1
|
Chow SP, Stevens S, Tran S, Donelenko S. Case Series: Synergistic Effect of Gabapentin and Adjuvant Pregabalin in Neuropathic Pain. J Pain Palliat Care Pharmacother 2023; 37:106-109. [PMID: 36512682 DOI: 10.1080/15360288.2022.2149669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gabapentin and pregabalin both exert high affinity to the α2δ subunit of the voltage-gated calcium channels which inhibits excitatory neurotransmitter release. The synergistic mechanism was described in rats given combinations of gabapentin and pregabalin. In this case series, we described 2 cases which may illustrate the synergistic effect of gabapentin and pregabalin in treatment resistant neuropathic pain. Low dose pregabalin was added to therapeutic gabapentin to achieve appreciable pain reduction in one case and improved quality of life in another case. Further research with more enrollment and longer study duration may help elucidate the appropriate dosing and potential associated side effects.
Collapse
|
2
|
Seitz KI, Ueltzhöffer K, Rademacher L, Paulus FM, Schmitz M, Herpertz SC, Bertsch K. Your smile won't affect me: Association between childhood maternal antipathy and adult neural reward function in a transdiagnostic sample. Transl Psychiatry 2023; 13:70. [PMID: 36828811 PMCID: PMC9958053 DOI: 10.1038/s41398-023-02364-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/26/2023] Open
Abstract
Aberrant activation in the ventral striatum (VS) during reward anticipation may be a key mechanism linking adverse childhood experiences (ACE) to transdiagnostic psychopathology. This study aimed to elucidate whether retrospectively reported ACE, specifically maternal antipathy, relate to monetary and social reward anticipation in a transdiagnostic adult sample. A cross-sectional neuroimaging study was conducted in 118 participants with varying levels of ACE, including 25 participants with posttraumatic stress disorder (PTSD), 32 with major depressive disorder (MDD), 29 with somatic symptom disorder (SSD), and 32 healthy volunteers (HVs). Participants underwent functional magnetic resonance imaging during a monetary and social incentive delay task, and completed a self-report measure of ACE, including maternal antipathy. Neural correlates of monetary and social reward anticipation and their association with ACE, particularly maternal antipathy, were analyzed. Participants showed elevated activation in brain regions underlying reward processing, including the VS, only while anticipating social, but not monetary rewards. Participants reporting higher levels of maternal antipathy exhibited reduced activation in the brain reward network, including the VS, only during social, but not monetary reward anticipation. Group affiliation moderated the association between maternal antipathy and VS activation to social reward anticipation, with significant associations found in participants with PTSD and HVs, but not in those with MDD and SSD. Results were not associated with general psychopathology or psychotropic medication use. Childhood maternal antipathy may confer risk for aberrant social reward anticipation in adulthood, and may thus be considered in interventions targeting reward expectations from social interactions.
Collapse
Affiliation(s)
- Katja I. Seitz
- grid.7700.00000 0001 2190 4373Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Kai Ueltzhöffer
- grid.7700.00000 0001 2190 4373Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Lena Rademacher
- grid.4562.50000 0001 0057 2672Social Neuroscience Lab, Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany ,grid.4562.50000 0001 0057 2672Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Frieder M. Paulus
- grid.4562.50000 0001 0057 2672Social Neuroscience Lab, Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany ,grid.4562.50000 0001 0057 2672Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Marius Schmitz
- grid.7700.00000 0001 2190 4373Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany ,grid.5252.00000 0004 1936 973XDepartment of Psychology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sabine C. Herpertz
- grid.7700.00000 0001 2190 4373Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Katja Bertsch
- grid.7700.00000 0001 2190 4373Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Heidelberg, Germany ,grid.5252.00000 0004 1936 973XDepartment of Psychology, Ludwig-Maximilians-University Munich, Munich, Germany
| |
Collapse
|
3
|
Schaffer AL, Brett J, Buckley NA, Pearson SA. Trajectories of pregabalin use and their association with longitudinal changes in opioid and benzodiazepine use. Pain 2022; 163:e614-e621. [PMID: 34382609 DOI: 10.1097/j.pain.0000000000002433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/11/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Concomitant use of pregabalin with opioids and/or benzodiazepines is common, despite the increased risks. However, clinical trials suggest pregabalin can have an opioid-sparing effect when treating acute postoperative pain. We explored how opioid and benzodiazepine use changed over time in people initiating pregabalin, using dispensing claims data for a 10% sample of Australians (2013-19). Among 142,776 people initiating pregabalin (median age = 61 years, 57% female), we used group-based trajectory modelling to identify 6 pregabalin dose trajectories in the first year postinitiation. Two trajectories involved discontinuation: after one dispensing (49%), and after 6 months of treatment (14%). Four trajectories involved persistent use with variable estimated median daily doses of 39 mg (16%), 127 mg (14%), 276 mg (5%), and 541 mg (2%). We quantified opioid and benzodiazepine use in the year before and after pregabalin initiation using generalised linear models. Over the study period, 71% were dispensed opioids and 34% benzodiazepines, with people on the highest pregabalin dose having highest rates of use. Opioid use increased postpregabalin initiation. Among people using both opioids and pregabalin, the geometric mean daily dose in oral morphine equivalents increased after pregabalin initiation in all trajectories, ranging from +5.9% (99% confidence interval 4.8%-7.0%) to +39.8% (99% confidence interval 38.3%-41.5%) in people on the highest daily pregabalin dose. Among people using both pregabalin and benzodiazepines, the dose remained constant over time for people in all trajectories. Notwithstanding its reputation as opioid-sparing, in this outpatient setting, we observed that people using opioids tended to use higher opioid daily doses after pregabalin initiation, especially those on high pregabalin doses.
Collapse
Affiliation(s)
- Andrea L Schaffer
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | - Jonathan Brett
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
| | - Nicholas A Buckley
- Biomedical Informatics and Digital Health, University of Sydney, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
- Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| |
Collapse
|
4
|
Schwartz SM, Barpujari A, Finnerup NB, Raja SN. Pharmacologic therapies for neuropathic pain: an assessment of reporting biases in randomized controlled trials. Pain 2022; 163:795-804. [PMID: 34348355 PMCID: PMC8810900 DOI: 10.1097/j.pain.0000000000002426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/22/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Several different reporting biases cited in scientific literature have raised concerns about the overestimation of effects and the subsequent potential impact on the practice of evidence-based medicine and human health. Up to 7% to 8% of the population experiences neuropathic pain (NP), and established treatment guidelines are based predominantly on published clinical trial results. Therefore, we examined published randomized controlled trials (RCTs) of first-line drugs for NP and assessed the relative proportions with statistically significant (ie, positive) and nonsignificant (ie, negative) results and their rates of citation. We determined the relationships between reported study outcome and the frequency of their citations with journal impact factor, sample size, time to publication after study completion, and study quality metrics. We also examined the association of study outcome with maximum study drug dosage and conflict of interest. We found that of 107 published RCTs, 68.2% reported a statistically significant outcome regarding drug efficacy for chronic peripheral and central NP. Positive studies were cited nearly twice as often as negative studies in the literature (P = 0.01), despite similar study sample size, quality metrics, and publication in journals with similar impact factors. The time to publication, journal impact factor, and conflict of interest did not differ statistically between positive and negative studies. Our observations that negative and positive RCTs were published in journals with similar impact at comparable time-lags after study completion are encouraging. However, the citation bias for positive studies could affect the validity and generalization of conclusions in literature and potentially influence clinical practice.
Collapse
Affiliation(s)
- Stefani M Schwartz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Awinita Barpujari
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Nanna Brix Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, United States
| |
Collapse
|
5
|
Hanna R, Bensadoun RJ, Beken SV, Burton P, Carroll J, Benedicenti S. Outpatient Oral Neuropathic Pain Management with Photobiomodulation Therapy: A Prospective Analgesic Pharmacotherapy-Paralleled Feasibility Trial. Antioxidants (Basel) 2022; 11:533. [PMID: 35326183 PMCID: PMC8944471 DOI: 10.3390/antiox11030533] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
Neuropathic pain (NP) can be challenging to treat effectively as analgesic pharmacotherapy (MED) can reduce pain, but the majority of patients do not experience complete pain relief. Our pilot approach is to assess the feasibility and efficacy of an evidence-based photobiomodulation (PBM) intervention protocol. This would be as an alternative to paralleled standard analgesic MED for modulating NP intensity-related physical function and quality of life (QoL) prospectively in a mixed neurological primary burning mouth syndrome and oral iatrogenic neuropathy study population (n = 28). The study group assignments and outcome evaluation strategy/location depended on the individual patient preferences and convenience rather than on randomisation. Our prospective parallel study aimed to evaluate the possible pre/post-benefit of PBM and to allow for a first qualitative comparison with MED, various patient-reported outcome measures (PROMs) based on Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT-II) were used for up to a nine-month follow-up period in both intervention groups (PBM and MED). The PBM protocol applied to the PBM group was as follows: λ810 nm, 200 mW, 0.088 cm2, 30 s/point, 9 trigger and affected points, twice a week for five consecutive weeks, whereas the MED protocol followed the National Institute of Clinical Excellence (NICE) guidelines. Our results showed that despite the severe and persistent nature of the symptoms of 57.50 ± 47.93 months at baseline in the PBM group, a notably rapid reduction in PISmax on VAS from 7.6 at baseline (T0) to 3.9 at one-month post-treatment (T3) could be achieved. On the other hand, mean PISmax was only reduced from 8.2 at baseline to 6.8 at T3 in the MED group. Our positive PBM findings furthermore support more patients' benefits in improving QoL and functional activities, which were considerably impaired by NP such as: eating, drinking and tasting, whereas the analgesic medication regimens did not. No adverse events were observed in both groups. To the best knowledge of the authors, our study is the first to investigate PBM efficacy as a monotherapy compared to the gold standard analgesic pharmacotherapy. Our positive data proves statistically significant improvements in patient self-reported NP, functionality, psychological profile and QoL at mid- and end-treatment, as well as throughout the follow-up time points (one, three, six and nine months) and sustained up to nine months in the PBM group, compared to the MED group. Our study, for the first time, proves the efficacy and safety of PBM as a potent analgesic in oral NP and as a valid alternative to the gold standard pharmacotherapy approach. Furthermore, we observed long-term pain relief and functional benefits that indicate that PBM modulates NP pathology in a pro-regenerative manner, presumably via antioxidant mechanisms.
Collapse
Affiliation(s)
- Reem Hanna
- Department of Oral Surgery, Dental Institute, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Surgical Sciences and Integrated Diagnostics, Laser Therapy Centre, University of Genoa, Viale Benedetto XV,6, 16132 Genoa, Italy;
| | - René Jean Bensadoun
- Department of Radiology Oncology, Centre De Haute Energie, 10 Boulevard Pasteur, 06000 Nice, France;
| | - Seppe Vander Beken
- Bredent Medical GmbH & Co., Gewerbegebiet Gartenäcker, Weißenhorner Str. 2, 89250 Senden, Germany;
| | - Patricia Burton
- Thor Photomedicine Ltd., Water Meadow, Chesham HP5 1LF, UK; (P.B.); (J.C.)
| | - James Carroll
- Thor Photomedicine Ltd., Water Meadow, Chesham HP5 1LF, UK; (P.B.); (J.C.)
| | - Stefano Benedicenti
- Department of Surgical Sciences and Integrated Diagnostics, Laser Therapy Centre, University of Genoa, Viale Benedetto XV,6, 16132 Genoa, Italy;
| |
Collapse
|
6
|
Seitz KI, Ehler N, Schmitz M, Schmitz SE, Dziobek I, Herpertz SC, Bertsch K. Affective and cognitive theory of mind in posttraumatic stress, major depressive, and somatic symptom disorders: Association with childhood trauma. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2022; 61:680-700. [PMID: 35102575 DOI: 10.1111/bjc.12357] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/12/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Childhood trauma constitutes a major risk factor for adult psychopathology, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and somatic symptom disorder (SSD). One potential mechanism linking childhood trauma to adult psychopathology may be alterations in theory of mind (ToM). Given the lack of transdiagnostic studies on the association between childhood trauma and ToM, further research is needed to elucidate whether and how childhood trauma relates to ToM impairments across and within diagnostic boundaries. DESIGN A cross-sectional study design was applied. METHODS A total of 137 individuals with varying levels of childhood trauma took part in this study, encompassing individuals with PTSD (n = 33), MDD (n = 33), SSD (n = 36), and healthy volunteers (HVs; n = 35). To assess ToM performance and childhood trauma, the Movie for the Assessment of Social Cognition was administered along with the Childhood Trauma Questionnaire. RESULTS Only individuals with PTSD, but not individuals with MDD or SSD, showed a worse ToM performance compared to HVs. In the whole sample, childhood trauma correlated negatively with ToM performance. Exploratory group-specific analyses revealed higher levels of childhood trauma to be associated with more excessive ToM errors in individuals with SSD, and notably with an enhanced ToM performance in individuals with MDD. CONCLUSIONS Our results indicate associations between childhood trauma and ToM impairments in a large, transdiagnostic sample. Provided replication in future studies, our findings suggest ToM capacities as a promising treatment target for individuals exposed to severe childhood trauma, at least or particularly with a diagnosis of PTSD. PRACTITIONER POINTS Our results suggest that individuals with a history of severe childhood trauma, at least or particularly with a clinical diagnosis of posttraumatic stress disorder, may benefit from therapeutic approaches targeting theory of mind capacities. Our findings indicate that higher levels of childhood trauma may be linked to a specific 'hypermentalizing' bias in somatic symptom disorder. Our findings further point towards an association between higher levels of childhood trauma and a heightened - rather than a diminished - sensitivity towards interpersonal cues in major depressive disorder. Provided further confirmatory evidence, our findings may support diagnosis-specific approaches in ameliorating theory of mind abilities in individuals with different mental disorders and a history of severe childhood trauma.
Collapse
Affiliation(s)
- Katja I Seitz
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Germany
| | - Nicola Ehler
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Germany
| | - Marius Schmitz
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Germany.,Department of Psychology, Ludwig-Maximilians-University Munich, Germany
| | - Sara E Schmitz
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Isabel Dziobek
- Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Germany.,Department of Psychology, Humboldt Universität zu Berlin, Germany
| | - Sabine C Herpertz
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Germany
| | - Katja Bertsch
- Department of General Psychiatry, Center for Psychosocial Medicine, Medical Faculty, Heidelberg University, Germany.,Department of Psychology, Ludwig-Maximilians-University Munich, Germany
| |
Collapse
|
7
|
Zhang X, Xu H, Zhang Z, Li Y, Pauer L, Liao S, Zhang F. Efficacy and Safety of Pregabalin for Fibromyalgia in a Population of Chinese Subjects. J Pain Res 2021; 14:537-548. [PMID: 33658841 PMCID: PMC7920593 DOI: 10.2147/jpr.s281483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/26/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Fibromyalgia (FM) may go underdiagnosed and untreated in China in part due to a lack of awareness and understanding of the condition, and limited available treatments. PATIENTS AND METHODS This randomized, double-blind, Phase III local registration trial compared the efficacy and safety of pregabalin (flexibly dosed 300-450 mg/day) versus placebo for the management of pain in Chinese adults diagnosed with FM according to American College of Rheumatology 1990 criteria, across 22 centers within China. Patients reported pain score of ≥40 mm on 100-mm scale (from 0 "no pain" to 100 "worst possible pain"). The primary efficacy endpoint was change from baseline to Week 14 in mean pain score (MPS). Secondary endpoints included measures of sleep and sleep interference. Safety and tolerability were monitored throughout. RESULTS Median pregabalin dose was 335 mg/day. A significant reduction from baseline to Week 14 in weekly MPS was seen for patients treated with pregabalin (n=170) versus placebo (n=164) (least-squares mean difference [95% confidence interval]: -0.73 [-1.10 to -0.36]; P=0.0001). Significantly greater proportions of patients experienced ≥30% and ≥50% reductions in MPS at Week 14 with pregabalin versus placebo. Pregabalin-treated subjects demonstrated improvements in measures of sleep and sleep interference. Pregabalin was generally well tolerated. The most common adverse events were dizziness and somnolence; no serious adverse events (SAEs) occurred in pregabalin-treated subjects. Nine placebo-treated subjects experienced SAEs. CONCLUSION Pregabalin (300-450 mg/day) is a safe and effective treatment for reducing pain and improving sleep in native Chinese subjects with FM. CLINICALTRIALSGOV IDENTIFIER NCT01387607.
Collapse
Affiliation(s)
- Xiao Zhang
- Department of Rheumatology, Guangdong General Hospital, Guangdong, People’s Republic of China
| | - Huji Xu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Affiliated to Second Military Medical University, Shanghai, People’s Republic of China
| | - Zhiyi Zhang
- School of Clinical Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, People’s Republic of China
| | - Yang Li
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People’s Republic of China
| | - Lynne Pauer
- Global Research and Development, Pfizer, Groton, CT, USA
| | - Shanmei Liao
- Pfizer China Statistics Department, Global Innovative Pharma Business, Shanghai, People’s Republic of China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Beijing, People’s Republic of China
| |
Collapse
|
8
|
Pregabalin prescribing patterns in Australian general practice, 2012-2018: a cross-sectional study. BJGP Open 2021; 5:bjgpopen20X101120. [PMID: 33172853 PMCID: PMC7960512 DOI: 10.3399/bjgpopen20x101120] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/01/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In 2013 pregabalin was subsidised by Australia's Pharmaceutical Benefits Scheme (PBS) for neuropathic pain. Since the subsidy, pregabalin prescribing has been increasing in Australia and so has related harm. There are concerns it is being prescribed for indications other than neuropathic pain, which have little evidence of efficacy. AIM To describe pregabalin prescribing in Australian general practice. DESIGN & SETTING A cross-sectional study of patients attending 445 general practice sites in the national MedicineInsight database from March 2012-February 2018. METHOD The following aspects were calculated: the proportion of prescriptions that were for pregabalin per year; the prevalence of pain conditions in patients prescribed pregabalin; and same-day prescribing of pregabalin with opioids or benzodiazepines. RESULTS Prescribing increased from 13 per 10 000 to 104 per 10 000 prescriptions between 2012-2013 and 2017-2018. A total of 1 891 623 patients were identified of whom 114 123 (6.0%) were prescribed pregabalin; 49.7% (n = 56 772) had a recorded diagnosis of neuropathic pain. Among people prescribed pregabalin without a recorded diagnosis of neuropathic pain, 43.5% (n = 24 927) had a diagnosis of back problems, 8.8% (n = 5073) chronic pain, and 26.4% (n = 30 146) had no pain diagnosis. Pregabalin was prescribed the same day as an opioid to 38.1% of patients (95% confidence interval [CI] = 37.1% to 39.1%) and a benzodiazepine to 13.1% of patients (95% CI = 12.5% to 13.7%). Patients with a diagnosis of chronic pain had the highest rate of same-day prescribing of pregabalin with an opioid (70.4%, 95% CI = 68.9% to 71.9%) or a benzodiazepine (25.8%, 95% CI = 24.2% to 27.4%) CONCLUSION: Substantial increases in pregabalin prescribing were identified in Australian general practice, but only half of patients had a neuropathic pain diagnosis recorded, the only approved indication for subsidy. High rates of same-day prescribing with opioids and benzodiazepines may put patients at increased risk of harm.
Collapse
|
9
|
Evaluating the impact of gabapentinoids on sleep health in patients with chronic neuropathic pain: a systematic review and meta-analysis. Pain 2021; 161:476-490. [PMID: 31693543 DOI: 10.1097/j.pain.0000000000001743] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic neuropathic pain (NP) is debilitating and impacts sleep health and quality of life. Treatment with gabapentinoids (GBs) has been shown to reduce pain, but its effects on sleep health have not been systematically evaluated. The objective of this systematic review and meta-analysis was to assess the relationship between GB therapy dose and duration on sleep quality, daytime somnolence, and intensity of pain in patients with NP. Subgroup comparisons were planned for high- vs low-dose GBs, where 300 mg per day or more of pregabalin was used to classify high-dose therapy. Trial data were segregated by duration less than 6 weeks and 6 weeks or greater. Twenty randomized controlled trials were included. Primary outcome measures included pain-related sleep interference and incidence of daytime somnolence. Secondary outcomes included daily pain scores (numerical rating scale 0-10) and patient global impression of change. Significant improvement in sleep quality was observed after 6 weeks of GB treatment when compared with placebo (standardized mean difference 0.39, 95% confidence interval 0.32-0.46 P < 0.001). Increased daytime somnolence was observed among all GB-treated groups when compared with placebo. Treated patients were also more likely to report improvement of patient global impression of change scores. Pain scores decreased significantly in patients both after 6 weeks of treatment (P < 0.001) and in trials less than 6 weeks (P = 0.017) when compared with placebo. Our data demonstrate that GBs have a positive impact on sleep health, quality of life, and pain in patients with NP syndromes. However, these benefits come at the expense of daytime somnolence.
Collapse
|
10
|
Yeh YC, Cappelleri JC, Marston XL, Shelbaya A. Effects of dose titration on adherence and treatment duration of pregabalin among patients with neuropathic pain: A MarketScan database study. PLoS One 2021; 16:e0242467. [PMID: 33471834 PMCID: PMC7816971 DOI: 10.1371/journal.pone.0242467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 10/25/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To examine pregabalin dose titration and its impact on treatment adherence and duration in patients with neuropathic pain (NeP). METHODS MarketScan database (2009-2014) was used to extract a cohort of incident adult pregabalin users with NeP who had at least 12 months of follow-up data. Any dose augmentation within 45 days following the first pregabalin claim was defined as dose titration. Adherence (measured by medication possession ratio/MPR) and persistence (measured as the duration of continuous treatment) were compared between the cohorts with and without dose titration. Logistic regressions and Cox proportional hazards models were used to identify the factors associated with adherence (MPR ≥ 0.8) and predictors of time to discontinuation. RESULTS Among the 5,186 patients in the analysis, only 18% of patients had dose titration. Patients who had dose titration were approximately 2.6 times as likely to be adherent (MPR ≥ 0.8) (odds ratio = 2.59, P < 0.001) than those who did not have dose titration. Kaplan-Meier analysis shows that the time to discontinuation or switch was significantly longer among patients who had dose titration (4.99 vs. 4.04 months, P = 0.009). CONCLUSIONS Dose titration was associated with improved treatment adherence and persistence among NeP patients receiving pregabalin. The findings will provide valuable evidence to increase physician awareness of dose recommendations in the prescribing information and to educate patients on the importance of titration and adherence.
Collapse
Affiliation(s)
- Yu-Chen Yeh
- Pharmerit International, Newton, MA, United States of America
- * E-mail:
| | - Joseph C. Cappelleri
- Department of Global Biometrics and Data Management, Pfizer Inc, New York, NY, United States of America
| | | | - Ahmed Shelbaya
- Department of Health Economics and Outcomes Research, Pfizer Inc, New York, NY, United States of America
- Mailman School of Public Health, Columbia University, New York, NY, United States of America
| |
Collapse
|
11
|
Freynhagen R, Baron R, Kawaguchi Y, Malik RA, Martire DL, Parsons B, Rey RD, Schug SA, Jensen TS, Tölle TR, Ushida T, Whalen E. Pregabalin for neuropathic pain in primary care settings: recommendations for dosing and titration. Postgrad Med 2021; 133:1-9. [PMID: 33423590 DOI: 10.1080/00325481.2020.1857992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pregabalin is one of the first-line treatments approved for the management of neuropathic pain (NeP). While many patients benefit from treatment with pregabalin, they are often treated with suboptimal doses, possibly due to unfamiliarity around prescribing the drug and/or side effects that can occur with up-titration. This narrative review discusses key aspects of initiating, titrating, and managing patients prescribed pregabalin therapy, and addresses concerns around driving and the potential for abuse, as well as when to seek specialist opinion. To ensure that patients derive maximum therapeutic benefit from the drug, we suggest a 'low and slow' dosing approach to limit common side effects and optimize tolerability alongside patients' expectations. When requiring titration to higher doses, we recommend initiating 'asymmetric dosing,' with the larger dose in the evening. Fully engaging patients in order for them to understand the expected timeline for efficacy and side effects (including their resolution), can also help determine the optimal titration tempo for each individual patient. The 'low and slow' approach also recognizes that patients with NeP are heterogeneous in terms of their optimal therapeutic dose of pregabalin. Hence, it is recommended that general practitioners closely monitor patients and up-titrate according to pain relief and side effects to limit suboptimal dosing or premature discontinuation.
Collapse
Affiliation(s)
- Rainer Freynhagen
- Center for Anaesthesiology, Intensive Care, Pain Medicine & Palliative Medicine, Benedictus Hospital, Feldafing, Germany
| | - Ralf Baron
- Department of Anaesthesiology, Technische Universtät München, Munich, Germany
| | - Yoshiharu Kawaguchi
- Division of Neurological Pain Research and Therapy, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Rayaz A Malik
- Department of Orthopaedic Surgery, Toyama University Hospital, Toyama, Japan; eWeill Cornell Medicine, Qatar, Doha, Qatar
| | | | | | | | - Stephan A Schug
- Argentine Institute for Neurological Research (IADIN), Buenos Aires, Argentina
| | | | - Thomas R Tölle
- Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, WA, Australia
| | - Takahiro Ushida
- Department of Neurology and Diabetic Neuropathy Consortium, Aarhus University Hospital, Aarhus, Denmark
| | - Ed Whalen
- Department of Neurology, Technische Universität München, Munich, Germany.,Multidisciplinary Pain Center, Aichi Medical University Hospital, Nagakute, Japan
| |
Collapse
|
12
|
Kim KH, Seo HJ, Abdi S, Huh B. All about pain pharmacology: what pain physicians should know. Korean J Pain 2020; 33:108-120. [PMID: 32235011 PMCID: PMC7136290 DOI: 10.3344/kjp.2020.33.2.108] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023] Open
Abstract
From the perspective of the definition of pain, pain can be divided into emotional and sensory components, which originate from potential and actual tissue damage, respectively. The pharmacologic treatment of the emotional pain component includes antianxiety drugs, antidepressants, and antipsychotics. The anti-anxiety drugs have anti-anxious, sedative, and somnolent effects. The antipsychotics are effective in patients with positive symptoms of psychosis. On the other hand, the sensory pain component can be divided into nociceptive and neuropathic pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are usually applied for somatic and visceral nociceptive pain, respectively; anticonvulsants and antidepressants are administered for the treatment of neuropathic pain with positive and negative symptoms, respectively. The NSAIDs, which inhibit the cyclo-oxygenase pathway, exhibit anti-inflammatory, antipyretic, and analgesic effects; however, they have a therapeutic ceiling. The adverse reactions (ADRs) of the NSAIDs include gastrointestinal problems, generalized edema, and increased bleeding tendency. The opioids, which bind to the opioid receptors, present an analgesic effect only, without anti-inflammatory, antipyretic, or ceiling effects. The ADRs of the opioids start from itching and nausea/vomiting to cardiovascular and respiratory depression, as well as constipation. The anticonvulsants include carbamazepine, related to sodium channel blockade, and gabapentin and pregabalin, related to calcium blockade. The antidepressants show their analgesic actions mainly through inhibiting the reuptake of serotonin or norepinephrine. Most drugs, except NSAIDs, need an up-dose titration period. The principle of polypharmacy for analgesia in case of mixed components of pain is increasing therapeutic effects while reducing ADRs, based on the origin of the pain.
Collapse
Affiliation(s)
- Kyung-Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hyo-Jung Seo
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Salahadin Abdi
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Billy Huh
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
13
|
Chiu T, Brett J, Pearson SA, Schaffer AL. Patterns of pregabalin initiation and discontinuation after its subsidy in Australia. Br J Clin Pharmacol 2020; 86:1882-1887. [PMID: 32153053 DOI: 10.1111/bcp.14276] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/22/2020] [Accepted: 02/26/2020] [Indexed: 01/01/2023] Open
Abstract
Following the 2013 public subsidy of pregabalin in Australia for neuropathic pain not responding to other medicines, use and misuse increased substantially. We used pharmaceutical dispensing claims for a 10% sample of Australians to quantify initiation, discontinuation and dispensing of other analgesics before and after initiation. We identified 130 770 people initiating pregabalin between 2013/14 and 2017/18 (median age: 61 years; 56.8% female). Discontinuation rates at 1-year increased from 77.0% in 2013/14 to 85.9% in 2017/18; 38% only had 1 dispensing. Approximately 1/3 (37.5%) initiated on the lowest strength capsule (25 mg) with only 31.2% later up-titrating to a higher strength. 47.4% and 53.0% were dispensed opioids within 180 days before and after pregabalin initiation, respectively. Many individuals are using pregabalin for short treatment durations and low dose ranges not consistent with treatment of neuropathic pain, which is generally a chronic condition. This may suggest poorer tolerability than observed in clinical trials, or use for other conditions, some of which may be for indications where the balance of benefits and risk is less clear.
Collapse
Affiliation(s)
- Tricia Chiu
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Jonathan Brett
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia.,Menzies Centre for Health Policy, The University of Sydney, Sydney, Australia
| | - Andrea L Schaffer
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
14
|
Alam U, Sloan G, Tesfaye S. Treating Pain in Diabetic Neuropathy: Current and Developmental Drugs. Drugs 2020; 80:363-384. [DOI: 10.1007/s40265-020-01259-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
15
|
Shaheen A, Alam SM, Ahmad A, Khan M. Clinical efficacy and tolerability of Gabapentinoids with current prescription patterns in patients with Neuropathic pain. Pak J Med Sci 2019; 35:1505-1510. [PMID: 31777483 PMCID: PMC6861489 DOI: 10.12669/pjms.35.6.652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To investigate the current dosing regimens of gabapentinoids in Pakistani patients with neuropathic pain and to compare their clinical efficacy and tolerability in terms of pain relief and adverse effects using difference in pain score as a treatment outcome. Methods: This observational, prospective study was conducted in 320 patients with neuropathic pain from August 2016 to March 2018 at Basic Medical Sciences Institute (BMSI), Karachi in collaboration with Shifa International Hospital and Benazir Bhutto Hospital, Islamabad. Demographic data, treatment-related adverse effects and pain intensity was documented at recruitment and follow up visits at two, four and eight weeks. Discontinuation due to adverse effects and lack of efficacy were also recorded. Data was entered and analyzed using SPSS version 22. Results: Mean age of patients was 52.57±12.47 and the most common ethnicity were Punjabi speaking population (66%). Diabetic neuropathy (51%) was the most common etiology followed by radicular pain (25%). Mean dosages of pregabalin and gabapentin were 114mg and 470mg respectively. Mean pain score was significantly reduced by gabapentinoids (<0.001). Dizziness, drowsiness and somnolence were frequent adverse effects. Common dosages for pregabalin and gabapentin were 75 mg/day and 300 mg/day respectively. Conclusion: Current dosing regimens of gabapentinoids in Pakistani patients with neuropathic pain were found to be efficacious at low dosages in comparison to international recommended dosages. Gabapentin and pregabalin were both similar in terms of reducing pain score but onset of pain relief was relatively faster with pregabalin. Dizziness, drowsiness and somnolence were frequently reported with both gabapentinoids; however, visual blurring, ataxia and weight gain were observed only with the use of pregabalin. Adverse effects are frequently observed with gabapentinoids which necessitates reverting back to low dosages or switching to other drugs for pain relief.
Collapse
Affiliation(s)
- Abida Shaheen
- Abida Shaheen, MPhil. Associate Professor, Pharmacology, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Syed Mahboob Alam
- Syed Mahboob Alam, PhD. Associate Professor, Pharmacology, Basic Medical Sciences Institute, JPMC, Karachi, Pakistan
| | - Arsalan Ahmad
- Arsalan Ahmad, MD. Professor, Neurology, Shifa College of Medicine, Islamabad, Pakistan
| | - Moosa Khan
- Moosa Khan, PhD. Associate Professor, Pharmacology, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
| |
Collapse
|
16
|
Azmi S, ElHadd KT, Nelson A, Chapman A, Bowling FL, Perumbalath A, Lim J, Marshall A, Malik RA, Alam U. Pregabalin in the Management of Painful Diabetic Neuropathy: A Narrative Review. Diabetes Ther 2019; 10:35-56. [PMID: 30565054 PMCID: PMC6349275 DOI: 10.1007/s13300-018-0550-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 12/18/2022] Open
Abstract
Pregabalin is a first-line treatment in all major international guidelines on the management of painful diabetic neuropathy (pDPN). Treatment with pregabalin leads to a clinically meaningful improvement in pain scores, offers consistent relief of pain and has an acceptable tolerance level. Despite its efficacy in relieving neuropathic pain, more robust methods and comprehensive studies are required to evaluate its effects in relation to co-morbid anxiety and sleep interference in pDPN. The sustained benefits of modulating pain have prompted further exploration of other potential target sites and the development of alternative GABAergic agents such as mirogabalin. This review evaluates the role of pregabalin in the management of pDPN as well as its potential adverse effects, such as somnolence and dizziness, which can lead to withdrawal in ~ 30% of long-term use. Recent concern about misuse and an increase in deaths linked to its use has led to demands for reclassification of pregabalin as a class C controlled substance in the UK. We believe these demands need to be tempered in relation to the difficulties it would create for repeat prescriptions for the many millions of patients with pDPN for whom pregabalin provides benefit.Plain Language Summary: Plain language summary available for this article.
Collapse
Affiliation(s)
- Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | | | - Andrew Nelson
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Adam Chapman
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Frank L Bowling
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Anughara Perumbalath
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Jonathan Lim
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Andrew Marshall
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Rayaz A Malik
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK.
- Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK.
| |
Collapse
|
17
|
Modulation of Opioid Transport at the Blood-Brain Barrier by Altered ATP-Binding Cassette (ABC) Transporter Expression and Activity. Pharmaceutics 2018; 10:pharmaceutics10040192. [PMID: 30340346 PMCID: PMC6321372 DOI: 10.3390/pharmaceutics10040192] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/14/2018] [Accepted: 10/16/2018] [Indexed: 12/23/2022] Open
Abstract
Opioids are highly effective analgesics that have a serious potential for adverse drug reactions and for development of addiction and tolerance. Since the use of opioids has escalated in recent years, it is increasingly important to understand biological mechanisms that can increase the probability of opioid-associated adverse events occurring in patient populations. This is emphasized by the current opioid epidemic in the United States where opioid analgesics are frequently abused and misused. It has been established that the effectiveness of opioids is maximized when these drugs readily access opioid receptors in the central nervous system (CNS). Indeed, opioid delivery to the brain is significantly influenced by the blood-brain barrier (BBB). In particular, ATP-binding cassette (ABC) transporters that are endogenously expressed at the BBB are critical determinants of CNS opioid penetration. In this review, we will discuss current knowledge on the transport of opioid analgesic drugs by ABC transporters at the BBB. We will also examine how expression and trafficking of ABC transporters can be modified by pain and/or opioid pharmacotherapy, a novel mechanism that can promote opioid-associated adverse drug events and development of addiction and tolerance.
Collapse
|
18
|
Li L, Han Y, Li T, Zhou J, Sun C, Xue Y. The analgesic effect of intravenous methylprednisolone on acute neuropathic pain with allodynia due to central cord syndrome: a retrospective study. J Pain Res 2018; 11:1231-1238. [PMID: 29983586 PMCID: PMC6025778 DOI: 10.2147/jpr.s160463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Central cord syndrome (CCS) may be associated with severe neuropathic pain that often resists to conventional pain therapy regimens and affects the patients’ quality of life (QoL) seriously. Current treatments for CCS-associated neuropathic pain have limited evidence of efficacy. This retrospective study was performed to present the effects of early treatment with methylprednisolone (MP) on acute neuropathic pain relief and the QoL in CCS patients. Patients and methods Data were collected from the medical records of CCS patients who suffered from acute neuropathic pain with allodynia. All the patients received intravenous MP treatment for up to 1 week. Patients were evaluated with standard measures of efficacy: neuropathic pain intensity, the area of allodynia, and the QoL at baseline, daily treatment, and at 1 and 3 months after the end of MP treatment. Results Thirty-four eligible patients were enrolled in our study. By the end of MP treatment, the proportion of patients who gained total or major (visual analog scale [VAS] score decreased by 50% or more) allodynia relief from the treatment was 91.18%, and a decrease in spontaneous pain was also observed. Moreover, this study showed MP could significantly improve the QoL of patients based on McGill Pain Questionnaire Short Form and EuroQol Five Dimensions Questionnaire. Four patients (11.76%) during MP treatment experienced mild or moderate side effects. None of the patients manifested CCS-associated neuropathic pain recurrence and MP-associated side effects at follow-up. Conclusion The current results suggested that MP offered an effective therapeutic alternative for relieving CCS-associated acute neuropathic pain with allodynia. Given the encouraging results of this study, it would be worthwhile to confirm these results in randomized placebo-controlled clinical trials.
Collapse
Affiliation(s)
- Liandong Li
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| | - Yawei Han
- Department of Histology and Embryology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Tengshuai Li
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| | - Jiaming Zhou
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| | - Chao Sun
- Department of Orthopaedics Surgery, Tianjin Metabolic Diseases Hospital & Tianjin Institution of Endocrinology, Tianjin, China.,Key Lab of Hormones and Development (National Health and Family Planning Commission of the PRC), Tianjin Key Laboratory of Metabolic Diseases, Tianjin, China
| | - Yuan Xue
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| |
Collapse
|