Transdermal fentanyl patch for postoperative analgesia in total knee arthroplasty: a randomized double-blind controlled trial

Transdermal Fentanyl Patch Effectiveness in Postoperative PainManagement in Orthopedic Patients: Literature Review

Controlling pain after major orthopedic surgery may be challenging, and it is related to delayed recovery, the development of chronic pain, and analgesic dependence. It is well known that effective postoperative pain control can reduce hospital stays by ensuring a more rapid rehabilitation,thereby decreasing the overall costs. Despite the development of analgesics, the use of opioids and their derivates remains the cornerstone of treatment for patients with acute moderate-to-severe pain in association with general or regional anesthesia. To reduce the risk of side effects and opioid addiction, considering the alarming epidemiological reports in relation to opioid abuse, combined analgesic methods are used, in addition to lower dosages or different forms of administration, such as transdermal administration. Fentanyl transdermal patches appear to be effective in controlling postoperative pain as part of multimodal analgesic regimens in knee and hip surgery, shoulder arthroplasty, traumatic fractures, and one-day surgery; this treatment has fewer associated side effects and can be safely used even in patients with renal impairment. It is also recommended for postoperative pain management in combination with a femoral-sciatic nerve block during foot and ankle surgery.

Comparison of the efficacy and safety of transdermal buprenorphine patch to conventional analgesics after operative fixation of extra capsular fracture of proximal femur

INTRODUCTION

Proximal femur fractures are common among older individuals and pose challenges in achieving effective post-operative analgesia. Age-related co-morbidities limit the selection of analgesics in this population. This study aimed to compare the safety and effectiveness of transdermal buprenorphine (TDB) patch with traditional analgesics after fixation of an extracapsular fracture of the proximal femur.

METHODOLOGY

A prospective randomized controlled study was conducted over a 2-year period, involving 60 patients who underwent surgery for extra capsular intertrochanteric fracture fixation. The patients were randomly assigned to two groups by random envelope method. Group A received an intravenous formulation of paracetamol and tramadol for the initial 48 h, followed by an oral formulation. Group B received a transdermal buprenorphine (TDB) patch delivering 5 mcg/hour immediately after surgery, which continued for 2 weeks postoperatively. During the 14-day monitoring period, patients' pain scores were assessed using the Visual Analog Scale (VAS) at rest and during movement. The primary objective was to maintain a VAS score of 4 or lower. Rescue analgesics were administered if the VAS score reached 6. The secondary objectives included evaluating the quantity of rescue analgesics required and monitoring for any adverse effects or complications.

RESULTS

Pain scores at rest and during movement were significantly lower in Group B at all-time points (p-value 0.0006 - ≤ 0.0001), and the requirement for rescue analgesia was also significantly lower in this group. The administration of the TDB patch did not result in any significant adverse effects.

CONCLUSION

TDB patch is secure and offers better compliance and analgesia than other analgesics in the postoperative period whilst treating proximal femur extra capsular fracture.

Improving postoperative analgesia in hallux valgus surgery: oral opioids suppression by addition of a single transdermal fentanyl patch: a prospective evaluation

The last decade there is an exponential increase in opioid related deaths. This is proven to be correlated with the rising medical prescription rates of strong opioids. We investigated whether pain after hallux valgus surgery under popliteal nerve block could be adequately controlled without the prescription of oral opioids, with a single transdermal fentanyl patch. In this prospective observational study with 100 patients undergoing corrective first metatarsal osteotomies we prospectively investigated the adverse effects and need for extra pain medication. The transdermal fentanyl patch was applied one hour before surgery, prior to the ultrasound guided popliteal nerve block. Patients filled out a questionnaire every 6 hours to evaluate the pain [VAS-score], nausea [PONV-score], activity [acivity and ambulation score] and the intake of extra medication. Postoperative pain was well controlled [Mean VAS 2,53]. The maximum mean VAS score [3.93] was recorded 36 hours postoperatively. 63.8% of patients had less pain than expected. No major adverse effects were reported by the patients. Nausea was mainly mild and the majority of patients reported 'no effect' or 'sometimes' effect on daily activities. In an era where surgeons need to be aware of the threat of overuse of strong opioids, the use of a single transdermal fentanyl patch in combination with an ultrasound guided nerve block can be a good alternative in hallux valgus surgery. The use of the patch seems to obviate the need for oral opioids after discharge. Nausea and vomiting were a concern - as expected -, but only at 24 and 36 hours. On the other hand nausea did not seem to affect activity, as there was a gradual increase in activity score over time.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty

BACKGROUND

One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur.

MATERIALS AND METHODS

This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2 years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48 h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5 mcg/h was applied at the beginning of surgery and was continued 2 weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14 days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any.

RESULTS

Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group.

CONCLUSION

TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

[Opioids in primary total joint arthroplasty: Interpretation of 2020 AAHKS/ASRA/AAOS/THS/TKS clinical practice guidelines]

In 2020, the American Association of Hip and Knee Surgeons (AAHKS), the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Orthopaedic Surgeons (AAOS), the American Hip Society (THS), the American Knee Society (TKS) have worked together to develop clinical practice guidelines on the use of Opioids in primary total joint arthroplasty (TJA). This clinical practice guideline formulates recommendations for common and important questions related to the efficacy and safety of Opioids in primary TJA. This article interprets the guideline to help doctors make clinical decisions.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

Effects of a Preoperative Transdermal Fentanyl Patch on Proinflammatory Cytokine and Pain Levels During the Postoperative Period: A Randomized Controlled Trial

OBJECTIVE

The main objectives of this article were to assess the effect of preoperative transdermal fentanyl patch (TFP) on interleukin (IL)-6 and IL-8 levels and pain after laparoscopic cholecystectomy.

MATERIALS AND METHODS

Patients received a TFP (25 μg/h) (patch group, n=30) or a placebo patch (control group, n=30) applied 14 hours before operation. After surgery, control group received intravenous continuous fentanyl (25 μg/h) with loading dose (25 μg). IL-6 and IL-8 levels were measured at admission and 1, 6, 12, 24, and 48 hours postoperatively. Pain score and consumption of rescue analgesic were evaluated too.

RESULTS

At 24 hours postoperatively, IL-6 and IL-8 reached a peak and then decreased. The peak IL-6 levels were 21.92(±6.22) and 24.91(±6.81) pg/mL in the patch and control group. The significant differences of IL-6 between groups were shown at 6 and 12 hours postoperatively (P=0.032, 0.0001). There were no significant differences in IL-8 levels and pain score.

CONCLUSIONS

Preoperative TFP attenuated the increase in IL-6 levels after surgery and provided similar analgesia to continuous fentanyl infusion. Preemptive TFP may have influence on proinflammatory reactions and pain control after surgery.

Consensus Perioperative Management Best Practices for Patients on Transdermal Fentanyl Patches Undergoing Surgery

PURPOSE OF REVIEW

The administration of a transdermal fentanyl patch can be complicated with different pharmacokinetics than other fentanyl preparations.

RECENT FINDINGS

The medical condition and baseline opioid requirements must all be carefully considered when dosing a fentanyl patch. An advantage of the fentanyl patch is its ability to bypass the gastrointestinal tract and in many patients, provide effective analgesia with minimal side effects. Fentanyl patches must be carefully administered since morbidity and/or mortality can result from the following: Giving higher doses than a patient needs, combining the medication with potent sedatives, or heating a fentanyl patch. The use of a transdermal fentanyl patch for the treatment of acute postoperative pain is not recommended and any patient undergoing a surgical procedure should have the fentanyl patch removed preoperatively. The current manuscript discusses the history of fentanyl and the fentanyl patch, as well as perioperative considerations, contraindications, current clinical efficacy, and clinical adversities related to the transdermal fentanyl patch. Regarding the heating of a transdermal fentanyl patch, which significantly increases blood levels of fentanyl, it is of the utmost importance that the patch be removed prior to surgery.

Is the transdermal fentanyl patch an efficient way to achieve acute postoperative pain control?: A randomized controlled trial

BACKGROUPD

This study investigated the plasma fentanyl concentration and efficacy of transdermal fentanyl patch (TFP) (25 μg/h) in the management of acute postoperative pain.

METHODS

Patients undergoing laparoscopic cholecystectomy were randomly allocated to 2 groups. The TFP group (n = 30) received a single TFP 25 μg/ h to the anterior chest wall 14 h before operation. The IV group (n = 30) received a placebo patch. After the operation, intravenous fentanyl infusion (25 μg/h) was begun with loading dose 25 μg in the IV group and only normal saline in the TFP group. Plasma fentanyl levels were measured at admission, 1, 6, 12, 24, and 48 h postoperatively. Pain severity and adverse effects were evaluated too.

RESULTS

The fentanyl level peaked 1 h after operation in the TFP group (3.27 ± 0.34 ng/mL) and 24 h postoperatively in the IV group (2.9 ± 0.42 ng/mL). Pain scores and the use of rescue analgesics were not significantly different between 2 groups. Respiratory depression was not happened in both groups.

CONCLUSIONS

The TFP (25 μg/h) affixed 14 h before surgery reached a higher constant concentration than the same dose setting of a constant IV infusion of fentanyl after surgery. Although the concentration of fentanyl was higher than those of previous researches, there was no respiratory depression. But, there was no advantage of reducing pain score and the use of rescue analgesics.

CLINICAL TRIAL REGISTRATION

(available at: http://cris.nih.go.kr, KCT0002221).

Transdermal fentanyl as an adjuvant to paravertebral block for pain control after breast cancer surgery: A randomized, double-blind controlled trial

Objective:

The aim of this study is to investigate the effect of transdermal fentanyl (TDF) as an adjuvant to paravertebral block (PVB) for pain control after breast cancer surgery.

Patients and Methods:

This randomized, double-blind trial included fifty females with breast cancer scheduled for surgery. They were randomly allocated into one of two equal groups. The TDF group used transdermal fentanyl patches (TFPs) 25 μg/h applied 10 h preoperative then PVB with 20 mL of bupivacaine 0.25% was done before induction of general anesthesia. The PVB group used placebo patches in addition to PVB the same way as TDF group. Postoperative pain was assessed with a visual analog scale (VAS) score up to 48 h. Intravenous morphine 0.1 mg/kg was given when the VAS is ≥ 3 or on patient request. The primary outcome measures were the time to first request for analgesia and the total analgesic consumption in the first 48 h.

Results:

Relative to the VAS score reading was 30 min. After the end of surgery, VAS score decreased significantly in the two groups up to 48 postoperative hours and was significantly lower in TDF group up to 24 h. The time to first request of additional analgesia was significantly longer, and total dose of morphine consumption was significantly lower in TDF group (P < 0.001, and P = 0.039, respectively).

Conclusion:

TFPs releasing 25 μg/h is a safe and effective adjuvant to PVB after breast cancer surgery. It provides adequate analgesia with reduction of opioid consumption and minimal adverse effects.

Comparative study of the efficacy of transdermal buprenorphine patches and prolonged-release tramadol tablets for postoperative pain control after spinal fusion surgery: a prospective, randomized controlled non-inferiority trial

PURPOSE

To compare the efficacy of a transdermal buprenorphine patch (5, 10, 15, and 20 μg/h) with that of oral tramadol (150, 200, 250, and 300 mg) for postoperative pain control after single level spinal fusion surgery.

METHODS

The present study (ClinicalTrials.gov, number NCT02416804) was a prospective, randomized controlled non-inferiority trial designed to determine the efficacy of buprenorphine TDS for alleviating postoperative pain following patient controlled analgesia (PCA) in persons underwent a single level posterior lumbar interbody fusion surgery through 1:1 allocation. The primary outcome was the Visual Analog Pain Scale (VAS) score for postoperative back pain at 7 days after surgery. The non-inferior margin of the VAS was set at δ = 1.5 points.

RESULTS

The VAS score (primary outcome) for postoperative back pain at 7 days after surgery in the Buprenorphine group was not inferior compared to the Tramadol group. The overall changes in VAS scores for postoperative pain during follow-up assessments over a 2-week period did not differ between both groups. However, the VAS scores for postoperative pain significantly improved with time after surgery in both groups. The patterns of changes in the VAS scores for postoperative pain during the follow-up period were not significantly different between the both groups.

CONCLUSIONS

The efficacy of buprenorphine TDS was not inferior to that of oral tramadol medication for alleviating postoperative pain in the subacute period from 72 h after surgery, following PCA administration. In addition, adverse events were similar between both groups.

Postoperative pain treatment after total knee arthroplasty: A systematic review

INTRODUCTION

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

METHODS

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L'Abbe Plots and trial sequential analysis.

RESULTS

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

CONCLUSION

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.