259-267. [DOI: 10.1016/j.bpa.2019.07.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
|
24
|
McNicol ED, Ferguson MC, Gallagher S, Schumann R. Single‐dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database Syst Rev 2019; 2019:CD013263. [PMCID: PMC6379096 DOI: 10.1002/14651858.cd013263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the analgesic efficacy and adverse effects of single‐dose IV ketorolac, compared with placebo or an active comparator, for moderate‐to‐severe postoperative pain in adults.
Collapse
Affiliation(s)
- Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
| | | | - Sean Gallagher
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
| | - Roman Schumann
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
| |
Collapse
|
25
|
Davis CS, Lieberman AJ, Hernandez-Delgado H, Suba C. Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review. Drug Alcohol Depend 2019; 194:166-172. [PMID: 30445274 DOI: 10.1016/j.drugalcdep.2018.09.022] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/31/2018] [Accepted: 09/15/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Opioid overdose is a continuing public health crisis. In response to an increasing recognition of the negative outcomes sometimes associated with the use of opioid analgesics, states have taken a number of steps attempting to reduce inappropriate prescribing of these medications. These include the imposition of strict legal limitations on the amount or duration that opioid analgesics may be prescribed or dispensed to patients with acute pain. METHODS We conducted a systematic, multi-source legal review of state laws that impose mandatory limits on the ability of medical professionals to prescribe or dispense opioids for the treatment of acute pain. We also systematically searched for and examined publicly available documents on state legislative and regulatory bodies' websites. All relevant laws were downloaded and systematically coded. RESULTS By the end of 2017, twenty-six states had passed laws that impose mandatory limits on the prescribing or dispensing of opioids for acute pain. The oldest of these laws became effective as early as 1989, but most are much newer: approximately 65% (17/26) were passed in 2017. There is wide variation in the characteristics of these laws. CONCLUSION Just over half of all states have enacted laws that restrict the prescribing or dispensing of opioids for acute pain. To date, there is no data on whether and to what extent these laws mediate opioid-related morbidity and mortality, as well as whether they are associated with negative unintended outcomes. Research into these questions is urgently needed.
Collapse
Affiliation(s)
- Corey S Davis
- Network for Public Health Law, Los Angeles, CA, USA; Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| | | | | | - Carli Suba
- Network for Public Health Law, Los Angeles, CA, USA
| |
Collapse
|
26
|
Daniels SE, Atkinson HC, Stanescu I, Frampton C. Analgesic Efficacy of an Acetaminophen/Ibuprofen Fixed-dose Combination in Moderate to Severe Postoperative Dental Pain: A Randomized, Double-blind, Parallel-group, Placebo-controlled Trial. Clin Ther 2018; 40:1765-1776.e5. [PMID: 30245281 DOI: 10.1016/j.clinthera.2018.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/20/2018] [Accepted: 08/25/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE Acute pain is a significant burden to the individual and to society. There is a clear need for a pain medication that provides improved analgesia over common analgesics, without compromising tolerability. The goal of this study was to determine the efficacy of a new fixed-dose combination of acetaminophen 975 mg and ibuprofen 292.5 mg (FDC 975/292.5) relative to acetaminophen or ibuprofen monotherapy, or placebo. METHODS This prospective, multicenter, randomized, double-blind, placebo-controlled, Phase III trial included 408 adult volunteers aged 18 to 60 years experiencing moderate to severe pain after surgical removal of at least 2 impacted third molars. Subjects were randomized in a 3:3:3:2 ratio to the following interventions: FDC 975/292.5, acetaminophen 975 mg, ibuprofen 292.5 mg, and placebo. Self-reported pain intensity scores were recorded over a 48-hour double-blind treatment period using a 100-mm visual analog scale. In addition, time to perceptible and meaningful pain relief was assessed by using the two-stopwatch method; use of rescue medication (oxycodone) was recorded; and patients rated their pain relief on a 5-point categorical scale. All adverse events during the 30-day study period were assessed. FINDINGS The majority of participants were female (67.4%) and white (90.0%), with a mean age of 24.8 years. Demographic and baseline characteristics were balanced across treatment groups, with a mean baseline pain score of 56.4 mm. The primary end point was the time-adjusted sum of pain intensity differences over 48 hours, which was found to be significantly greater for FDC 975/292.5 than for both monotherapies and placebo (all, P < 0.001). The robustness of the procedures used in the calculation of the primary end point was confirmed in a series of sensitivity analyses. Statistical superiority of the combination was evident in all secondary end points (time to meaningful pain relief, maximum pain score, response rate, participants using supplementary analgesia, time to rescue, oxycodone consumption, and categorical pain relief score) with the exception of time to perceptible pain relief versus monotherapies and the time to peak response versus ibuprofen. The percentage of patients reporting adverse events was 37.3% in the FDC 975/292.5 group, with no significant differences between treatment groups. Nausea was the most common adverse event across all groups. IMPLICATIONS Overall, the fixed-dose combination of acetaminophen and ibuprofen provided greater and more rapid analgesia than comparable doses of either agent alone or placebo in adults after removal of impacted third molars. ClinicalTrials.gov identifier: NCT01420653.
Collapse
Affiliation(s)
| | | | | | - Chris Frampton
- Department of Medicine, University of Otago, Christchurch, New Zealand.
| |
Collapse
|
27
|
McNicol ED, Ferguson MC, Schumann R. Single-dose intravenous diclofenac for acute postoperative pain in adults. Cochrane Database Syst Rev 2018; 8:CD012498. [PMID: 30153336 PMCID: PMC6353087 DOI: 10.1002/14651858.cd012498.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, reduces the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous diclofenac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: the Cochrane Central Register of Controlled Trials (Cochrane Register of Studies Online), MEDLINE, and Embase on 22 May 2018. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA We included randomized trials that compared a single postoperative dose of intravenous diclofenac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for review inclusion, assessed risk of bias, and extracted data.Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period.Our secondary outcomes were time to, and number of participants using rescue medication; withdrawals due to lack of efficacy, AEs, and for any cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related AEs. We performed a post hoc analysis of opioid-related AEs, to enable indirect comparisons with other analyses of postoperative analgesics.For subgroup analysis, we planned to analyze different doses and formulations of parenteral diclofenac separately.We assessed the overall quality of the evidence for each outcome using GRADE and created two 'Summary of findings' tables. MAIN RESULTS We included eight studies, involving 1756 participants undergoing various surgeries (dental, mixed minor, abdominal, and orthopedic), with 20 to 175 participants receiving intravenous diclofenac in each study. Mean study population ages ranged from 24.5 years to 54.5 years. Intravenous diclofenac doses varied among and within studies, ranging from 3.75 mg to 75 mg. Five studies assessed newer formulations of parenteral diclofenac that could be administered as an undiluted intravenous bolus. Most studies had an unclear risk of bias for several domains and a high risk of bias due to small sample size. The overall quality of evidence for each outcome was generally low for reasons including unclear risk of bias in studies, imprecision, and low event numbers.Primary outcomeThree studies (277 participants) produced a number needed to treat for an additional beneficial outcome (NNTB) for at least 50% of maximum pain relief versus placebo of 2.4 (95% confidence interval (CI) 1.9 to 3.1) over four hours (low-quality evidence). Four studies (436 participants) produced an NNTB of 3.8 versus placebo (95% CI 2.9 to 5.9) over six hours (low-quality evidence). No studies provided data for the comparison of intravenous diclofenac with another NSAID over four hours. At six hours there was no difference between intravenous diclofenac and another NSAID (low-quality evidence).Secondary outcomesFor secondary efficacy outcomes, intravenous diclofenac was generally superior to placebo and similar to other NSAIDs.For time to rescue medication, comparison of intravenous diclofenac versus placebo demonstrated a median of 226 minutes for diclofenac versus 80 minutes for placebo (5 studies, 542 participants, low-quality evidence). There were insufficient data for pooled analysis for comparisons of diclofenac with another NSAID (very low-quality evidence).For the number of participants using rescue medication, two studies (235 participants) compared diclofenac with placebo. The number needed to treat to prevent one additional harmful event (NNTp) (here, the need for rescue medication) compared with placebo was 3.0 (2.2 to 4.5, low-quality evidence). The comparison of diclofenac with another NSAID included only one study (98 participants). The NNTp was 4.5 (2.5 to 33) for ketorolac versus diclofenac (very low-quality evidence).The numbers of participants withdrawing were generally low and inconsistently reported (very low-quality evidence). Participant withdrawals were: 6% (8/140) diclofenac versus 5% (7/128) placebo, and 9% (8/87) diclofenac versus 7% (6/82) another NSAID for lack of efficacy; 2% (4/211) diclofenac versus 0% (0/198) placebo, and 3% (4/138) diclofenac versus 2% (2/129) another NSAID due to AEs; and 11% (21/191) diclofenac versus 17% (30/179) placebo, and 18% (21/118) diclofenac versus 15% (17/111) another NSAID for any cause.Overall adverse event rates were similar between intravenous diclofenac and placebo (71% in both groups, 2 studies, 296 participants) and between intravenous diclofenac and another NSAID (55% and 58%, respectively, 2 studies, 265 participants) (low-quality evidence for both comparisons). Serious and specific AEs were rare, preventing meta-analysis.There were sufficient data for a dose-effect analysis for our primary outcome for only one alternative dose, 18.75 mg. Analysis of the highest dose employed in each study demonstrated a relative benefit compared with placebo of 1.9 (1.4 to 2.4), whereas for the group receiving 18.75 mg, the relative benefit versus placebo was 1.6 (1.2 to 2.1, 2 studies). Compared to another NSAID, the high-dose analysis demonstrated a relative benefit of 0.9 (0.8 to 1.1), for the group receiving 18.75 mg, the relative benefit was 0.78 (0.65 to 0.93). For direct comparison of high dose versus 18.75 mg, the proportion of participants with at least 50% pain relief was 66% (90/137) for the high-dose arm versus 57% (77/135) in the low-dose arm. There were insufficient data for subgroup meta-analysis of different diclofenac formulations. AUTHORS' CONCLUSIONS The amount and quality of evidence for the use of intravenous diclofenac as a treatment for postoperative pain is low. The available evidence indicates that postoperative intravenous diclofenac administration offers good pain relief for the majority of patients, but further research may impact this estimate. Adverse events appear to occur at a similar rate to other NSAIDs. Insufficient information is available to assess whether intravenous diclofenac has a different rate of bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was insufficient information to evaluate the efficacy and safety of newer versus traditional formulations of intravenous diclofenac. There was a lack of studies in major and cardiovascular surgeries and in elderly populations, which may be at increased risk for adverse events.
Collapse
Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | | |
Collapse
|
28
|
Do children undergoing bilateral myringotomy with placement of ventilating tubes benefit from pre-operative analgesia? A double-blinded, randomised, placebo-controlled trial. The Journal of Laryngology & Otology 2018; 132:685-692. [PMID: 29998815 DOI: 10.1017/s0022215118001111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A double-blinded, randomised, placebo-controlled trial was conducted to determine whether routine pre-operative analgesia is beneficial in reducing post-operative ear pain following bilateral myringotomy and tube placement. METHODS Forty-five children (aged 3-15 years) were randomised to receive either pre-operative analgesics (paracetamol and ibuprofen) (n = 21) or placebo (n = 24). All children underwent sevoflurane gas induction with intranasal fentanyl (2 mcg/kg) to reduce the incidence of emergence agitation. Post-operative pain scores were measured using the Wong-Baker Faces Pain Rating Scale. Median pain scores taken 90 minutes post-surgery, and the highest pain score recorded prior to 90 minutes, were analysed. RESULTS There were no statistical differences between the median pain scores at 90 minutes or subsequent need for rescue analgesia. Emergence agitation did not occur in any child. Inadvertent ear trauma, use of an intravenous cannula or airway adjunct did not affect pain scores. CONCLUSION Routine pre-operative analgesia does not reduce pain scores in the early post-operative period. Simple analgesics are effective for rescue analgesia in the minority of cases.
Collapse
|
29
|
Hacker KE, Reynolds RK, Uppal S. Ongoing strategies and updates on pain management in gynecologic oncology patients. Gynecol Oncol 2018; 149:410-419. [DOI: 10.1016/j.ygyno.2018.01.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/24/2018] [Accepted: 01/30/2018] [Indexed: 12/23/2022]
|
30
|
Benefits and harms associated with analgesic medications used in the management of acute dental pain. J Am Dent Assoc 2018; 149:256-265.e3. [DOI: 10.1016/j.adaj.2018.02.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 01/08/2023]
|
31
|
|
32
|
Mauermann E, Ruppen W, Bandschapp O. Different protocols used today to achieve total opioid-free general anesthesia without locoregional blocks. Best Pract Res Clin Anaesthesiol 2017; 31:533-545. [DOI: 10.1016/j.bpa.2017.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 12/20/2022]
|
33
|
Abstract
Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.
Collapse
|
34
|
Candido KD, Perozo OJ, Knezevic NN. Pharmacology of Acetaminophen, Nonsteroidal Antiinflammatory Drugs, and Steroid Medications: Implications for Anesthesia or Unique Associated Risks. Anesthesiol Clin 2017; 35:e145-e162. [PMID: 28526157 DOI: 10.1016/j.anclin.2017.01.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroids, historically used in perioperative management, are potent analgesic medications. They primarily inhibit the cyclooxygenase (COX) enzyme, decreasing the synthesis of prostaglandins, and modulating pain and temperature. Acetaminophen does not inhibit this synthesis at the inflammatory site. The primary mechanism of action of corticosteroids involves regulation of nuclear expression of genes involved in inflammatory pathways and other systemic effects. Metaanalyses have added purposeful perioperative indications, clarified misconceptions, and established protocols for administering these drugs. Some indications, doses, clinical considerations, and adverse effects need to be further studied.
Collapse
Affiliation(s)
- Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA; Department of Anesthesiology, University of Illinois, 1740 W. Taylor Street, Chicago, IL 60612, USA; Department of Surgery, University of Illinois, 840 S. Wood Street, Chicago, IL 60612, USA.
| | - Oscar J Perozo
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 West Wellington Avenue, Suite 4815, Chicago, IL 60657, USA; Department of Anesthesiology, University of Illinois, 1740 W. Taylor Street, Chicago, IL 60612, USA; Department of Surgery, University of Illinois, 840 S. Wood Street, Chicago, IL 60612, USA
| |
Collapse
|
35
|
Kim HS, McCarthy DM, Mark Courtney D, Lank PM, Lambert BL. Benzodiazepine-opioid co-prescribing in a national probability sample of ED encounters. Am J Emerg Med 2017; 35:458-464. [DOI: 10.1016/j.ajem.2016.11.054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022] Open
|
36
|
Van Hout MC, Rich E, Dada S, Bergin M. "Codeine Is My Helper": Misuse of and Dependence on Codeine-Containing Medicines in South Africa. QUALITATIVE HEALTH RESEARCH 2017; 27:341-350. [PMID: 26582195 DOI: 10.1177/1049732315613764] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Misuse of codeine-containing medicines is an emerging global public health concern. The majority of research has been conducted in developed countries (European Members States, Australia, the United States). This study aimed to gain an understanding of unique individual and collective experiences of trajectories of codeine misuse and dependence in South Africa. In-depth interviews were conducted with a purposive sample of adult codeine misusers and dependents ( n = 25). Narratives were analyzed using the empirical phenomenological psychological five-step method. Nine themes with 63 categories emerged, with two additional high levels of abstraction. Findings are illustrated: participant profile and product preferences, motives for use, transitioning to misuse and dependence, pharmacy purchasing and alternative sourcing routes, effects and withdrawal experiences, help-seeking and treatment experiences, and strategies for prevention. The study underscores the need for continued support for enhanced patient awareness of risk of habit forming use and related health consequences and professional pharmacovigilance.
Collapse
Affiliation(s)
| | - Eileen Rich
- 2 Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Pretoria and Cape Town, South Africa
| | - Siphokazi Dada
- 2 Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Pretoria and Cape Town, South Africa
| | - Michael Bergin
- 1 School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
| |
Collapse
|
37
|
Buprenorphine-Naloxone in the Treatment of Codeine Dependence: a Scoping Review of Clinical Case Presentations. Int J Ment Health Addict 2017. [DOI: 10.1007/s11469-016-9655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
38
|
McNicol ED, Ferguson MC, Schumann R. Single dose intravenous diclofenac for acute postoperative pain in adults. Cochrane Database Syst Rev 2017; 2017:CD012498. [PMCID: PMC6464978 DOI: 10.1002/14651858.cd012498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the analgesic efficacy and adverse effects of a single dose of intravenous diclofenac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults.
Collapse
Affiliation(s)
| | | | - Roman Schumann
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonUSA
| |
Collapse
|
39
|
McDonough M. Commentary on Cairns et al. (2016): Over-the-counter codeine in Australia-questioning the efficacy of current restrictions or re-scheduling. Addiction 2016; 111:1854-5. [PMID: 27605083 DOI: 10.1111/add.13525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 11/30/2022]
|
40
|
Foley M, Carney T, Rich E, Parry C, Van Hout MC, Deluca P. Medical professionals' perspectives on prescribed and over-the-counter medicines containing codeine: a cross-sectional study. BMJ Open 2016; 6:e011725. [PMID: 27417200 PMCID: PMC4947827 DOI: 10.1136/bmjopen-2016-011725] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To explore prescribing practitioners' perspectives on prescribed codeine use, their ability to identify dependence and their options for treatment in the UK. DESIGN Cross-sectional design using a questionnaire containing closed-ended and open-ended items. SETTING A nationally representative sample of prescribing professionals working in the UK. PARTICIPANTS 300 prescribing professionals working in primary care and pain settings. RESULTS Participants stated that they regularly reviewed patients prescribed codeine, understood the risks of dependence and recognised the potential for codeine to be used recreationally. Over half the participants felt patients were unaware of the adverse health consequences of high doses of combination codeine medicines. One-quarter of participants experienced patient resentment when asking about medicines containing codeine. Just under 40% of participants agreed that it was difficult to identify problematic use of codeine without being informed by the patient and did not feel confident in identification of codeine dependence. Less than 45% of all participants agreed that codeine dependence could be managed effectively in general practice. Slow or gradual withdrawal was the most popular suggested treatment in managing dependence. Education and counselling was also emphasised in managing codeine-dependent patients in primary care. CONCLUSIONS Communication with patients should involve assessment of patient understanding of their medication, including the risk of dependence. There is a need to develop extra supports for professionals including patient screening tools for identifying codeine dependence. The support structure for managing codeine-dependent patients in primary care requires further examination.
Collapse
Affiliation(s)
- Michelle Foley
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Eileen Rich
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Charles Parry
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Paolo Deluca
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
41
|
Wenzel JT, Schwenk ES, Baratta JL, Viscusi ER. Managing Opioid-Tolerant Patients in the Perioperative Surgical Home. Anesthesiol Clin 2016; 34:287-301. [PMID: 27208711 DOI: 10.1016/j.anclin.2016.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Management of acute postoperative pain is important to decrease perioperative morbidity and improve patient satisfaction. Opioids are associated with potential adverse events that may lead to significant risk. Uncontrolled pain is a risk factor in the transformation of acute pain to chronic pain. Balancing these issues can be especially challenging in opioid-tolerant patients undergoing surgery, for whom rapidly escalating opioid doses in an effort to control pain can be associated with increased complications. In the perioperative surgical home model, anesthesiologists are positioned to coordinate a comprehensive perioperative analgesic plan that begins with the preoperative assessment and continues through discharge.
Collapse
Affiliation(s)
- John T Wenzel
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA.
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8130, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| |
Collapse
|
42
|
A Comparative Exploration of Community Pharmacists’ Views on the Nature and Management of Over-the-Counter (OTC) and Prescription Codeine Misuse in Three Regulatory Regimes: Ireland, South Africa and the United Kingdom. Int J Ment Health Addict 2016. [DOI: 10.1007/s11469-016-9640-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
43
|
Van Hout MC, Norman I. Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 27:17-22. [DOI: 10.1016/j.drugpo.2015.09.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 08/26/2015] [Accepted: 09/19/2015] [Indexed: 10/23/2022]
|
44
|
Impact of a Mandatory Prescription Drug Monitoring Program on Prescription of Opioid Analgesics by Dentists. PLoS One 2015; 10:e0135957. [PMID: 26274819 PMCID: PMC4537135 DOI: 10.1371/journal.pone.0135957] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/29/2015] [Indexed: 11/19/2022] Open
Abstract
Prescription Drug Monitoring Programs (PDMP) are statewide databases that collect data on prescription of controlled substances. New York State mandates prescribers to consult the PDMP registry before prescribing a controlled substance such as opioid analgesics. The effect of mandatory PDMP on opioid drug prescriptions by dentists is not known. This study investigates the impact of mandatory PDMP on frequency and quantity of opioid prescriptions by dentists in a dental urgent care center. Based on the sample size estimate, we collected patient records of a 3-month period before and two consecutive 3-month periods after the mandatory PDMP implementation and analyzed the data on number of visits, treatment types and drug prescriptions using Chi-square tests. For patients who were prescribed pain medications, 452 (30.6%), 190 (14.1%), and 140 (9.6%) received opioid analgesics in the three study periods respectively, signifying a statistically significant reduction in the number of opioid prescriptions after implementation of the mandatory PDMP (p<0.05). Total numbers of prescribed opioid pills in a 3-month period decreased from 5096 to 1120, signifying a 78% reduction in absolute quantity. Prescriptions for non-opioid analgesics acetaminophen increased during the same periods (p<0.05). We conclude that the mandatory PDMP significantly affected the prescription pattern for pain medications by dentists. Such change in prescription pattern represents a shift towards the evidence-based prescription practices for acute postoperative pain.
Collapse
|
45
|
Derry S, Wiffen PJ, Moore RA. Single dose oral ibuprofen plus caffeine for acute postoperative pain in adults. Cochrane Database Syst Rev 2015; 2015:CD011509. [PMID: 26171993 PMCID: PMC6481458 DOI: 10.1002/14651858.cd011509.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is good evidence that combining two different analgesics in fixed doses in a single tablet can provide better pain relief in acute pain and headache than either drug alone, and that the drug-specific benefits are essentially additive. This appears to be broadly true in postoperative pain and migraine headache across a range of different drug combinations, and when tested in the same and different trials. Adding caffeine to analgesics also increases the number of people obtaining good pain relief. Combinations of ibuprofen and caffeine are available without prescription in some parts of the world. OBJECTIVES To assess the analgesic efficacy and adverse effects of a single oral dose of ibuprofen plus caffeine for moderate to severe postoperative pain, using methods that permit comparison with other analgesics evaluated in standardised trials using almost identical methods and outcomes. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, two clinical trial registries, and the reference lists of articles. The date of the most recent search was 1 February 2015. SELECTION CRITERIA Randomised, double-blind, placebo- or active-controlled clinical trials of single dose oral ibuprofen plus caffeine for acute postoperative pain in adults. DATA COLLECTION AND ANALYSIS Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. We used the area under the pain relief versus time curve to derive the proportion of participants with at least 50% pain relief over six hours prescribed either ibuprofen plus caffeine or placebo. We calculated the risk ratio (RR) and number needed to treat to benefit (NNT). We used information on the use of rescue medication to calculate the proportion of participants requiring rescue medication and the weighted mean of the median time to use. We also collected information on adverse effects. MAIN RESULTS We identified five randomised, double-blind studies with 1501 participants, but only four had been published and had relevant outcome data. These four studies were of high quality, although two of the studies were small.Both ibuprofen 200 mg + caffeine 100 mg and ibuprofen 100 mg + caffeine 100 mg produced significantly more participants than placebo who achieved at least 50% of maximum pain relief over six hours, and both doses significantly reduced remedication rates (moderate quality evidence). For at least 50% of maximum pain relief, the NNT was 2.1 (95% confidence interval 1.8 to 2.5) for ibuprofen 200 mg + caffeine 100 mg (four studies, 334 participants) and 2.4 (1.9 to 3.1) for ibuprofen 100 mg + caffeine 100 mg (two studies, 200 participants) (moderate quality evidence). These values were close to those predicted by published models for combination analgesics in acute pain, and were supported by low (good) NNT values for prevention of remedication.Adverse event rates were low, and no sensible analysis was possible. AUTHORS' CONCLUSIONS For ibuprofen 200 mg + caffeine 100 mg particularly, the low NNT value is among the lowest (best) values for analgesics in this pain model. The combination is not commonly available, but can be probably be achieved by taking a single 200 mg ibuprofen tablet with a cup of modestly strong coffee or caffeine tablets. In principle, this can deliver good analgesia at lower doses of ibuprofen.
Collapse
|
46
|
Abstract
BACKGROUND Diclofenac is a nonsteroidal anti-inflammatory drug, available as a potassium salt (immediate release) or sodium salt (enteric coated to suppress dissolution in the stomach). This review updates an earlier review published in the Cochrane Database of Systematic Reviews (Issue 2, 2009) entitled 'Single dose oral diclofenac for acute postoperative pain in adults'. OBJECTIVES To assess the analgesic efficacy and adverse effects of a single oral dose of diclofenac for moderate to severe postoperative pain, using methods that permit comparison with other analgesics evaluated in standardised trials using almost identical methods and outcomes. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, two clinical trial registries, and the reference lists of articles. The date of the most recent search was 9 March 2015. SELECTION CRITERIA Randomised, double-blind, placebo-controlled clinical trials of single dose, oral diclofenac (sodium or potassium) for acute postoperative pain in adults. DATA COLLECTION AND ANALYSIS Two review authors independently considered studies for inclusion in the review, assessed risk of bias, and extracted data. We used the area under the pain relief versus time curve to derive the proportion of participants with at least 50% pain relief over six hours prescribed either diclofenac or placebo. We calculated the risk ratio (RR) and number needed to treat to benefit (NNT). We used information on the use of rescue medication to calculate the proportion of participants requiring rescue medication and the weighted mean of the median time to use. We also collected information on adverse effects. MAIN RESULTS This update included three new studies, providing a 26% increase in participants in comparisons between diclofenac and placebo. We included 18 studies involving 3714 participants, 1902 treated with diclofenac and 1007 with placebo. This update has also changed the focus of the review, examining the effects of formulation in more detail than previously. This is a result of increased understanding of the importance of speed of onset in determining analgesic efficacy in acute pain.The largest body of information, for diclofenac potassium 50 mg, in seven studies, produced an NNT for at least 50% of maximum pain relief compared with placebo of 2.1 (95% confidence interval (CI) 1.9 to 2.5) (high quality evidence). There was a graded improvement in efficacy as doses rose from 25 mg to 100 mg, both for participants achieving at least 50% maximum pain relief, and for remedication within 6 to 8 hours. Fast-acting formulations (dispersible products, solutions, and softgel formulations) had a similar efficacy for a 50 mg dose, with an NNT of 2.4 (2.0 to 3.0). Diclofenac sodium in a small number of studies produced a lesser effect, with an NNT of 6.6 (4.1 to 17) for the 50 mg dose.Adverse event rates were low in these single dose studies, with no difference between diclofenac and placebo (moderate quality evidence). AUTHORS' CONCLUSIONS Diclofenac potassium provides good pain relief at 25 mg, 50 mg, and 100 mg doses. Diclofenac sodium has limited efficacy and should probably not be used in acute pain.
Collapse
|
47
|
Dexketoprofen/tramadol: randomised double-blind trial and confirmation of empirical theory of combination analgesics in acute pain. J Headache Pain 2015; 16:541. [PMID: 26123824 PMCID: PMC4485659 DOI: 10.1186/s10194-015-0541-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 06/12/2015] [Indexed: 11/30/2022] Open
Abstract
Background Combination analgesics are effective in acute pain, and a theoretical framework predicts efficacy for combinations. The combination of dexketoprofen and tramadol is untested, but predicted to be highly effective. Methods This was a randomised, double-blind, double-dummy, parallel-group, placebo-controlled, single-dose trial in patients with moderate or severe pain following third molar extraction. There were ten treatment arms, including dexketoprofen trometamol (12.5 mg and 25 mg) and tramadol hydrochloride (37.5 mg and 75 mg), given as four different fixed combinations and single components, with ibuprofen 400 mg as active control as well as a placebo control. The study objective was to evaluate the superior analgesic efficacy and safety of each combination and each single agent versus placebo. The primary outcome was the proportion of patients with at least 50 % max TOTPAR over six hours. Results 606 patients were randomised and provided at least one post-dose assessment. All combinations were significantly better than placebo. The highest percentage of responders (72 %) was achieved in the dexketoprofen trometamol 25 mg plus tramadol hydrochloride 75 mg group (NNT 1.6, 95 % confidence interval 1.3 to 2.1). Addition of tramadol to dexketoprofen resulted in greater peak pain relief and greater pain relief over the longer term, particularly at times longer than six hours (median duration of 8.1 h). Adverse events were unremarkable. Conclusions Dexketoprofen trometamol 25 mg combined with tramadol hydrochloride 75 mg provided good analgesia with rapid onset and long duration in a model of moderate to severe pain. The results of the dose finding study are consistent with pre-trial calculations based on empirical formulae. Trial registration EudraCT (2010-022798-32); Clinicaltrials.gov (NCT01307020). Electronic supplementary material The online version of this article (doi:10.1186/s10194-015-0541-5) contains supplementary material, which is available to authorized users.
Collapse
|
48
|
Hobson A, Wiffen PJ, Conlon JA. As required versus fixed schedule analgesic administration for postoperative pain in children. Cochrane Database Syst Rev 2015; 2015:CD011404. [PMID: 25719451 PMCID: PMC6464683 DOI: 10.1002/14651858.cd011404.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute postoperative pain occurs as a result of tissue damage following surgery. Administering the appropriate analgesia to children is a complex process and it is unclear whether children's postoperative pain is more successfully treated by using 'as required' (when pain occurs) (termed 'pro re nata' or PRN) or (irrespective of pain at the time of administration). OBJECTIVES To assess the efficacy of as required versus fixed schedule analgesic administration for the management of postoperative pain in children under the age of 16 years. SEARCH METHODS On 2 July 2014, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL databases. We reviewed the bibliographies of all included studies and of reviews, and searched two clinical trial databases, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, to identify additional published or unpublished data. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing PRN versus ATC analgesic administration for postoperative pain in children under the age of 16 years who had undergone any surgical procedure requiring postoperative pain relief, in any setting. DATA COLLECTION AND ANALYSIS Two review authors (AH, PW) independently extracted efficacy and adverse event data, examined issues of study quality, and assessed risk of bias as recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included three RCTs (four reports) of 246 children aged under 16 years undergoing tonsillectomy. Children were given weight-appropriate doses of the study medication, either PRN or ATC, by a parent or carer at home for up to four days following surgery. We did not identify any studies assessing the management of postoperative pain in children in any other setting (i.e. as an inpatient). All studies included in this review were based on the use of paracetamol, and an opioid was added to paracetamol in two studies. Analgesics were administered either orally (tablet or elixir) or rectally (suppository). Reporting quality was poor and there were fewer than 50 children in each arm. Mean pain intensity scores decreased over time, as did medication use. However, children were still reporting pain at the final assessment, suggesting that no administration schedule provided adequate analgesia. There were no significant differences in pain intensity scores at any time point. The studies reported adverse events that may have been related to the study medication, such as nausea and vomiting, and constipation, but no statistically significant differences were noted between the groups. There were too few data from only three small studies and meta-analysis was not possible. One study reported that a higher amount of analgesics was consumed in the ATC group compared with the PRN group: it would have been helpful to show that the higher volume in the ATC group led to better analgesia but we were not able to demonstrate this. AUTHORS' CONCLUSIONS There was limited evidence available to draw any conclusions about the efficacy of PRN versus ATC analgesic administration for the management of postoperative pain in children.
Collapse
Affiliation(s)
- Anna Hobson
- Cochrane Pain, Palliative and Supportive Care Group, Pain Research Unit, The Churchill Hospital, Old Road, Oxford, UK, OX3 7LE.
| | | | | |
Collapse
|
49
|
Derry S, Karlin SM, Moore RA. Single dose oral ibuprofen plus codeine for acute postoperative pain in adults. Cochrane Database Syst Rev 2015; 2015:CD010107. [PMID: 25927097 PMCID: PMC6540848 DOI: 10.1002/14651858.cd010107.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This is an update of the original Cochrane review published in Issue 3, 2013. There is good evidence that combining two different analgesics in fixed doses in a single tablet can provide better pain relief in acute pain and headache than either drug alone, and that the drug-specific effects are essentially additive. This appears to be broadly true in postoperative pain and migraine headache across a range of different drug combinations and when tested in the same and different trials. Some combinations of ibuprofen and codeine are available without prescription (but usually only from a pharmacy) where the dose of codeine is lower, and with a prescription when the dose of codeine is higher.Use of combination analgesics that contain codeine has been a source of some concern because of misuse from over-the-counter preparations. OBJECTIVES To assess the analgesic efficacy and adverse effects of a single oral dose of ibuprofen plus codeine for acute moderate-to-severe postoperative pain using methods that permit comparison with other analgesics evaluated in standardised trials using almost identical methods and outcomes. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, ClinicalTrials.gov, and the reference lists of articles. The date of the most recent search was 1 December 2014. SELECTION CRITERIA Randomised, double-blind, placebo- or active-controlled clinical trials of single dose oral ibuprofen plus codeine for acute postoperative pain in adults. DATA COLLECTION AND ANALYSIS Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. We used the area under the pain relief versus time curve to derive the proportion of participants prescribed ibuprofen plus codeine, placebo, or the same dose of ibuprofen alone with at least 50% pain relief over six hours, using validated equations. We calculated the risk ratio (RR) and number needed to treat to benefit (NNT). We used information on the use of rescue medication to calculate the proportion of participants requiring rescue medication and the weighted mean of the median time to use. We also collected information on adverse effects. Analyses were planned for different doses of ibuprofen and codeine, but especially for codeine where we set criteria for low (< 10 mg), medium (10 to 20 mg), and high (> 20 mg) doses. MAIN RESULTS Since the last version of this review no new studies were found. Information was available from six studies with 1342 participants, using a variety of doses of ibuprofen and codeine. In four studies (443 participants) using ibuprofen 400 mg plus codeine 25.6 mg to 60 mg (high dose codeine) 64% of participants had at least 50% maximum pain relief with the combination compared to 18% with placebo. The NNT was 2.2 (95% confidence interval 1.8 to 2.6) (high quality evidence). In three studies (204 participants) ibuprofen plus codeine (any dose) was better than the same dose of ibuprofen (69% versus 55%) but the result was barely significant with a relative benefit of 1.3 (1.01 to 1.6) (moderate quality evidence). In two studies (159 participants) ibuprofen plus codeine appeared to be better than the same dose of codeine alone (69% versus 33%), but no analysis was done. There was no difference between the combination and placebo in the reporting of adverse events in these acute studies (moderate quality evidence). AUTHORS' CONCLUSIONS The combination of ibuprofen 400 mg plus codeine 25.6 mg to 60 mg demonstrates good analgesic efficacy. Very limited data suggest that the combination is better than the same dose of either drug alone, and that similar numbers of people experience adverse events with the combination as with placebo.
Collapse
Affiliation(s)
| | - Samuel M Karlin
- University of OxfordPain Research and Nuffield Department of Clinical NeurosciencesPain Research UnitChurchill HospitalOxfordOxfordshireUKOX3 7LE
| | | | | |
Collapse
|
50
|
Single dose oral ibuprofen plus caffeine for acute postoperative pain in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011509] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|