Potential economic impact of using a proprietary willow bark extract in outpatient treatment of low back pain: an open non-randomized study

An open, non-randomised, study (postmarketing surveillance) was carried out on three groups of patients aged 18 to 80 presenting over an 18 month period with acute exacerbations of low back pain. The objective was to assess the possible economic impact of including a regular dose of proprietary willow bark extract (Assalix) in the treatment provided. A first group of 115 patients, presenting to 3 general practitioners in the first 3 months, was prescribed a daily dose of extract containing 120 mg of salicin (group W120). They also had access, if necessary, to the range of conventional treatments allowed for in the general practitioners' budgets. A second group of 112 patients presenting to the same general practitioners over the next 15 months, was prescribed extract equivalent to 240 mg salicin per day (group W240). A third "control" or "comparator" group of 224 patients, presenting to 3 orthopedists (specialists in physical medicine) over the whole 18 month period, received only the conventional therapeutic options allowed in the orthopedists' budgets (Group C). In the group C patients, the exacerbations had been shorter but the pain had been more intense as judged by Arhus Index and Total Pain Index. After 4 weeks of treatment, about 40% of group W240 patients were free of pain whether or not they had to resort to supplementary treatments. In group W120 as a whole, about 19% of patients were pain-free at 4 weeks, but only 8% of those who did not resort to supplementary treatment. In group C, 18% of patients were painfree. These findings were reflected reasonably well in the changes in the Arhus Index and Total Pain Index, and the findings in group W240 were consistent with those in a previous randomised controlled trial. Multivariable modelling to examine for possible confounding effects tended to identify membership of group W240 as an independent explanator of better pain relief than membership of group C. Though the measures of effect tended to be similar in group W120 as a whole and group C, the avoidance of more expensive conventional treatments in group W120 meant that the average cost per patient of treatment was reduced by about 35-50% (health service and private costings respectively). The better pain relief in group W240 was accompanied by an even smaller reliance on supplementary conventional treatments than in group W120 but the extra savings on these were outweighed by the extra cost of the additional Assalix so that the average cost per patient was reduced by 14-40% of the costs in group C. The possibility is discussed that, if orthopedists had relied more on regular full dosing with NSAIDs, they might have increased the effectiveness and reduced the cost of their treatment, though with the possibility of more side effects. Substituting established NSAIDs with COX-2 inhibitors might reduce the side effects, but at greater cost than with the Assalix.

Effect of salicis cortex extract on human platelet aggregation

The bark of Salix species contains several prodrugs of salicylate, mainly salicin. The aim of this study was to investigate if during pain treatment with Salicis cortex extract platelet aggregation was affected. A total of 51 patients were enrolled in the study. Thirty-five patients suffering from acute exacerbations of chronic low back pain received randomly and double-blind either Salicis cortex extract with 240 mg salicin/day (n = 19) or placebo (n = 16). Further sixteen patients with stable chronic ischemic heart disease were given 100 mg acetylsalicylate per day. Platelet aggregation was studied using an aggregometer. As aggregating agents, arachidonic acid (500 micrograms/ml), adenosine di-phosphate (2 x 10(-5) M) and collagen (0.18 microgram/ml) were used. The mean maximal arachidonic acid induced platelet aggregation was 61%, 78% and 13% in the Salicis cortex extract, placebo and acetylsalicylate groups. Acetylsalicylate had a significant inhibitory effect on platelet aggregation compared to Salicis cortex extract (p = 0.001) and placebo (p = 0.001). There was also a significant difference between the placebo and the willow bark-treated groups in the maximal platelet aggregation induced by arachidonic acid (p = 0.04) and ADP (p = 0.01). No statistical difference was found between the groups when collagen was applied to the human platelets. Daily consumption of Salicis cortex extract with 240 mg salicin per day affects platelet aggregation to a far lesser extent than acetylsalicylate. Further investigation needs to clarify if this finding is of clinical relevance in patients with impaired thrombocyte function.

Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study

PURPOSE

Herbal medicines are widely used for the treatment of pain, although there is not much information on their effectiveness. This study was designed to evaluate the effectiveness of willow (Salix) bark extract, which is widely used in Europe, for the treatment of low back pain.

SUBJECTS AND METHODS

We enrolled 210 patients with an exacerbation of chronic low back pain who reported current pain of 5 or more (out of 10) on a visual analog scale. They were randomly assigned to receive an oral willow bark extract with either 120 mg (low dose) or 240 mg (high dose) of salicin, or placebo, with tramadol as the sole rescue medication, in a 4-week blinded trial. The principal outcome measure was the proportion of patients who were pain-free without tramadol for at least 5 days during the final week of the study.

RESULTS

The treatment and placebo groups were similar at baseline in 114 of 120 clinical features. A total of 191 patients completed the study. The numbers of pain-free patients in the last week of treatment were 27 (39%) of 65 in the group receiving high-dose extract, 15 (21%) of 67 in the group receiving low-dose extract, and 4 (6%) of 59 in the placebo group (P <0.001). The response in the high-dose group was evident after only 1 week of treatment. Significantly more patients in the placebo group required tramadol (P <0.001) during each week of the study. One patient suffered a severe allergic reaction, perhaps to the extract.

CONCLUSION

Willow bark extract may be a useful and safe treatment for low back pain.

Phyto-anti-inflammatories. A systematic review of randomized, placebo-controlled, double-blind trials

Herbal treatments are often used to treat rheumatic symptoms. This systematic review is aimed at determining the clinical efficacy of this approach. Computer literature searches are carried out to locate all placebo-controlled, double-blind, randomized trials in this area. Nineteen studies meet the inclusion criteria. They are heterogeneous in terms of remedies tested, patients treated, and trial methodology applied. Most of the studies suggest that herbal remedies can have symptomatic effects beyond placebo. It is concluded that phyto-anti-inflammatories have considerable, albeit under-researched, potential in the symptomatic treatment of rheumatic disorders.

Physicochemical properties of harpagoside and its in vitro release from Harpagophytum procumbens extract tablets

The objective of this investigation was to characterize the active-component harpagoside of Harpagophytum extract from a physico-chemical perspective and to determine its in-vitro release from tablets according to DAB 1996. It was found that both pure harpagoside and harpagoside in Harpagophytum extract have an octanol-water distribution coefficient of approximately 4 which is neither dependent on temperature nor on pH. The mean harpagoside content in Harpagophytum tablets of Batch 9102 was 16.4 mg (S.D. 0.2; S.E. 0.03). Related to a tablet weight of 365 mg (100%), this corresponds to a haragoside content of 4.5% (S.D. 0.049; S.E. 0.006). On average the tablets disintegrate after 18 +/- 3 minutes (mean +/- SD). The tablets taken from Batch 9102 released the active component harpagoside well, with a t50 of 13.5 min, a t90 of 23 min and a t95 of 25 min in relation to 16.5 mg of harpagoside per dose. Harpagoside content decreased by about 10% in artificial gastric fluid within a period of 3 hours and remained stable in artificial intestinal fluid for a period of 6 hours.

Effectiveness of Harpagophytum extract WS 1531 in the treatment of exacerbation of low back pain: a randomized, placebo-controlled, double-blind study

Two daily doses of oral Harpagophytum extract WS 1531 (600 and 1200, respectively, containing 50 and 100 mg of the marker harpagoside) were compared with placebo over 4 weeks in a randomized, double-blind study in 197 patients with chronic susceptibility to back pain and current exacerbations that were producing pain worse than 5 on a 0-10 visual analogue scale. The principal outcome measure, based on pilot studies, was the number of patients who were pain free without the permitted rescue medication (tramadol) for 5 days out of the last week. The treatment and placebo groups were well matched in physical characteristics, in the severity of pain, duration, nature and accompaniments of their pain, the Arhus low back pain index and in laboratory indices of organ system function. A total of 183 patients completed the study. The numbers of pain-free patients were three, six and 10 in the placebo group (P), the Harpagophytum 600 group (H600) and the Harpagophytum 1200 group (H1200) respectively (P = 0.027, one-tailed Cochrane-Armitage test). The majority of responders' were patients who had suffered less than 42 days of pain, and subgroup analyses suggested that the effect was confined to patients with more severe and radiating pain accompanied by neurological deficit. However, subsidiary analyses, concentrating on the current pain component of the Arhus index, painted a slightly different picture, with the benefits seeming, if anything, to be greatest in the H600 group and in patients without more severe pain, radiation or neurological deficit. Patients with more pain tended to use more tramadol, but even severe and unbearable pain would not guarantee that tramadol would be used at all, and certainly not to the maximum permitted dose. There was no evidence for Harpagophytum-related side-effects, except possibly for mild and infrequent gastrointestinal symptoms.

A survey on pain complaints and health care utilization in a German population sample

A postal survey was carried out on every 71st person aged between 18 and 80 in the population registers in County Regierungsbezirk Karlsruhe in the State of Baden-Würtemberg. It asked 2127 persons whether they had, in the previous 6 months, experienced any form of unduly prolonged pain (as distinct from brief intercurrent self-limiting episodes related to injury inflammation etc.) and, if so, to specify its location, duration, severity and persistence. It also sought information on the resulting calls on healthcare professionals and the degree of satisfaction with treatments received. The age and gender distributions of the sample selected for survey matched those in the population from which it was drawn. Of the 1420 respondents, only 1304 declared their age and gender--a condition for inclusion in the analysis. Of these, 610 reported some form of unduly prolonged pain, which had lasted more than a year in 530. For all pain lasting longer than a year, the estimated prevalence of mild pain was 11%, severe 25% and intolerable 3.5%: the corresponding estimates for persistent as opposed to episodic pain were 2% for mild, 10% for sever and 1% for intolerable. Pain was present in more than one anatomical location in most of those who reported it. Musculoskeletal pain was overwhelmingly the most common. Increasing age, obesity and being female pre-disposed to the reporting of pain, with women being more liable to report headache and pain in the neck and shoulder. One hundred and thirty-six pain reporters either gave no information on consultation or sought no help from healthcare professionals: a third of the remainder consulted more than one professional, with general practitioners and specialists in physical medicine (niedergelassener Orthopäde) being the most common. A wide variety of treatments were used, with oral medications, massage, exercises, mud pack and heat treatment being the most popular; two-thirds of sufferers used more than one type of treatment. The most popular types of treatment tended also to be the most successful, except for oral medication (which was also the most heterogeneous). Multiple logistic regression analyses identified consistent associations between duration and severity of pain, the number of sites where it was reported, the numbers of healthcare professionals consulted and the number of treatments tried, and the same groupings of features were associated with decreased likelihood of overall satisfaction with treatment received.

Evidence for antirheumatic effectiveness of Herba Urticae dioicae in acute arthritis: A pilot study

Forty individuals suffering from an acute arthritis took part in an open randomized study comparing the effects of 50 mg diclofenac plus stewed Herba Urticae dioicae (stinging nettles) with 200 mg diclofenac. Thirty-seven patients completed the study. Assessment was based on the decrease of the elevated acute phase protein CRP and the clinical signs of acute arthritis (physical impairment, subjective pain and pressure pain (patient assessment) and stiffness (physician assessment). All assessments were done on a verbal rating scale from 0 to 4. In both groups median scores improved by about 70% relative to the initial value. Only minor adverse effects occurred during treatment. The authors conclude, that stewed Herba Urticae dioicae may enhance the NSAID antirheumatic effectiveness.

[Treatment of pain with peridural administration of opioids]

The advantages and disadvantages associated with epidural opioids require careful selection of the opioid and its dosage. There is presently no ideal opioid available for epidural use. Comparative pharmacokinetic data help to select the appropriate epidural opioid. Morphine (provided it is given in small doses and volumes) is very appropriate for epidural pain treatment, especially for longer periods of treatment, due to excellent analgesia and very low systemic morphine concentrations. The faster onset of analgesia with epidural pethidine, alfentanil und fentanyl make these opioids recommendable. However, due to the increased risk of respiratory depression during continuous treatment, these drugs should not be given over extended periods. Epidural administration of methadone, sufentanil und buprenorphine cannot be recommended since the advantages over systemic use do not outweigh the risks. Epidural tramadol may be useful in clinical routine, if opioids are not available and supervision of the patient is not guaranteed, because tramadol is not restricted by law and has a low potential for central depressive effects. The safety of the patients should be paramount. If patients are harmed by inappropriate opioids or dose regimens this will discredit a valuable for treating postoperative pain. Postoperative epidural dosages should be as low as possible and be titrated to the patient's individual needs for analgesia. Epidural morphine treatment is an alternative to step 4 of the WHO treatment regimen for patients with intractable pain or those suffering from systemic opioid side effects. Careful selection of patients helps to increase successful treatment. If implantable devices (ports or pumps, according to the life expectancy) are employed, the intrathecal route of administration is preferable to the epidural route, as the latter has a 10 times higher morphine dose requirement.

Use of alfentanil for in vitro fertilization oocyte retrieval

STUDY OBJECTIVES

To determine alfentanil levels with a specific radioimmunoassay in serum and ovarian follicular fluid.

DESIGN

Observational study.

SETTING

University hospital.

PATIENTS

14 ASA status I women undergoing oocyte retrieval for in vitro fertilization.

INTERVENTIONS

General anesthesia was induced with alfentanil 15 micrograms/kg and midazolam 2 mg and maintained with alfentanil 0.5 mg, 60% nitrous oxide (N2O) in oxygen (O2) and midazolam up to a total of 4 mg. Oocyte retrieval was performed using a transvaginal ultrasound guided technique, 34 to 36 hours after human chorionic gonadotrophin administration.

MEASUREMENTS AND MAIN RESULTS

Mean procedure time for oocyte retrieval was 18 +/- 2.4 (SEM) minutes. All patients were fully awake within 5 minutes and all patients except one were able to move from the operating table to the stretcher with minimal help. Mean total protein concentration in the follicular fluid was 3.8 +/- 0.4 mg%. Maximal serum alfentanil concentrations (Cmax) were attained 5 minutes after start of the procedure (tmax) and were 92 +/- 20 ng/ml. In contrast, alfentanil concentrations in the follicular fluid increased constantly throughout the procedure up to 8.9 +/- 0.8 ng/ml at 15 minutes. Clinical pregnancy rate was 3 of 14 patients.

CONCLUSION

It is evident that during the oocyte retrieval procedure, the alfentanil concentrations in the follicular fluid are about ten-fold smaller than the serum alfentanil concentrations at the same time points. Similar pharmacokinetics have been shown when propofol was used as anesthetic. The low accumulation of alfentanil in the follicular fluid increases the attractiveness of alfentanil for anesthesia during oocyte retrieval for in vitro fertilization.

Comparison of morphine with and without fentanyl for epidural analgesia after major abdominal surgery

BACKGROUND AND OBJECTIVES

The study compared bolus injection of fentanyl versus morphine to supplement epidural infusion of morphine for pain relief after major abdominal surgery.

METHODS

Postoperative epidural analgesia was activated by patient request for pain relief. Thirty patients were given a loading dose (random assignment, double-blind administration) of 2 mg of morphine (group M, n = 15) or 60 micrograms of fentanyl (group F/M, n = 15), along with an epidural infusion of 0.2 mg/h of morphine. Additional boluses of 0.5 mg of morphine (group M) or 25 micrograms of fentanyl (group F/M) were given according to individual need. If patients were painfree for 3 hours, the infusion rate for morphine was reduced by 50%.

RESULTS

Both treatments provided similar degrees of analgesia, although onset time was shorter for the F/M group (P < .05). To obtain 24 hours of analgesia, group M needed 18.0 mg of morphine, while group F/M needed 4.7 mg of morphine and 1.48 mg of fentanyl. For group M, mean serum concentrations of morphine decreased from 18 ng/mL at 1 hour from the start of treatment to 5 ng/mL at 24 hours. For group F/M, serum morphine stayed at approximately 4 ng/mL, but serum fentanyl increased from 0.28 ng/mL at 5 minutes to about 0.8 ng/mL at 16 hours.

CONCLUSIONS

When fentanyl is added continuously to epidural morphine, the resulting higher total serum levels of opioids during prolonged treatment may increase the risk of respiratory depression. Combining the two opioids for the loading dose, however, may be valuable to shorten the onset time of analgesia.

Patient-controlled epidural diamorphine for post-operative pain: verbal rating and visual analogue assessments of pain

Twenty-two patients were studied while receiving epidural analgesia with diamorphine after major lower abdominal surgery under combined regional and general anaesthesia. Epidural PCA began when the intraoperative epidural block with bupivacaine wore off enough for the patient to request treatment. It was started with 2 mg of diamorphine and continued with a reducible background infusion that was initially set at 0.2 mg h-1 and supplemented by on-demand doses of 0.2 mg, with a lockout time of 15 min. The patients received routine post-operative monitoring and care, with pain at rest being assessed on a four-point verbal rating scale (VRS, none, mild, moderate, severe) at 5, 10, 15, 30, 45, 60, 90 and 120 min from the start of ePCA, then hourly until 24 h and then 2-hourly until 48 h. VRS on coughing and a 10 cm visual analogue score (VAS) at rest and on coughing were recorded at the same times at 4 h, then 4 hourly until 24 h and then at 48 h, at which times, blood samples were also taken to measure morphine concentrations by radioimmunoassay. Analgesia started promptly and reached a maximum at between 30 and 45 min, accompanied by maximum sedation. Thereafter clinically acceptable analgesia was maintained without undue sedation for 48 h, though pain on coughing was less well controlled than pain at rest. After the initial loading dose of diamorphine, the 95% confidence intervals (CI) for further consumption were 3.7 to 17 mg (average 9.7) in the first 24 h and 2.1 to 12.9 mg (average 6.7 mg) in the second 24 h. The plasma morphine concentrations rose to a plateau by about 15 min, with concentrations within 95% CI from 0 to 11 ng mliters-1 (average 5 ng mliters-1. The VRS and VAS pain scores were analysed by a conservative approach that treated them as ordinal data, and by a parametric approach that treated them as interval data. Both approaches conveyed broadly similar information about the post-operative analgesia.

Assessment of pain threshold and pain tolerance in women in labour and in the early post-partum period by pressure algometry

The changes in the pressure pain threshold (PPThr) and pressure pain tolerance (PPTol) in 41 parturients have been studied during the active phase of labour and in the early post-partum period. The sensitivity to pressure stimuli was examined with an electronic pressure algometer placed on the sternum during the interval between painful contractions, after extradural analgesia and 24 h after childbirth. Prior to extradural analgesia, mean (+/- SD), PPThr and PPTol were 4.9 +/- 1.6 kg 0.25 cm-2 and 6.9 +/- 1.8 kg 0.25 cm-2, respectively. Similar values were recorded 1 h after induction of the extradural block when the pain of labour was abolished. At 24 h post-delivery, a significant decrease in both PPThr and PPTol was noted (P < 0.001). The lack of influence of extradural analgesia on pressure algometry values, and the elevated sensitivity to pain in the early post-partum period, may be related to the influence of pregnancy and labour on the appreciation of pain.

Epidural versus subcutaneous administration of alfentanil for the management of postoperative pain

This study was designed to compare the efficacy and serum concentrations of alfentanil given subcutaneously (SQ) or epidurally (EPID) for treatment of postoperative pain. Following abdominal surgery, patients (n = 12) were randomly assigned to receive double-blind SQ or EPID alfentanil over 24 h via the allocated route (1 mg along with 0.2 mg/h and 0.2-mg boluses on demand) and saline via the other route of administration using a patient-controlled analgesic (PCA) delivery system. Significantly less EPID alfentanil produced better quality analgesia and fewer side effects than SQ alfentanil. The fact that EPID analgesia was maintained with serum alfentanil concentrations less than those producing systemic analgesia confirms the spinal site of the EPID alfentanil action.

A randomized double-blind comparison of epidural sufentanil versus intravenous sufentanil or epidural fentanyl analgesia after major abdominal surgery

This randomized double-blind study compared epidural sufentanil (SEPI) with intravenous sufentanil (SIV) or epidural fentanyl (FEPI) analgesia in 45 patients after major abdominal operations. On first complaint of severe postoperative pain, SIV patients were given a 15-micrograms bolus and then a 5 micrograms/h infusion of sufentanil intravenously. SEPI patients were given the same bolus and infusion, but epidurally. FEPI patients had a 60-micrograms bolus and 20 micrograms/h infusion of fentanyl epidurally. All patients also received a bolus injection and then an infusion of coded saline via the alternate route. Analgesic requirements were tailored continuously to individual needs by patient-controlled supplementary boluses of 3.1 micrograms of sufentanil or 12.5 micrograms of fentanyl, or by 50% reduction in opiate infusion rate at predetermined intervals. Pain scores, circulatory variables, and respiratory rate did not differ between groups. Mean opiate dose requirements (+/- SD) to maintain analgesia for 24 h were 202 +/- 43 micrograms (SIV), 149 +/- 45 micrograms (SEPI), and 627 +/- 226 micrograms (FEPI). The relative analgesic potencies (AP) calculated from the equianalgesic dose requirement ratios were 1.4 for AP-sufentanil IV/EPI and 4.2 for AP-epidural F/S. SIV patients required more supplementary boluses than SEPI patients, were more sedated during the entire treatment, and had higher PaCO2 and higher serum sufentanil concentrations within the first 3 h of treatment. In addition, severe respiratory depression occurred in four SIV patients soon after the start of treatment, despite serum sufentanil concentrations of less than 0.3 ng/mL.(ABSTRACT TRUNCATED AT 250 WORDS)