Home-based high tone therapy may alleviate chemotherapy-induced neuropathic symptoms in patients with colorectal cancer: A randomized double-blind placebo-controlled pilot evaluation

BACKGROUND

Most oncologic patients receiving chemotherapy suffer from neuropathy, which not only severely affects quality of life but also may lead to chemotherapy dose reductions or even discontinuation of cancer therapy. Still, it is difficult to sufficiently control these symptoms with the currently available pharmacological treatments. High tone therapy was reported to be an effective option for neuropathies due to different etiologies. However, to date, there are no studies on high tone therapy in patients with chemotherapy-induced peripheral neuropathy.

METHODS

This randomized, double-blind, and placebo-controlled two-center study was conducted at the Departments of Physical and Rehabilitation Medicine at the Clinics Donaustadt and Ottakring, Vienna, Austria. Patients with histologically verified colorectal carcinoma treated with a platin derivate and neuropathic symptoms were invited to participate. High tone therapy took place in a home-based setting using the HiToP 191 PNP ® or placebo device for three weeks. Neuropathic symptoms and quality of life were assessed via questionnaires. After the follow-up examination, an opt-in was offered to the patients in the placebo group in terms of an open-label treatment with a verum HiToP PNP ® device. In addition, patients with chemotherapy-induced peripheral neuropathy due to various malignant diseases were treated in an open-label setting reflecting a clinical application observation. These patients are reported as a separate group.

RESULTS

In the verum group, there was a significant reduction of paresthesias and mental stress due to paresthesias from baseline until end of therapy, compared to placebo. These findings were observed in the opt-in subgroup, as well. In the open-label clinical application observation group, intensity and mental stress due to paresthesia, pain, cramps, and intensity of tightness/pressure were significantly lower at the end of therapy, compared to baseline.

CONCLUSIONS

Home-based high tone therapy brought about a significant alleviation in paresthesias and mental stress due to paresthesias in the verum but not the placebo group. In the clinical application observation, a significant alleviation in several further neuropathic symptoms was seen.

TRIAL REGISTRATION

This study was registered at clinicaltrials.gov (NCT06048471, 03/02/2020).

Characterizing Gabapentinoid Use Among Patients With Isolated Low Back Pain

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Gabapentinoids have been increasingly studied as a non-narcotic option for neuropathic and postoperative pain. However, there is evidence suggesting that off-label use of these medications for the treatment of isolated LBP is not effective. The purpose of the current study was to evaluate prescription patterns for gabapentinoids among patients with isolated low back pain.

METHODS

Adult patients with LBP were abstracted from the 2019 M91Ortho PearlDiver dataset using International Classification of Diseases (ICD-10) code M54.5. Patients were excluded if they had a diagnosis of neurologic symptoms, history of spinal surgery, spinal fracture, or conditions for which gabapentinoids are FDA approved. Gabapentinoid and narcotic prescriptions within one year of LBP diagnosis were identified. Patient characteristics and prescriber specialty were extracted from the dataset and predictors of gabapentinoid prescriptions were determined using univariate and multivariate analyses.

RESULTS

Among the 1,158,875 isolated LBP patients, gabapentinoids were prescribed for 11%, narcotics for 8%, and both for 3%. The most common prescriber specialties included: primary care physicians (45%), nurse practitioners (15%), and pain management physicians (5%). Independent predictors of gabapentinoid prescriptions included: female sex, region of the country, and insurance type (P-values <.001).

CONCLUSIONS

Of nearly 1.2 million patients with isolated LBP, 14.2% were prescribed gabapentinoids within one year of their LBP diagnosis. Patient characteristics predictive of receiving gabapentinoids were predominantly non-clinical factors.

Trends in consultations and prescribing for rheumatic and musculoskeletal diseases: an electronic primary care records study

BACKGROUND

Rheumatic and musculoskeletal diseases (RMDs) are common and generally managed in primary care through supported self-care, physiotherapy, analgesia, and specialist referral where indicated. The COVID-19 pandemic led to abrupt changes in primary care delivery, including moves to remote consulting, pauses on group-based self-care, and restricted referrals.

AIM

To describe how patterns of UK primary healthcare consultations and analgesic prescribing relating to RMDs changed during the COVID-19 pandemic.

DESIGN AND SETTING

Observational study using routinely collected national primary care electronic health record data from the Clinical Practice Research Datalink between 1 April 2017 and 1 October 2021.

METHOD

RMD and analgesic SNOMED-CT codes were derived through consensus and published work. Prevalent and incident RMD-related consultations were determined, and RMD consultations matched to prevalent and incident analgesia prescriptions. Joinpoint regression was used to describe trends over time.

RESULTS

Prevalent and incident RMD consultations steadily increased until March 2020 when a substantial drop occurred as pandemic- related restrictions were introduced; levels had not recovered to pre-pandemic highs by October 2021. While incident and prevalent analgesic prescribing also reduced around March 2020, the proportion of patients with an RMD consultation prescribed any analgesic increased from 27.72% in February 2020 to 38.15% in April 2020, with increases across all analgesic groups. A higher proportion of strong opioid prescriptions was seen in the most deprived areas.

CONCLUSION

Pandemic-associated restrictions led to fewer primary care consultations and relative increases in analgesic prescribing, including strong opioids, for RMDs in the UK. Policymakers must consider the impact of these changes in future healthcare resource planning.

Efficacy and safety of pregabalin in eye pain: A systematic review

BACKGROUND

The pregabalin is approved for the management of persistent pain. The aim of this study is to assess the advantages and disadvantages of the use of pregabalin in eye pain management.

METHODS

The PubMed, Cochrane Library, Embase, and Web of Science databases were searched until January 2022 for randomized controlled trials. Randomized, double-blinded trials comparing pregabalin with placebo in eye pain management were included. The primary outcome was visual analog scale or numerical rating scale at acute (24 hours) and chronic (≥7 days after surgery) timepoints. The secondary outcomes were analgesic medication requirements and pregabalin-related complications (nausea, vomiting, dizziness, and headache). We also compared the effect of pregabalin on dry-eye syndrome.

MAIN RESULTS

Six relevant articles were identified that studied the use of pregabalin as pain relief for photorefractive keratectomy (n = 2), laser epithelial keratomileusis (n = 1), laser-assisted in situ keratomileusis (n = 1), eyelid surgery (n = 1), and dacryocystorhinostomy (n = 1). Pregabalin was associated with a significant reduction in pain scores (95% confidence interval = -0.41 [-0.76--0.06]) 24 hours after surgical procedures. The data were insufficient to draw conclusions regarding dry eye symptoms. Because of the high heterogeneity of outcomes regarding adverse effects, there is no conclusion regarding the safety of pregabalin in eye pain.

CONCLUSIONS

Pregabalin reduced acute eye pain but had no significant effect on long-term analgesia after ophthalmological surgery in adults. It had no effect on dry-eye symptoms after ocular surgery. Further studies on the safety of pregabalin in eye pain management are required to draw solid conclusions.

Comparing the therapeutic effects of pregabalin and gabapentin after transforaminal epidural nerve block in lumbar radiculopathy

Lumbar radiculopathy can be presented as low back pain and radiating pain. Transforaminal epidural steroid injection (TFESI) has been used to treat radicular pain, and after the injection, additional medications such as gabapentinoids including pregabalin (PGB) and gabapentin (GBP) can be administered to relieve remnant pain. However, little is known about the effectiveness of gabapentinoids in relieving pain after transforaminal epidural steroid injection. This study was conducted to compare the effect of pregabalin and gabapentin in lumbar radiculopathy patients who underwent transforaminal epidural steroid injection. One hundred seven patients who received TFESI and had taken PGB or GBP after the intervention at Daegu Catholic University Medical Center from January 2013 to August 2021 were included in this study. Visual Analogue Scale (VAS) was evaluated in all patients. Among 107 patients, 57 (53.3%) patients took PGB and 50 (46.7%) patients took GBP after TFESI. The PGB and GBP groups showed reduced VAS scores according to visit (P < .001). However, no statistically significant differences in VAS scores according to the types of medication (P = .811) and change aspects according to visit were observed between the PGB and GBP groups (P = .947). The study findings suggest that both pregabalin and gabapentin can be equally used to reduce pain in lumbar radiculopathy patients who underwent TFESI. Further studies with larger sample size are needed to generalize the findings of this study.

A snapshot on the usage pattern of gabapentinoids in Oman

Background

Since their introduction as adjunct anticonvulsants, the use of gabapentinoids (gabapentin and pregabalin) has increased substantially worldwide to include a wide range of clinical conditions. Various reports have demonstrated that they possess addiction liability and can produce effects similar to traditional recreational drugs, such as significant euphoric effects, enhanced sociability, and relaxation. However, there is limited information on the use of these agents in the Middle East.

Objectives

Here, we describe the usage pattern of gabapentinoids at Sultan Qaboos University Hospital, a tertiary care medical institution in Oman.

Methods

Adult patients (≥18 years) who were prescribed gabapentinoids for six months (March-August 2019) were included in this retrospective cross-sectional study. Indications and dosing regimens were reviewed according to the Food and Drug Administration labeling. Controlled and restricted drugs were reviewed using Oman National Formulary. Institutional ethical approval was obtained before conducting the study.

Results

We analyzed 291 prescriptions. The mean (standard deviation, SD) age was 60.5 years (SD = 13.0) with the age group of ≥60 years being the most common (190, 65.3%). Most of patients were females (178, 61.2%). The majority of prescriptions were for outpatients (85.8%). Drugs were prescribed as refill and follow-up in 116 (40.0%) and 97 (33.4%) of prescriptions, respectively. Diabetic peripheral neuropathy (50, 79.4%) was the most labeled indication for both. Off-label use was 128 (51.8%) and 31 (70.5%) for pregabalin and gabapentin, respectively, with lower back pain as being the most common indication for both drugs. A total of 54 (19.0%) patients were using at least one of the psychotropic drugs.

Conclusions

Our findings indicate that gabapentinoids are frequently prescribed for off-label use. Awareness programs and the establishment of policy for the use of these drugs are required to ensure their rational use and prevent misuse and/or abuse.

Use of pharmacological and nonpharmacological treatments for chronic noncancer pain among people using opioids: a longitudinal cohort study

ABSTRACT

Although multimodal management of chronic noncancer pain (CNCP) is recommended, long-term treatment utilization patterns among people using opioids are not well known. The Pain and Opioids IN Treatment study recruited Australian adults receiving opioids for CNCP for more than 6 weeks from community pharmacies. Pharmacological (opioid and nonopioid analgesics and psychotropic medicines) and nonpharmacological (physical, mental health, and specialized) treatments used in the previous 12 months and 30 days were collected annually over 4 years (2015-2018). Associations were explored between 30-day treatment use and sociodemographic characteristics and pain measures. Overall, 1334 participants completed at least one annual follow-up. The median pain severity (5.0, interquartile range [IQR] 3.8 to 6.3) and pain interference scores (5.7, IQR 3.9-7.3) indicated moderate pain throughout the study period, despite most participants reporting the use of nonopioid pharmacological (12 month: 97.6% and 30 day: 96.8%) and nonpharmacological treatments (12 month: 91.8% and 30 day: 66.1%). Some treatment use was inconsistent with guidelines: ongoing nonsteroidal anti-inflammatory drugs and sedative-hypnotic use were common, whereas fewer people engaged with pain management programs (12 month: 22.3%). Private health insurance was associated with using physical (adjusted odds ratio 1.61, 99.5% confidence intervals 1.15-2.24) and specialized nonpharmacological treatments (adjusted odds ratio 1.47, 99.5% confidence intervals 1.14-1.91). This study demonstrates that many Australians taking opioids long-term for CNCP also use nonopioid pharmacological and nonpharmacological treatments. The use of pharmacological treatments including nonsteroidal anti-inflammatory drugs, psychotropic medicines, and gabapentinoids, outside guidelines, warrants review. Furthermore, despite Australia's universal healthcare scheme subsidising some nonpharmacological treatments, overall use of these treatments was associated with having private health insurance, highlighting a need for more equitable service provision.

Preemptive multimodal analgesia and post-operative pain outcomes in total hip and total knee arthroplasty

BACKGROUND

Use of multimodal analgesia (MMA) prior to orthopedic surgery has been adopted by many practitioners as a strategy to minimize use of opioid medications. The purpose of this investigation was to quantify the effect of a preemptive three-drug regimen (acetaminophen, celecoxib, and gabapentin) in terms of post-operative opioid consumption and pain control in the field of total joint arthroplasty.

METHODS

A retrospective chart review was conducted on 1691 patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) and stratified by whether they received a preemptive three medication analgesic therapy (acetaminophen, celecoxib, and gabapentin) within 30 to 60 min prior to entering the operating room. Post-operative opioid consumption as well as subjectively reported patient pain scores were assessed throughout their hospital stay.

RESULTS

A total of 1416 eligible patients were identified with 485 undergoing THA and 931 undergoing TKA. Statistically significant reductions in oral morphine equivalents were shown on post-operative day zero and two within the TKA cohort, and non-significant reductions were demonstrated in other intervals for both procedure types. Statistically significant reductions in patient reported pain scores were shown in nearly every time interval in both procedure types.

CONCLUSION

The receipt of preemptive acetaminophen, celecoxib, and gabapentin 30-60 min prior to total joint arthroplasty demonstrated modest reductions in opioid requirements post-operatively. Patients receiving preemptive MMA reported lower pain scores throughout nearly every time interval during their admission after surgery. Further investigations are warranted regarding optimal preoperative medication therapies to promote adequate post-operative pain control-and ultimately diminished opioid consumption-in the setting of total joint arthroplasty.

Implementation and Evaluation of a Digitally Enabled Precision Public Health Intervention to Reduce Inappropriate Gabapentinoid Prescription: Cluster Randomized Controlled Trial

Background

Digital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale.

Objective

The aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior.

Methods

This study was developed as part of the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans’ Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention.

Results

The trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2%, P=.004; postal: mean reduction of 11.2%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: –0.058, postal: –0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8%, postal: 2.0%, P=.02).

Conclusions

Our digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions.

Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale

The gabapentinoids, gabapentin, and pregabalin, target the α₂δ subunits of voltage-gated calcium channels. Initially licensed for pain and seizures, they have become widely prescribed drugs. Many of these uses are off-label for psychiatric indications, and there is increasing concern about their safety, so it is particularly important to have good evidence to justify this usage. We conducted a systematic review and meta-analysis of the evidence for three of their common psychiatric uses: bipolar disorder, anxiety, and insomnia. Fifty-five double-blind randomised controlled trials (RCTs) and 15 open-label studies were identified. For bipolar disorder, four double-blind RCTs investigating gabapentin, and no double-blind RCTs investigating pregabalin, were identified. A quantitative synthesis could not be performed due to heterogeneity in the study population, design and outcome measures. Across the anxiety spectrum, a consistent but not universal effect in favour of gabapentinoids compared to placebo was seen (standardised mean difference [SMD] ranging between -2.25 and -0.25). Notably, pregabalin (SMD -0.55, 95% CI -0.92 to -0.18) and gabapentin (SMD -0.92, 95% CI -1.32 to -0.52) were more effective than placebo in reducing preoperative anxiety. In insomnia, results were inconclusive. We conclude that there is moderate evidence of the efficacy of gabapentinoids in anxiety states, but minimal evidence in bipolar disorder and insomnia and they should be used for these disorders only with strong justification. This recommendation applies despite the attractive pharmacological and genetic rationale for targeting voltage-gated calcium channels.

Is gabapentin a safe and effective treatment for nonneuropathic pain?

ABSTRACT

A review of the recent literature found that compared with placebo or other pain medications, gabapentin did not significantly reduce nonneuropathic pain. The drug also is associated with an increased risk of adverse reactions, including somnolence, dizziness, and nausea. Given the lack of efficacy and risk of adverse reactions, gabapentin should not be used for nonneuropathic pain.

Gabapentinoids: The rise of a new misuse epidemics?

Gabapentinoids and opioids have in common that they are used in medicine in the treatment of pain, and by addicts in recreational use. In recent years, in the context of the "opioid epidemics", gabapentinoids, which had a reputation for low risk of abuse, have been increasingly prescribed. This was accompanied by increasingly frequent abuses, the patients most at risk being those suffering from opiate addiction. However, gabapentinoids increase the risks associated with opioids or other sedatives, due to a synergy of central depressant effects. This leads to reconsider the framework of their prescription and the management of chronic pain.

Trends in the Utilization and Dose of Gabapentinoids in Combination With Opioids in an Injured Worker Population Between 2008 and 2018

OBJECTIVE

To determine long term (11 year) trends in gabapentin and pregabalin prescribing among workers' compensation claimants at various opioid dose combinations (low, medium, high, and very high) in Louisiana.

METHOD

A longitudinal study of 18,737 claimants who filled any prescriptions between 2008 and 2018.

RESULTS

The proportion of claimants prescribed opioids alone at all dose levels decreased dramatically. The proportion claimants prescribed the combination of low dose opioids and low dose gabapentinoids increased (7.7% to 10.9%). Prescribing higher daily doses of gabapentinoids was associated with higher daily doses of opioids. Gabapentinoid prescribing was associated with continued prescribing of medium and high dose opioids as claims matured.

CONCLUSIONS

Overall opioid prescribing decreased over time, while prescribing low dose opioids with gabapentinoids, increased.

A Retrospective Analysis of Gabapentinoid and Opioids to Opioid Monotherapy for Pain Relief in Patients with Chronic Neck and Low Back Pain

OBJECTIVE

We compared the reduction in pain and opioid consumption in patients with chronic spinal pain on concomitant gabapentinoids and opioids with patients using opioids only.

DESIGN

This was a retrospective chart review of patients with chronic neck or low back pain who were on opioids with at least a 24-month follow-up.

SETTING

Single-center pain clinic in an urban setting.

SUBJECTS

167 patients with chronic spinal pain lasting at least six months.

METHODS

Patients on gabapentin or pregabalin were included in the gabapentinoid group, while the other patients were included in the non-gabapentinoid group. Primary outcome was assessment of pain scores measured via a numeric rating scale (NRS), and secondary outcomes were response to the treatment (>2 point reduction on NRS) and daily opioid use measured in morphine milliequivalents.

RESULTS

Pain scores were reduced in the first six months and plateaued after that in both groups. At the end of 24 months, the average pain score was 6.71 in the gabapentinoid group, while the average pain score was 7.18 in the non-gabapentinoid group. There was no statistical significance between the groups (p = 0.28). There was no difference in response to treatment in gabapentinoid group (33.3%) when compared with non-gabapentinoid group (32.7%). We also failed to find any significant difference in daily opioid usage between the two groups.

CONCLUSION

Gabapentinoids may not lead to reduction in pain or opioid consumption in patients with chronic spinal pain. A careful approach must be adopted while prescribing gabapentinoids in the chronic spinal pain patient population.

Perioperative nonopioid analgesia reduces postoperative opioid consumption in knee arthroscopy: a systematic review and meta-analysis

PURPOSE

The opioid epidemic has prompted an emphasis on investigating opioid-sparing alternatives for pain management following knee arthroscopy. This review evaluated the effects of perioperative nonopioid adjunct analgesia on postoperative opioid consumption and pain control in patients undergoing knee arthroscopy.

METHODS

A systematic review and meta-analysis was performed using the following databases: PubMed, Embase, Web of Science, MEDLINE, and SCOPUS. Prospective comparative studies assessing the efficacy of various perioperative nonopioid analgesic strategies in patients undergoing knee arthroscopy were included. Twenty-five studies (n = 2408) were included.

RESULTS

Pre-emptive nonopioid pain medications demonstrated a reduction in cumulative postoperative oral morphine equivalent (OME) consumption by 11.8 mg (95% CI - 18.3, - 5.4, p ≤ 0.0001) and VAS pain scores by 1.5 (95% CI - 2.3, - 0.7, p < 0.001) at 24 h compared to placebo. Postoperative nonopioid pain medications significantly reduced cumulative postoperative OME consumption by 9.7 mg (95% CI - 14.4, - 5.1, p < 0.001) and VAS pain scores by 1.0 (95% CI - 1.354, - 0.633, p < 0.001) at 24 h compared to placebo. Saphenous nerve blocks significantly reduced cumulative postoperative OME consumption by 6.5 mg (95% CI - 10.3, - 2.6, p = 0.01) and VAS pain scores by 0.8 (- 1.4, - 0.3, p = 0.03) at 24 h compared to placebo. Both preoperative patient education and postoperative cryotherapy reduced postoperative opioid consumption.

CONCLUSION

Perioperative nonopioid pharmacotherapy, saphenous nerve blocks, and cryotherapy for patients undergoing knee arthroscopy significantly reduce opioid consumption and pain scores when compared to placebo at 24 h postoperatively. These interventions should be considered in efforts to reduce opioid consumption in patients undergoing knee arthroscopy. More research is needed to determine which interventions can reduce pain outside of the immediate postoperative period and the potential synergistic effects of combining interventions.

LEVEL OF EVIDENCE

II.

Characterization of inpatient care for patients admitted to a psychiatric hospital with a home opioid prescription

Introduction

Patients with mental illness are particularly at risk for OUD, and due to this higher risk, providers may be more inclined to withhold their home opioids when they are admitted to a psychiatric hospital. Patients whose home opioids are continued or withheld during admission may be treated differently with respect to pain control, orders for nonopioid adjunctive pain agents, orders for intramuscular as-needed medications, orders for seclusion and/or restraints, and outpatient referrals for OUD treatment. The objective of this retrospective pilot study was to characterize inpatient care for these 2 patient populations.

Methods

Thirty-one inpatient encounters were reviewed for patients who had opioid prescriptions before admission and were discharged from the medical center's psychiatric service from June 1 through August 31, 2019.

Results

Orders for nonopioid adjunctive pain agents and intramuscular as-needed medications trended higher for the opioid-withheld group, suggesting greater polypharmacy and patient dissatisfaction compared with the opioid-continued group. Additionally, what became evident was the lack of consistent and clear documentation regarding the discharge plans for the patients' home opioid and OUD treatment.

Discussion

These findings may prompt inpatient interdisciplinary teams to develop a better process of documentation to facilitate continuity of care.

Investigating the prescribing trajectory and geographical drug utilisation patterns of gabapentinoids in primary care in England: An ecological study

AIMS

This study aimed to investigate the prescribing trajectory, geographical variation and population factors, including socioeconomic status (SES), related to prescribing gabapentinoids in primary care in England.

METHODS

This ecological study applied practice-level dispensing data and statistics from the UK National Health Service Digital and Office for National Statistics from 2013 to 2019. The prescribing of gabapentinoids (in defined daily doses [DDDs]/1000 people) was measured annually and quarterly. General practices were categorised according to the quarterly prescribing in a group-based trajectory model. The one-year prescribing in 2018/19 was associated with practice-level covariates in a mixed-effects multilevel regression, adjusted for the cluster-effects of Clinical Commissioning Groups (CCGs) and mapped geographically.

RESULTS

The annual national prescription rate increased by 70% from 2800 to 4773 DDDs/1000 people in the time period 2013/14 to 2018/19. General practices were stratified into six trajectory groups. Practices with the highest level and the greatest increase in prescribing (n = 789; 9.8%) are mainly located in the north of England and along the east and south coastline. Socioeconomic status, demographic characteristics and relevant disease conditions were significantly associated with the prescribing. For every decrease in the Index of Multiple Deprivation decile (becoming less affluent), prescribing of gabapentinoids increased significantly by 203 (95% CI: 183-222) DDDs/1000 registrants.

CONCLUSIONS

Gabapentinoid prescribing trajectories varied across geographical regions and are associated with socioeconomic status, CCG locality (geography) and other population characteristics. These factors should be considered in future studies investigating the determinants of gabapentinoid prescribing and the risk of harms associated with gabapentinoids.

Efficacy of thermotherapy for herpes zoster and postherpetic neuralgia: A protocol for systemic review and meta-analysis

BACKGROUND

Herpes zoster (HZ), is a painful skin rash disease with cutaneous symptoms and acute zoster-associated pain (ZAP). Postherpetic neuralgia (PHN), as the most frequent sequela of HZ, can persist a long time. Both HZ and PHN may significantly impact the quality of life and made great economical afford to affected patients. Its optimal treatment on HZ and PHN is still an urgent problem. In China, thermotherapy, including moxibustion and fire needle, is widely used because they can quickly promote the recovery of shingles and reduce the occurrence of PHN. Thermotherapy can also reduce pain intensity, relieve anxiety, and improve quality of life of PHN. Based on the current literatures, the effect and safety of thermotherapy will be systematically evaluated to provide appropriate complementary therapies for HZ and PHN.

METHODS

Studies search for eligible randomized controlled trials (RCTs) that use thermotherapy including fire needle and moxibustion for HZ or PHN from the following databases: PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biology Medicine Database (CBM), Technology Periodical database (VIP), and Wanfang database. Language restrictions for retrieving literature are English and Chinese. Their data extraction will be done by 2 researchers. Mean difference (MD) or relative risk (RR) with fixed or random effect model in terms of 95% confidence interval (CI) will be adopted for the data synthesis. To evaluate the risk of bias, the Cochrane's risk of bias assessment tool will be utilized. The sensitivity or subgroup analysis will also be conducted when meeting high heterogeneity (I2 > 50%).

RESULTS

This meta-analysis will provide an authentic synthesis of the thermotherapy's effect on HZ and PHN, including incidence of postherpetic neuralgia and adverse events.

DISCUSSION

The findings of the review offer updated evidence and identify whether thermotherapy can be an effective treatment for HZ and PHN for clinicians.

REGISTRATION NUMBER

INPLASY2020110009.

Influence of single nucleotide polymorphism of LAT1 on therapeutic response to gabapentinoids in Pakistani patients with neuropathic pain

Gabapentinoids are substrate of L-type amino acid transporter 1 (LAT1) for distribution across the blood-brain barrier. The present study aimed to evaluate the effect of LAT1 rs4240803 genetic polymorphism on the clinical efficacy and tolerability of gabapentinoids in Pakistani patients with neuropathic pain. Three-hundred and ninety-two patients were recruited, genotyped for SNP rs4240803, and followed up for eight weeks to evaluate the clinical response to gabapentinoids in terms of pain relief, inadequate response, and the emergence of adverse events. LAT1 rs4240803 GG, GA, and AA genotype frequency were 33.42%, 47.96% and 18.62%, respectively. Out of 392 patients, 323 responded to the treatment and 17.6% discontinued either due to insufficient response or intolerable adverse events (AEs). GA genotype was more frequent in non-responder group (P ˂ 0.001). Maximum pain responders (≥50%) in combination with the lowest incidence of AEs were observed in the GG group, whereas partial responders belonged to GA genotype and with the highest frequency of somnolence (83.6%) and dizziness (69.9%). Overall, 72.5% patients with GA genotype experienced AEs (P ˂ 0.001). In conclusion, clinical outcomes of gabapentinoids are influenced by LAT1 rs4240803 polymorphism and population pharmacogenetics should be considered to evaluate the maximum potential of gabapentinoids in the management of neuropathic pain.

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Background

Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients.

Methods

Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences.

Results

In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, −10; 95% CI, −12 to −9), 12 h (mean difference, −9; 95% CI, −10 to −7), 24 h (mean difference, −7; 95% CI, −8 to −6), and 48 h (mean difference, −3; 95% CI, −5 to −1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance.

Conclusions

No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients.

Editor’s Perspective

What We Already Know about This Topic

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A repeated cross-sectional study of factors associated with pregabalin-positive poisoning deaths in Ireland

BACKGROUND

The increasing use of pregabalin and the presence of pregabalin in poisoning deaths, particularly with opioids, highlight it as a potential drug of abuse. In this study we examined factors associated with pregabalin-positive poisoning deaths (PPPD) between 2013 and 2016 in Ireland.

METHODS

Data were extracted from the National Drug-Related Deaths Index (NDRDI). Analysis included univariate and multivariate logistic regression to estimate unadjusted and adjusted odds ratios (OR) and 95 % confidence intervals (CI) for factors associated with PPPD (primary outcome) by logistic regression models for the total sample and stratified by gender.

RESULTS

Pregabalin was present on 240 (16 %) toxicology reports of 1489 poisoning deaths; significantly rising from 15 (4.5 %) in 2013 to 94 (26 %) in 2016. Women (AOR 2.69, 95 % CI: 1.95-3.70), opioid misuse (AOR 1.74, 95 % CI: 1.17-2.59), in receipt of treatment for problem drug use (AOR 1.95, 95 % CI: 1.33-2.86) and year of death (2016 vs 2013) (AOR 7.95, 95 % CI: 4.58-13.79) were associated with increased odds of PPPD. Alcohol dependence was associated with reduced odds of PPPD (AOR 0.59, 95 % CI: 0.41-0.85). For men, opioid misuse, in receipt of treatment for problem drug use, and year of death were associated with increased odds of PPPD, while alcohol dependence was associated with reduced odds of PPPD. For women, in receipt of treatment for problem drug use and year of death were associated with increased odds of PPPD.

CONCLUSIONS

Enhanced training to prescribers and treatment providers on the potential risks associated with pregabalin, particularly among people who use drugs, is required.

Patterns of gabapentin and pregabalin use and misuse: Results of a population-based cohort study in France

AIMS

The aim of this study was to assess the use and factors associated with the misuse of gabapentin and pregabalin in the general French population, through a cohort study in the EGB (General Sample of Beneficiaries), a national representative sample of the French general population.

METHODS

New users of gabapentin and pregabalin were identified from June 2006 to December 2014, and new users of duloxetine served as control group. Misuse was defined as a use of higher daily doses than recommended. Cox proportional hazard regression models were performed to identify associated factors of misuse.

RESULTS

Misuse was more frequent in the 8692 new users of pregabalin (12.8%) than in the 1963 gabapentin (6.6%) or the 3214 duloxetine new users (9.7%) (P < 0.001). Factors associated with misuse were pregabalin (hazard ratio [HR] 1.48; 95% confidence interval [CI] [1.29-1.69]), age (HR_{[18-45] versus > 70 years} 1.98 [1.70-2.31] and HR_{[58-70] versus > 70 years} 1.25 [1.06-1.47]), multiple prescribers (HR_{2 or 3 versus 1 prescriber} 1.29 [1.15-1.45]; HR_{4 or more versus 1 prescriber} 1.54 [1.30-1.83]), cancer (1.28 [1.11-1.47]), multiple sclerosis (1.53 [1.07-2.18]), neuropathy (1.85 [1.19-2.89]), depression (1.26 [1.07-1.49]) and methadone (2.61 [1.16-5.84]). After this first episode of drug misuse, 11.6% of gabapentin and 10.7% of pregabalin misusers developed a primary addiction.

CONCLUSION

In a cohort of new users, misuse is more likely to occur in new users of pregabalin, with different associated factors of misuse compared to gabapentin and duloxetine. Health professionals and prescribers must be aware of this misuse potential, which could lead to abuse and dependence.

Benefits and harms of pregabalin in the management of neuropathic pain: a rapid review and meta-analysis of randomised clinical trials

OBJECTIVE

To assess the benefits and harms of pregabalin in the management of neuropathic pain.

DESIGN

Rapid review and meta-analysis of phase III, randomised, placebo-controlled trials.

PARTICIPANTS

Adults aged 18 years and above with neuropathic pain defined according to the International Association for the Study of Pain criteria.

INTERVENTIONS

Pregabalin or placebo.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcomes were pain (as measured using validated scales) and adverse events. Our secondary outcomes were sleep disturbance, quality of life, Patient Global Impression of Change, Clinician Global Impression scale, anxiety and depression scores, overall discontinuations and discontinuations because of adverse events.

RESULTS

We included 28 trials comprising 6087 participants. The neuropathic pain conditions studied were diabetic peripheral neuropathy, postherpetic neuralgia, herpes zoster, sciatica (radicular pain), poststroke pain and spinal cord injury-related pain. Patients who took pregabalin reported significant reductions in pain (numerical rating scale (NRS)) compared with placebo (standardised mean difference (SMD) -0.49 (95% CI -0.66 to -0.32, p<0.00001), very low quality evidence). Pregabalin significantly reduced sleep interference scores (NRS) compared with placebo (SMD -0.38 (95% CI -0.50 to -0.26, p<0.00001), moderate quality evidence. Pregabalin significantly increased the risk of adverse events compared with placebo (RR 1.33 (95% CI 1.23 to 1.44, p<0.00001, low quality evidence)). The risks of experiencing weight gain, somnolence, dizziness, peripheral oedema, fatigue, visual disturbances, ataxia, non-peripheral oedema, vertigo and euphoria were significantly increased with pregabalin. Pregabalin was significantly more likely than placebo to lead to discontinuation of the drug because of adverse events (RR 1.91 (95% CI 1.54 to 2.37, p<0.00001), low quality evidence).

CONCLUSION

Pregabalin has beneficial effects on some symptoms of neuropathic pain. However, its use significantly increases the risk of a number of adverse events and discontinuation due to adverse events. The quality of the evidence from journal publications is low.

Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial

AIMS

To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy.

METHODS

We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment.

RESULTS

Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes.

CONCLUSIONS

Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02056431).