Comparative efficacy of lidocaine-prilocaine cream and vaginal misoprostol in reducing pain during levonorgestrel intrauterine device insertion in women delivered only by cesarean delivery: A randomized controlled trial

OBJECTIVE

To compare efficacy of lidocaine-prilocaine (LP) cream versus misoprostol versus placebo before levonorgestrel-releasing intrauterine device (LNG-IUD) insertion.

METHODS

This randomized controlled trial (RCT) was conducted in a tertiary referral hospital from April 30, 2020 to March 1, 2021 on 210 parous women willing to receive LNG-IUD and delivered only by elective cesarean delivery (CD). Participants received 200 μg vaginal misoprostol or 5 ml of LP cream 5% or placebo 3 h before LNG-IUS insertion. Primary outcome was pain during LNG-IUD insertion, while secondary outcomes were pain 10 min post-procedure, ease of insertion, patient satisfaction, insertion time, and drug side effects.

RESULTS

Pain during LNG-IUS insertion was reduced in LP group and misoprostol group compared to placebo group (2.1 ± 1.0 vs 3.7 ± 1.6; p <0.001) and (2.3 ± 1.3 vs 3.7 ± 1.6; p <0.001), respectively. Ease of procedure and patient satisfaction were significantly higher in LP and misoprostol groups than placebo (P <0.001). Need for additional analgesia was significantly higher in placebo group than in the other two groups (P = 0.009). Adverse events were not significantly different between the three groups except vomiting and abdominal cramps, which were higher with misoprostol.

CONCLUSION

LP cream and 200 μg of vaginal misoprostol administration before LNG-IUD insertion in women delivered only by elective CD effectively reduced pain during insertion and 10 min post-procedure with easier insertions, high patient satisfaction, and tolerable side effects. Pain reduction with LP cream was clinically significant.

Safety and Pharmacokinetics of PSD502 in Healthy Chinese Male and Female Volunteers: Two Randomized, Double-Blind, Placebo-Controlled, Phase I Trials

BACKGROUND AND OBJECTIVE

PSD502 is a metered-dose spray for premature ejaculation. The two trials aimed to evaluate the safety and pharmacokinetics of PSD502 in healthy Chinese male and female individuals.

METHODS

Two phase I, randomized, double-blind, placebo-controlled trials were conducted in men (Trial 1) and women (Trial 2). The participants were randomized 3:1 to receive PSD502 (7.5 mg of lidocaine and 2.5 mg of prilocaine per spray) or a placebo. For male individuals, a single dose (three sprays) once daily was applied to the glans penis for 21 days except for nine sprays (three doses) on days 7 and 14, 4 h apart for each dose. For female individuals, two sprays were applied to the vagina and one to the cervix once daily for 7 days. The primary endpoint was safety. Pharmacokinetics analysis was also performed.

RESULTS

Twenty-four male and 24 female individuals were recruited. Treatment-emergent adverse events occurred in 38.9% (7/18) of male individuals and 66.7% (12/18) of female individuals in the PSD502 group, respectively. Both trials reported 50.0% (3/6) treatment-emergent adverse events for the placebo. No grade ≥ 3 treatment-emergent adverse events, serious adverse events, or treatment-emergent adverse events leading to early withdrawal or discontinuation occurred. After consecutive applications, lidocaine and prilocaine cleared rapidly in both trials. Plasma concentrations exhibited high inter-individual variability. The maximum plasma concentrations of active ingredients were far below the anticipated minimum toxic concentrations. The area under the plasma concentration-time curve of metabolites were ≤ 20% of the parent drugs. No clinically significant accumulations were observed in the two trials.

CONCLUSIONS

PSD502 was well tolerated and showed low plasma concentrations in healthy Chinese male and female individuals.

Effect of 5% EMLA Cream on Postoperative Sore Throat in Adults Following General Endotracheal Anesthesia: A Randomized Placebo-Controlled Study

BACKGROUND

Postoperative sore throat (POST) is a distressing complaint in adults after endotracheal intubation. This study aimed to evaluate the effect of topical application of a eutectic mixture of local anesthetics (EMLA) cream over the endotracheal tube (ETT) cuff on the incidence and severity of POST, cough, and hoarseness of voice in adults after surgery.

METHODS

In this randomized, placebo-controlled study, adult patients 18 to 65 years old, in American Society of Anesthesiologists (ASA) physical status I and II, and of either sex were scheduled to receive 5% EMLA cream (intervention arm) or lubricant gel (placebo-controlled arm) applied over the ETT cuff. POST was graded as none (0), mild (1), moderate (2), or severe (3). A score of ≥2 was considered as significant POST. The incidence of POST at the sixth postoperative hour was the primary outcome. Secondary outcomes included the incidence of POST at 0, second, and 24 hours, and the incidence of significant POST (score ≥2). The incidence and severity of postoperative cough and hoarseness of voice were recorded simultaneously.

RESULTS

Two hundred and four patients completed the study. The incidence of POST was significantly lower in the EMLA group versus placebo at the sixth postoperative hour (4.9% vs 40.1%; relative risk [RR], 0.12; 95% confidence interval [CI], 0.05-0.29; P < .001); and at 0 hour (74.5% vs 93.1%; RR, 0.8; 95% CI, 0.7-0.9; P < .001) and second hour (51.9% vs 84.3%; RR, 0.61; 95% CI, 0.5-0.75; P < .001) but comparable at 24 hours (1.9% vs 3.9%; RR, 0.5; 95% CI, 0.09-2.67; P = .4). The number needed to treat to prevent POST with EMLA cream application was 5 at 0 hour and 3 at the second and sixth hour. The proportion of patients with significant POST over 24 hours were less in the EMLA group (9.8% vs 43.1%; P < .001). The incidence of postoperative cough and hoarseness of voice was significantly less at the 0, second, and sixth hours in the EMLA group, but comparable at 24 hours. The incidence of severe cough (8.8% vs 31.4%; P < .001) and hoarseness of voice (2% vs 7.4%; P < .001) over 24 hours was less in the EMLA group.

CONCLUSIONS

The application of EMLA cream over ETT cuff reduces the incidence and severity of POST, cough, and hoarseness of voice in adults after general anesthesia in the early postoperative period compared to lubricant gel.

Comparing the effects of cold compress and Xyla-p cream on hemodynamic changes in hemodialysis patients during venipuncture

Background The vital signs reflect the physiological state of patients in various clinical conditions. The purpose of this study was to compare the effects of cold compress and Xyla-P cream on hemodynamical changes during venipuncture in hemodialysis patients. Methods and Material In this clinical trial study, 50 patients under hemodialysis were selected by simple random sampling. The patients were then randomly assigned to either Xyla-P cream, cold compress or placebo groups. The vital signs (blood pressure and pulse) were measured upon two intermittent hemodialysis sessions before and after venipuncture. Data were analyzed using repeated measures analysis of variance. Results The mean alternation in systolic blood pressure was significantly different comparing the placebo and cold compress groups before and after intervention (p<0.001). However, the difference was not significant between the Xyla-P cream group and either placebo (p=0.402) or ice compress (p=0.698) groups. The difference of the mean diastolic blood pressure was significant comparing the placebo group with either the Xyla-P cream group (p=0.003) or cold compress group (p<0.001) before and after intervention. In addition, there was a significant difference in the mean number of heartbeats comparing the control group with either the Xyla-P cream group (p<0.001) or cold compress group (p<0.001) before and after the intervention. Conclusions Considering the beneficial effects of ice compress and the Xyla-P cream on reduction of cardiovascular parameters, it is recommended to use these methods in hemodialysis patients during venipuncture.

Interventions for intra-operative pain relief during postpartum mini-laparotomy tubal ligation

BACKGROUND

Postpartum mini-laparotomy tubal ligation (PPTL) is a contraceptive method that works by interrupting the patency of the fallopian tubes. Several methods are used for intraoperative pain relief, such as systemic administration of opioids or intraperitoneal instillation of lidocaine.

OBJECTIVES

To evaluate the effectiveness of and adverse effects associated with interventions for pain relief in women undergoing PPTL.

SEARCH METHODS

We searched for eligible studies published on or before 31 July 2017 in the CENTRAL Register of Studies Online, MEDLINE, Embase, PsycINFO, and CINAHL. We examined review articles and searched registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCT) that compared perioperative pain relief measures during PPTL.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles, abstracts, and full-text articles of potentially relevant studies for inclusion. We extracted the data from the included studies, assessed risk of bias, and calculated and compared results. Discrepancies were resolved by discussion, or by consulting a third review author. We computed the inverse variance risk ratio (RR) with 95% confidence interval (CI) for binary outcomes, and the mean difference (MD) with 95% CI for continuous variables.

MAIN RESULTS

We found only three RCTs, in which a total of 230 postpartum women participated. Most of our analyses were based on relatively small numbers of patients and studies. Overall, the certainty of evidence regarding the effectiveness of interventions was low, due to risk of bias and imprecision. We found very low-certainty evidence regarding the safety of interventions because of risk of bias and imprecision. Two studies had unclear risk of selection bias. One study had unclear risk of reporting bias and a high risk of other bias associated with the study protocol.Women who received an intraperitoneal instillation of lidocaine experienced lower intensity intraperitoneal pain than those given a placebo (pooled MD -3.34, 95% CI -4.19 to -2.49, three studies, 190 participants, low-certainty evidence), or an intramuscular injection of morphine (MD -4.8, 95% CI -6.43 to -3.17, one study, 40 participants, low-certainty evidence). We found no clear difference in intraperitoneal pain between women who had an intramuscular injection of morphine added to an intraperitoneal instillation of lidocaine and those who had an intraperitoneal instillation of lidocaine alone (MD -0.40, 95% CI -1.52 to 0.72, one study, 40 participants, low-certainty evidence). An intramuscular injection of morphine alone was not effective for intraperitoneal pain relief compared to placebo (MD 0.50, 95% CI -1.33 to 2.33, one study, 40 women, low-certainty evidence). None of the studies reported any serious adverse events but the evidence was very low-certainty. Intraperitoneal instillation of lidocaine may reduce the number of women requiring additional pain control when compared to placebo (RR 0.27, 95% CI 0.17 to 0.44, three studies, 190 women, low-certainty evidence).

AUTHORS' CONCLUSIONS

An intraperitoneal instillation of lidocaine during postpartum mini-laparotomy tubal ligation before fallopian tubes were tied may offer better intraperitoneal pain control, although the evidence regarding adverse effects is uncertain. We found no clear difference in intraperitoneal pain between women who received a combination of an injection of morphine, and intraperitoneal instillation of lidocaine and those who received an intraperitoneal instillation of lidocaine alone. These results must be interpreted with caution, since the evidence overall was low to very low-certainty.

Analgesic effect of trigger point injection and EMLA for shoulder pain in patients undergoing total laparoscopic hysterectomy: A randomized controlled study

BACKGROUD

The purpose of this study was to evaluate the effects of trigger point injection (TPI) and eutectic mixture local anesthetics (EMLA) cream on the postoperative shoulder pain in patients undergoing total laparoscopic hysterectomy.

METHODS

In this randomized, single-blinded, and controlled study, total 75 patients were randomly allocated to TPI group (n = 25), EMLA group (n = 25), and control group (n = 25). TPI group received TPIs with 2 mL of 0.2% ropivacaine, and EMLA group received an occlusive dressing with EMLA cream 2 g on both shoulders. Overall, abdominal, and shoulder pains were evaluated at rest and in motion on postoperative day 3.

RESULTS

The incidence of shoulder pain was significantly reduced in EMLA group (56%) compared to control (88%) or TPI (88%) groups (P = .025 in both); the severity of shoulder pain was mitigated in EMLA and TPI groups compared to control group (P < .001, each). Consequently, the overall pain decreased in EMLA group and TPI group (P = .023). The patients with exercise habit (n = 31) showed lower incidence of pain than patients without exercise habit (n = 26) (P = .002, P = .005, and P = .037 in overall, abdominal, and shoulder pain, respectively). TPI or EMLA treatments decreased shoulder pain irrespective of exercise habit (P = .001 and P < .001, respectively), but decreased overall pain only in patients without exercise habit (P = .019). Lastly, EMLA lowered overall pain score at the time of first analgesic request in ward compared to control group (P = .02).

CONCLUSIONS

TPI and EMLA with occlusive dressing effectively reduced the shoulder pain after total laparoscopic hysterectomy.

Fortacin™ Spray for the Treatment of Premature Ejaculation

Premature ejaculation (PE) is a common complaint of male sexual dysfunction affecting men and their partners and consequently causing significant personal and interpersonal distress. Increased sensitivity of the glans penis and abnormalities of the afferent-efferent reflex pathway within the ejaculatory process are involved in the occurrence of PE. Drugs that either selectively reduce penile sensitization or modify the afferent-efferent reflex are well established therapeutic options for PE. Fortacin™ is the first topical treatment to be officially approved for the treatment of primary PE in adult men, and is mentioned as an experimental aerosol (as TEMPE) in the current European Association of Urology guidelines. It was approved for use in the European Union and launched in the United Kingdom in November 2016. Fortacin™ is a eutectic-like mixture of lidocaine 150 mg/mL and prilocaine 50 mg/mL that meets the requirements of an ideal treatment for PE because it is fast acting (within 5 minutes), has durable effects, can be easily used "on-demand", and shows minimal side-effects. The metered-dose spray delivery system allows the desensitizing agents to be deposited in a dose-controlled, concentrated film onto the glans penis consequently reducing its sensitivity. This is translated into a delaying of the ejaculatory latency time without adversely affecting the sensation of ejaculation and orgasmic pleasure. The efficacy and safety of Fortacin™ have been proven by means of increased ejaculatory latency, control, and sexual satisfaction in large scale studies demonstrating the significant benefits for both patients and their partners.