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Myers A, Gelotte C, Zuckerman A, Zimmerman B, Shenoy A, Qi D, Cooper SA. Analgesic onset and efficacy of a fast-acting formulation of acetaminophen in a postoperative dental impaction pain model. Curr Med Res Opin 2024; 40:267-277. [PMID: 38124555 DOI: 10.1080/03007995.2023.2294946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Speed of onset can be critical to an analgesic's efficacy treating acute pain. To enhance onset, a new oral acetaminophen formulation intended to be fast acting was developed. Two studies evaluated the analgesic onset, efficacy, and safety of this fast-acting acetaminophen (FA-acetaminophen) tablet relative to commercial acetaminophen caplets (ES-acetaminophen) and commercial ibuprofen liquid-filled gelatin capsules (LG-ibuprofen). METHODS Two single-center, single-dose, inpatient, randomized, double-blind, triple-dummy, placebo-controlled, parallel group design clinical trials were conducted using the postoperative dental impaction pain model. Subjects were healthy men and women aged 17-50 years experiencing moderate-to-severe pain after surgical extraction of at least three impacted third molars. In both studies, four treatment groups were evaluated: 1,000 mg acetaminophen as two 500 mg FA-acetaminophen tablets, 1,000 mg as two 500 mg ES-acetaminophen caplets, 400 mg ibuprofen as two 200 mg LG-ibuprofen capsules, and placebo. To maintain blinding, each subject received six units of study medication. Times to confirmed perceptible pain relief (TCPR) and meaningful pain relief (TMPR) were obtained using the double-stopwatch method. Pain intensity and relief were measured over 6 h following drug administration using a 0-10 numerical rating scale. Time to use of rescue medication (naproxen sodium) and subject global evaluations of study medications at 6 h were collected. Pharmacokinetic blood sampling and safety assessments were performed. RESULTS Studies 1 and 2 enrolled 240 and 420 subjects, respectively. No clinically important differences among treatment groups were observed for any demographic or baseline characteristics. Efficacy results showed all active treatments statistically superior to placebo. In Study 1, TCPR was statistically significantly shorter for FA-acetaminophen compared to ES-acetaminophen and LG-ibuprofen. In Study 2, no statistically significant differences in TCPR were noted across the active treatment groups. In Study 1, FA-acetaminophen 1,000 mg provided significantly shorter TMPR compared with LG-ibuprofen but not compared with ES-acetaminophen. In Study 2, no significant differences in TMPR were noted across the active treatment groups. In both Study 1 and 2 at 15 min after administration of study drug, PID and PAR scores were greater for FA-acetaminophen than LG-ibuprofen. CONCLUSIONS Both studies suggested FA-acetaminophen had faster onset of action compared to ES-acetaminophen and LG-Ibuprofen. In light of the difference in TCPR and TMPR results between Study 1 and 2, an additional study is needed to further investigate time to analgesic onset of FA-acetaminophen compared with ES-acetaminophen and LG-Ibuprofen. STUDY REGISTRY NUMBERS Study 1: NCT02735122; Study 2: NCT03224403.
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Affiliation(s)
- Andrew Myers
- McNeil Healthcare Division, Johnson and Johnson Consumer Inc, Fort Washington, PA, USA
| | - Cathy Gelotte
- McNeil Healthcare Division, Johnson and Johnson Consumer Inc, Fort Washington, PA, USA
| | - Annette Zuckerman
- McNeil Healthcare Division, Johnson and Johnson Consumer Inc, Fort Washington, PA, USA
| | - Brenda Zimmerman
- McNeil Healthcare Division, Johnson and Johnson Consumer Inc, Fort Washington, PA, USA
| | - Ami Shenoy
- McNeil Healthcare Division, Johnson and Johnson Consumer Inc, Fort Washington, PA, USA
| | - Dan Qi
- Vita Spes LLC, Princeton, NJ, USA
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Nasr Isfahani M, Etesami H, Ahmadi O, Masoumi B. Comparing the efficacy of intravenous morphine versus ibuprofen or the combination of ibuprofen and acetaminophen in patients with closed limb fractures: a randomized clinical trial. BMC Emerg Med 2024; 24:15. [PMID: 38273252 PMCID: PMC10809472 DOI: 10.1186/s12873-024-00933-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION This study aims to investigate the effectiveness of intravenous ibuprofen or intravenous ibuprofen plus acetaminophen compared to intravenous morphine in patients with closed extremity fractures. METHODS A triple-blinded randomized clinical trial was conducted at a tertiary trauma center in Iran. Adult patients between 15 and 60 years old with closed, isolated limb fractures and a pain intensity of at least 6/10 on the visual analog scale (VAS) were eligible. Patients with specific conditions or contraindications were not included. Participants were randomly assigned to receive intravenous ibuprofen, intravenous ibuprofen plus acetaminophen, or intravenous morphine. Pain scores were assessed using the visual analog scale at baseline and 5, 15, 30, and 60 min after drug administration. The primary outcome measure was the pain score reduction after one hour. RESULTS Out of 388 trauma patients screened, 158 were included in the analysis. There were no significant differences in age or sex distribution among the three groups. The pain scores decreased significantly in all groups after 5 min, with the morphine group showing the lowest pain score at 15 min. The maximum effect of ibuprofen was observed after 30 min, while the ibuprofen-acetaminophen combination maintained its effect after 60 min. One hour after injection, pain score reduction in the ibuprofen-acetaminophen group was significantly more than in the other two groups, and pain score reduction in the ibuprofen group was significantly more than in the morphine group. CONCLUSION The study findings suggest that ibuprofen and its combination with acetaminophen have similar or better analgesic effects compared to morphine in patients with closed extremity fractures. Although morphine initially provided the greatest pain relief, its effect diminished over time. In contrast, ibuprofen and the ibuprofen-acetaminophen combination maintained their analgesic effects for a longer duration. The combination therapy demonstrated the most sustained pain reduction. The study highlights the potential of non-opioid analgesics in fracture pain management and emphasizes the importance of initiation of these medications as first line analgesic for patients with fractures. These findings support the growing trend of exploring non-opioid analgesics in pain management. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05630222 (Tue, Nov 29, 2022). The manuscript adheres to CONSORT guidelines.
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Affiliation(s)
- Mehdi Nasr Isfahani
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Trauma Data Registration Center, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Etesami
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Student Research Committee, Vice Chancellery for Research, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Ahmadi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Masoumi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Song J, Li Y, Waljee JF, Gunaseelan V, Brummett CM, Englesbe MJ, Bicket MC. What evidence is needed to inform postoperative opioid consumption guidelines? A cohort study of the Michigan Surgical Quality Collaborative. Reg Anesth Pain Med 2024; 49:23-29. [PMID: 37247946 PMCID: PMC10684823 DOI: 10.1136/rapm-2023-104581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION To balance adequate pain management while minimizing opioid-related harms after surgery, opioid prescribing guidelines rely on patient-reported use after surgery. However, it is unclear how many patients are required to develop precise guidelines. We aimed to compare patterns of use, required sample size, and the precision for patient-reported opioid consumption after common surgical procedures. METHODS We analyzed procedure-specific 30-day opioid consumption data reported after discharge from 15 common surgical procedures between January 2018 and May 2019 across 65 hospitals in the Michigan Surgical Quality Collaborative. We calculated proportions of patients using no pills and the estimated number of pills meeting most patients' needs, defined as the 75th percentile of consumption. We compared several methods to model consumption patterns. Using the best method (Tweedie), we calculated sample sizes required to identify opioid consumption within a 5-pill interval and estimates of pills to meet most patients' needs by calculating the width of 95% CIs. RESULTS In a cohort of 10,688 patients, many patients did not consume any opioids after all types of procedures (range 20%-40%). Most patients' needs were met with 4 pills (thyroidectomy) to 13 pills (abdominal hysterectomy). Sample sizes required to estimate opioid consumption within a 5-pill wide 95% CI ranged from 48 for laparoscopic appendectomy to 188 for open colectomy. The 95% CI width for estimates ranged from 0.7 pills for laparoscopic cholecystectomy to 7.0 pills for ileostomy/colostomy. CONCLUSIONS This study demonstrates that profiles of opioid consumption share more similarities than differences for certain surgical procedures. Future investigations on patient-reported consumption are required for procedures not currently included in prescribing guidelines to ensure surgeons and perioperative providers can appropriately tailor recommendations to the postoperative needs of patients.
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Affiliation(s)
- Jiyeon Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Yi Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
| | - Vidhya Gunaseelan
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
| | - Mark C Bicket
- Opioid Prescribing Engagement Network, Institute for Health Policy and Innovation, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Ching-Wei H, Tsai SLH, Chen CH, Tang HC, Su CY, Tischler EH, Yang YC, Chan YS, Chiu CH, Chen ACY. Early versus delayed mobilization for arthroscopic rotator cuff repair (small to large sized tear): a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2023; 24:938. [PMID: 38049792 PMCID: PMC10694899 DOI: 10.1186/s12891-023-07075-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND The timing to start passive or active range of motion (ROM) after arthroscopic rotator cuff repair remains unclear. This systematic review and meta-analysis evaluated early versus delayed passive and active ROM protocols following arthroscopic rotator cuff repair. The aim of this study is to systematically review the literature on the outcomes of early active/passive versus delayed active/passive postoperative arthroscopic rotator cuff repair rehabilitation protocols. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) published up to April 2022 comparing early motion (EM) versus delayed motion (DM) rehabilitation protocols after arthroscopic rotator cuff repair for partial and full-thickness tear was conducted. The primary outcome was range of motion (anterior flexion, external rotation, internal rotation, abduction) and the secondary outcomes were Constant-Murley score (CMS), Simple Shoulder Test Score (SST score) and Visual Analogue Scale (VAS). RESULTS Thirteen RCTs with 1,082 patients were included in this study (7 RCTs for early passive motion (EPM) vs. delayed passive motion (DPM) and 7 RCTs for early active motion (EAM) vs. delayed active motion (DAM). Anterior flexion (1.40, 95% confidence interval (CI), 0.55-2.25) and abduction (2.73, 95%CI, 0.74-4.71) were higher in the EPM group compared to DPM. Similarly, EAM showed superiority in anterior flexion (1.57, 95%CI, 0.62-2.52) and external rotation (1.59, 95%CI, 0.36-2.82), compared to DAM. There was no difference between EPM and DPM for external rotation, retear rate, CMS and SST scores. There was no difference between EAM and DAM for retear rate, abduction, CMS and VAS. CONCLUSION EAM and EPM were both associated with superior ROM compared to the DAM and DPM protocols. EAM and EPM were both safe and beneficial to improve ROM after arthroscopic surgery for the patients with small to large sized tears.
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Affiliation(s)
- Hu Ching-Wei
- Department of Orthopaedic Surgery, Keelung branch, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Sung Laurent Huang Tsai
- Department of Orthopaedic Surgery, Keelung branch, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Chien-Hao Chen
- Department of Orthopaedic Surgery, Keelung branch, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Hao-Che Tang
- Department of Orthopaedic Surgery, Keelung branch, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Chun-Yi Su
- Department of Orthopaedic Surgery, Keelung branch, Bone and Joint Research Center, Chang Gung Memorial Hospital, Chang Gung University, F7, No 222 Mai-King Road, Keelung, Taiwan
| | - Eric H Tischler
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Yi-Chiang Yang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Sheng Chan
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou & University College of Medicine, Taoyuan City, Taiwan
- Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital Taiwan, Taoyuan City, Taiwan
| | - Chih-Hao Chiu
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou & University College of Medicine, Taoyuan City, Taiwan.
- Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital Taiwan, Taoyuan City, Taiwan.
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan.
| | - Alvin Chao Yu Chen
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou & University College of Medicine, Taoyuan City, Taiwan.
- Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital Taiwan, Taoyuan City, Taiwan.
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Pérez-González F, Abusamak M, Sáez-Alcaide LM, García-Denche JT, Marino FAT. Effect of time-dependent ibuprofen administration on the post operatory after impacted third molar extraction: a cross-over randomized controlled trial. Oral Maxillofac Surg 2023; 27:699-706. [PMID: 35918624 PMCID: PMC9345738 DOI: 10.1007/s10006-022-01104-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate time-dependent administration of ibuprofen in a lower third molar extraction model. METHODS Eleven patients requiring bilateral surgical removal of lower third molars were recruited and randomized into a blinded crossover randomized controlled trial. For 3 days after surgery, the control group was prescribed ibuprofen 400 mg every 8 h. On the other hand, the experimental group received also ibuprofen 400 mg at breakfast and lunch, replacing the dinner intake with a placebo. Pain measurements (Visual Analog Scale from 0 to 10) were recorded at baseline, 24, 48, and 72 h postoperatively. Facial swelling and trismus were also measured at baseline, 24, and 72 h postoperatively. RESULTS Postoperative swelling and pain perception did not show significative difference between the control and experimental groups at 24, 48, and 72 h. Trismus was significantly lower in the control group than in the experimental group at 72 h postoperatively (p = 0.008). Rescue medication consumption seemed to be comparable between groups. CONCLUSION Eliminating night time ibuprofen might be insignificant for pain control after third molar extraction.
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Affiliation(s)
- Fabián Pérez-González
- Faculty of Dentistry, Department of Dental Clinical Specialties, University Complutense of Madrid, Plaza Ramón y Cajal S/N, 28040, Madrid, Spain.
| | - Mohammad Abusamak
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
| | - Luis Miguel Sáez-Alcaide
- Faculty of Dentistry, Department of Dental Clinical Specialties, University Complutense of Madrid, Plaza Ramón y Cajal S/N, 28040, Madrid, Spain
| | - Jesus Torres García-Denche
- Faculty of Dentistry, Department of Dental Clinical Specialties, University Complutense of Madrid, Plaza Ramón y Cajal S/N, 28040, Madrid, Spain
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Cronin WA, Nealeigh MD, Harry NM, Kerr C, Cyr KL, Velosky AG, Highland KB. Appendectomy Pain Medication Prescribing Variation in the U.S. Military Health System. Mil Med 2023:usad419. [PMID: 37951595 DOI: 10.1093/milmed/usad419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
INTRODUCTION Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System. MATERIALS AND METHODS This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED). RESULTS Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only. CONCLUSIONS Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.
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Affiliation(s)
- William A Cronin
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Nathaniel M Harry
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
| | - Christopher Kerr
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
| | - Kyle L Cyr
- Department of Anesthesiology, Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD 20814, USA
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Alexander G Velosky
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr., #100, Bethesda, MD 20817, USA
- Enterprise Intelligence and Data Solutions (EIDS) Program Office, Program Executive Office, Defense Healthcare Management Systems (PEO DHMS), 3515 S. General McMullen, Building 1, San Antonio, TX 78226, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Jeske AH, Anderson A, Do KA, Ning J, Ma J, Bruera E. Patterns of opioid use among Texas dental practitioners during the COVID-19 pandemic. J Opioid Manag 2023; 19:523-532. [PMID: 38189194 DOI: 10.5055/jom.0837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The primary objective of this study is to assess factors that influence opioid prescribing by dentists and the role of these factors in the practice of dental pain control. DESIGN A 25-question survey instrument was distributed to the study population for anonymous responses, covering dentist and practice demographics and opioid prescribing characteristics. SETTING Private solo and group practice settings, including general practitioners and dental specialists. PARTICIPANTS Potential participants included all active members of a large state dental professional association. MAIN OUTCOME MEASURES They were practitioner and practice demographic traits, types of opioids prescribed, and statistical correlations. Outcome variables included practice type, practitioner gender, practice location, practice model, and years in practice. Categorical covariates were summarized statistically by frequencies and percentages, and continuous covariates were summarized by means, medians, ranges, and standard deviations. RESULTS Strongest correlations with opioid prescribing included general practitioner (vs specialist) and male gender. The coronavirus disease 2019 pandemic was confirmed as having exerted a significant impact on opioid prescribing among the survey respondents. CONCLUSIONS Further research is warranted to assess post-pandemic opioid prescribing patterns, and additional educational strategies regarding limitations of opioid prescriptions should be applied to general, rather than specialty, dental practitioners.
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Affiliation(s)
- Arthur H Jeske
- University of Texas School of Dentistry at Houston, Houston, Texas
| | - Aimee Anderson
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas. ORCID: https://orcid.org/0000-0002-2464-5343
| | - Kim-Anh Do
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas. ORCID: https://orcid.org/0000-0001-8710-7131
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Junsheng Ma
- Department of Data Science, Sumitomo Dainippon Pharma Oncology, Inc., Cambridge, Massachusetts. ORCID: https://orcid.org/0000-0003-1704-7019
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas. ORCID: https://orcid.org/0000-0002-8745-0412
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Sivapornpan S, Punyashthira A, Chantawong N, Wisarnsirirak P, Maireang K, Thaweekul Y, Poomtavorn Y, Pattaraarchachai J, Suwannarurk K. The Efficacy of Oral Etoricoxib in Pain Control During Colposcopy-Directed Cervical Biopsy: A Randomized Control Trial. Asian Pac J Cancer Prev 2023; 24:2855-2859. [PMID: 37642074 PMCID: PMC10685209 DOI: 10.31557/apjcp.2023.24.8.2855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE To investigate the effectiveness and safety of oral etoricoxib administration before colposcopic procedure for pain relief during and after colposcopy. METHODS A prospective double-blind, randomized controlled trial was conducted at the colposcopy unit of Thammasat University Hospital, Thailand from August 2022 to January 2023. The participants were women undergoing colposcopy. They were allocated into two groups: etoricoxib group and control group. Thirty minutes prior to colposcopy, the participants received etoricoxib or placebo tablet. A numerical rating scale was used to evaluate pain upon speculum insertion, 3% acetic acid application, directed cervical biopsy (CDB), endocervical curettage (ECC), and 10 minutes and 24 hours after colposcopy. RESULT One hundred and ten women were recruited and were divided equally into study and control groups. The mean age of participants was 42.6 years old. One-fourth of cases (29/110) had cervical intraepithelial neoplasia grade 2 or more histology. Subjects in etoricoxib group had less median pain scores during CDB, ECC, and 10-minute and 24-hour post procedure than the control group with statistical significance. Both groups had comparable side effects. CONCLUSION Administration of oral etoricoxib 30 minutes before colposcopy could reduce pain during and up to 24-hour post colposcopy with minimal side effects.
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Affiliation(s)
- Sarunya Sivapornpan
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Awassada Punyashthira
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Nopwaree Chantawong
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Pattra Wisarnsirirak
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Karicha Maireang
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Yuthadej Thaweekul
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Yenrudee Poomtavorn
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Junya Pattaraarchachai
- Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Komsun Suwannarurk
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
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Erlenwein J, Leister N, Castello R, Wirz S. [Principles of acute pain therapy-An overview taking special features in the patient collective of ophthalmology into consideration]. DIE OPHTHALMOLOGIE 2023; 120:701-710. [PMID: 37340245 DOI: 10.1007/s00347-023-01888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/22/2023]
Abstract
For many years the quality of perioperative pain management in general has been repeatedly reported as inadequate and there is significant evidence to indicate that this is also true after surgical procedures in ophthalmology. The patient population in ophthalmology is quite challenging due to numerous comorbidities and a high average age resulting in numerous contraindications and organ dysfunctions and requiring special knowledge to ensure high quality acute pain management. The following overview covers basic knowledge of acute pain management, with a particular focus on analgesic approaches and the specifics of the patient population and the associated limitations in terms of analgesic and co-analgesic pharmacological options.
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Affiliation(s)
- Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37085, Göttingen, Deutschland.
| | - Nicolas Leister
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät und Universitätsklinikum Köln, Universität zu Köln, Köln, Deutschland
| | - Roberto Castello
- Interdisziplinärer Arbeitskreis Ophthalmoanästhesie, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V., Nürnberg, Deutschland
| | - Stefan Wirz
- Abteilung für Anästhesie, Interdisziplinäre Intensivmedizin, Schmerzmedizin/Palliativmedizin - Zentrum für Schmerzmedizin, Weaningzentrum, Cura Krankenhaus der GFO Kliniken Bonn, Bad Honnef, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinik Bonn, Bonn, Deutschland
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10
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Steiness J, Hägi-Pedersen D, Lunn TH, Nørskov AK, Lindberg-Larsen M, Graungaard BK, Lundstrøm LH, Lindholm P, Brorson S, Bieder MJ, Beck T, Skettrup M, von Cappeln AG, Thybo KH, Varnum C, Pleckaitiene L, Anker Pedersen N, Overgaard S, Mathiesen O, Jakobsen JC. Pain treatment after total hip arthroplasty: Detailed statistical analysis plan for the RECIPE randomised clinical trial. Acta Anaesthesiol Scand 2023; 67:372-380. [PMID: 36539915 DOI: 10.1111/aas.14179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The RECIPE trial systematically investigates the effects of different combinations of paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty. To preserve transparency, minimise risk of bias and to prevent data-driven analysis, we present this detailed statistical analysis plan. METHODS The RECIPE trial is a randomised, blinded, parallel four-group multicenter clinical trial for patients undergoing planned primary total hip arthroplasty. Interventions are initiated preoperatively and continued for 24 h postoperatively. Primary outcome is total opioid consumption 0-24 h after end of surgery. Primary analysis will be performed in the modified intention to treat population of all patients undergoing total hip arthroplasty, and all analyses will be stratified for site. We will perform pairwise comparisons between each of the four groups. The primary outcome will be analysed using the van Elteren test and we will present Hodges-Lehmann median differences and confidence intervals. Binary outcomes will be analysed using logistic regression. To preserve a family-wise error rate of <0.05, we will use a Bonferroni-adjusted alfa of 0.05/6 = 0.0083 for all six pairwise comparisons between groups when analysing the primary outcome. We will systematically assess the underlying statistical assumptions for each analysis. Data will be analysed by two blinded independent statisticians, and we will write abstracts covering all possible combinations of conclusions, before breaking the blind. DISCUSSION The RECIPE trial will provide important information on benefit and harm of combinations of the most frequently used non-opioid analgesics for pain after primary hip arthroplasty.
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Affiliation(s)
- Joakim Steiness
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.,Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Troels H Lunn
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark.,Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Anders K Nørskov
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.,Department of Anaesthesiology, North Zealand Hospital, Hillerød, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Orthopaedic Surgery and Traumatology, Odense University Hospital Svendborg, Svendborg, Denmark.,Department of Anaesthesiology, Vejle Hospital, Vejle, Denmark
| | - Ben K Graungaard
- Department of Anaesthesiology, Gentofte Hospital, Copenhagen, Denmark
| | - Lars H Lundstrøm
- Department of Anaesthesiology, North Zealand Hospital, Hillerød, Denmark
| | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark.,Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Manuel J Bieder
- Department of Orthopaedic Surgery, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
| | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Gentofte Hospital, Copenhagen, Denmark
| | - Adam G von Cappeln
- Department of Anaesthesiology, Odense University Hospital Svendborg, Svendborg, Denmark
| | - Kasper H Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.,Department of Anaesthesiology, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Vejle Hospital, Vejle, Denmark
| | | | | | - Søren Overgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark.,Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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11
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Do U, Pook M, Najafi T, Rajabiyazdi F, El-Kefraoui C, Balvardi S, Barone N, Elhaj H, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial. Surg Endosc 2023; 37:2269-2280. [PMID: 35918552 DOI: 10.1007/s00464-022-09472-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery. METHODS Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis. RESULTS Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires). CONCLUSION Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.
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Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Tahereh Najafi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Fateme Rajabiyazdi
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Division of Experimental Surgery, McGill University, Montreal, QC, Canada.,Department of Surgery, McGill University, Montreal, QC, Canada.,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Division of Experimental Surgery, McGill University, Montreal, QC, Canada. .,Department of Surgery, McGill University, Montreal, QC, Canada. .,Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada. .,Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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12
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Analgesic Efficacy of Intravenous Ibuprofen in the Treatment of Postoperative Acute Pain: A Phase III Multicenter Randomized Placebo-ControlledDouble-Blind Clinical Trial. Pain Res Manag 2023; 2023:7768704. [PMID: 36926379 PMCID: PMC10014159 DOI: 10.1155/2023/7768704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/05/2023] [Accepted: 02/07/2023] [Indexed: 03/12/2023]
Abstract
Objective To evaluate the analgesic efficacy and safety of different does of intravenous ibuprofen (IVIB) in the treatment of postoperative acute pain. Methods Patients with an intravenous (IV) patient-controlled analgesia device after abdominal or orthopedic surgery were randomly divided into placebo, IVIB 400 mg, and IVIB 800 mg groups. The first dosage of study medicines was given intravenously 30 minutes (min) before surgery ended, followed by six hours (h) intervals for a total of eight doses following surgery. The demographic characteristics and procedure data, cumulative morphine consumption, the visual analog scale (VAS), the area under the curve (AUC) of VAS, patient satisfaction score (PSS), the rates of treatment failure (RTF), and adverse events (AEs) and serious adverse event (SAEs) were recorded during the period of trial. Result A total of 345 patients were enrolled in the full analysis set (FAS), and of 326 participants were valid data set (VDS). Demographic characteristics, disease features, and medical history of patients were not significantly different between groups. Total morphine consumption of the IVIB 400 mg group (11.14 ± 7.14 mg; P = 0.0011) and the IVIB 800 mg group (11.29 ± 6.45 mg; P = 0.0014) was significantly reduced compared with the placebo group (14.51 ± 9.19 mg) for 24 h postoperatively, there was no significant difference between the IVIB 400 mg and IVIB 800 mg groups (P = 0.9997). The placebo group had significantly higher VAS and the AUCs of VAS than those in the IVIB 400 mg and the IVIB 800 mg groups at rest and movement for 24 h postoperatively (P < 0.05), and there was no significant difference between the IVIB 400 mg and IVIB 800 mg groups (P > 0.05). RTF was slightly higher in the placebo group than IVIB 400 mg group and 800 mg group, and no statistical significance (P < 0.690). PSS in the IVIB 400 mg (P = 0.0092) and the IVIB 800 mg groups (P = 0.0011) was higher than the placebo group for pain management, there was also no significant difference between the IVIB 400 mg and IVIB 800 mg groups (P = 0.456). The incidence of RTF (P = 0.690) and AEs (P > 0.05) were not different among the three groups. Conclusion Intermittent IV administration of ibuprofen 400 mg or 800 mg within 24 h after surgery in patients undergoing abdominal and orthopedic surgery significantly decreased morphine consumption and relieved pain, without increasing the incidence of AEs.
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13
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Rana T, Daniels K, Dang S, Li JC, Freeman CG, Duffy A, Curry J, Luginbuhl A, Cottrill E, Cognetti D. Postoperative opioid-prescribing practices in otolaryngology: Evidence-based guideline outcomes. Laryngoscope Investig Otolaryngol 2022; 8:313-321. [PMID: 36846420 PMCID: PMC9948590 DOI: 10.1002/lio2.990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/13/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives We previously reported that >50% of postoperative opioids prescribed at our institution went unused for common otolaryngologic procedures. Based on these findings, we instituted multimodal, evidence-based guidelines for postoperative pain management. In the second part of our multiphasic study, we evaluated the effects of these guidelines on (1) quantity of unused opioids, (2) patient satisfaction, and (3) institutional perceptions toward the opioid epidemic and prescribing guidelines. Methods Standardized, procedure-specific opioid prescription guidelines were created using prospective data from the first phase of our study and evidence from current literature. Again, we examined sialendoscopy, parotidectomy, parathyroidectomy/thyroidectomy, and transoral robotic surgery (TORS). Patients were surveyed at their first postoperative appointment. Groups from Phases I and II were compared. Attending physicians were surveyed before the start of the multiphasic project and after prescribing guidelines were implemented. Results Prescribing guidelines led to an average reduction in prescribed morphine milligram equivalents (MME) per patient by: 48% (sialendoscopy), 63% (parotidectomy), 60% (para/thyroidectomy), and 42% (TORS). Average used MME per patient for parotidectomy was significantly reduced (64%). The proportion of unused MME per patient and patient satisfaction scores did not significantly change after guidelines were implemented. Conclusion Implementation of opioid-prescribing guidelines and the use of multimodal analgesia substantially reduced the amount of opioids prescribed across all procedures without impacting patient satisfaction. Level of Evidence 2.
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Affiliation(s)
- Tanvi Rana
- Sidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Kelly Daniels
- Sidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA,Department of Otolaryngology–Head and Neck SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Sophia Dang
- Sidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA,Department of Otolaryngology–Head and Neck SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Jonathan C. Li
- Sidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Cecilia G. Freeman
- Sidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Alexander Duffy
- Department of Otolaryngology–Head and Neck SurgeryThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Joseph Curry
- Department of Otolaryngology–Head and Neck SurgeryThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Adam Luginbuhl
- Department of Otolaryngology–Head and Neck SurgeryThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Elizabeth Cottrill
- Department of Otolaryngology–Head and Neck SurgeryThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - David Cognetti
- Department of Otolaryngology–Head and Neck SurgeryThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
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14
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Leth MF, Bukhari S, Laursen CCW, Larsen ME, Tornøe AS, Jakobsen JC, Maagaard M, Mathiesen O. Risk of serious adverse events associated with non-steroidal anti-inflammatory drugs in orthopaedic surgery. A protocol for a systematic review. Acta Anaesthesiol Scand 2022; 66:1257-1265. [PMID: 35986625 PMCID: PMC9826397 DOI: 10.1111/aas.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Postoperative pain is a common condition following orthopaedic surgeries and causes prolonged hospitalisation, delayed rehabilitation and hamper the quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics and anti-inflammatory mediators in the treatment of postoperative pain. The association of NSAIDs with serious adverse events may however keep some clinicians and clinical decision makers from using NSAIDs perioperatively. The evidence regarding the risks of serious adverse events following perioperative use of NSAIDs in orthopaedic surgery is sparse and needs to be assessed in a systematic review. This is a protocol for a systematic review that aims to identify the risks of serious adverse events from perioperative use of NSAIDs in orthopaedic patients. METHODS Our methodology is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess if NSAIDs versus placebo, usual care or no intervention, will influence the risks of serious adverse events in patients undergoing orthopaedic surgery. We will include all randomised trials assessing the use of NSAIDs perioperatively. To identify trials we will search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register, Science Citation Index Expanded on Web of Science and BIOSIS. Two authors will screen the literature and extract data. We will use the 'Risk of Bias 2 tool' to assess trials. Extracted data will be analysed using RStudio and Trial Sequential Analysis. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). DISCUSSION This systematic review can potentially aid clinicians and clinical decision makers in the use of NSAIDs for treatment of postoperative pain following orthopaedic surgeries.
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Affiliation(s)
- Morten Fiil Leth
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark
| | - Shaheer Bukhari
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark
| | | | - Mia Esta Larsen
- Department of AnaesthesiologyJuliane Marie Centre ‐ RigshospitaletCopenhagenDenmark
| | | | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Copenhagen University Hospital – RigshospitaletCopenhagenDenmark,Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of AnaesthesiologyZealand University HospitalKøgeDenmark,Department of Clinical MedicineCopenhagen UniversityCopenhagenDenmark
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15
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Steiness J, Hägi-Pedersen D, Lunn TH, Lindberg-Larsen M, Graungaard BK, Lundstrom LH, Lindholm P, Brorson S, Bieder MJ, Beck T, Skettrup M, von Cappeln AG, Thybo KH, Gasbjerg KS, Overgaard S, Jakobsen JC, Mathiesen O. Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial. BMJ Open 2022; 12:e058965. [PMID: 36190737 PMCID: PMC9438203 DOI: 10.1136/bmjopen-2021-058965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Multimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of different combinations of paracetamol, ibuprofen and dexamethasone following total hip arthroplasty. METHODS AND ANALYSIS RECIPE is a randomised, placebo-controlled, parallel 4-group, blinded trial with 90-day and 1-year follow-up performed at nine Danish hospitals. Interventions are initiated preoperatively and continued for 24 hours postoperatively. Eligible participants undergoing total hip arthroplasty are randomised to:group A: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous placebo; group B: oral paracetamol 1000 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group C: oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg+oral placebo; group D: oral paracetamol 1000 mg × 4+oral ibuprofen 400 mg × 4+intravenous dexamethasone 24 mg.Primary outcome is cumulative opioid consumption at 0-24 hours. Secondary outcomes are pain at rest, during mobilisation and during a 5 m walk and adverse events. Follow-up includes serious adverse events and patient reported outcome measures at 90 days and 1 year. A total of 1060 participants are needed to demonstrate a difference of 8 mg in 24-hour morphine consumption assuming an SD of 24.5 mg, a risk of type I errors of 0.0083 and a risk of type 2 errors of 0.2. Primary analysis will be a modified intention-to-treat analysis.With this trial we aim to verify recommendations for pain treatment after total hip arthroplasty, and investigate the role of dexamethasone as an analgesic adjuvant to paracetamol and ibuprofen. ETHICS AND DISSEMINATION This trial is approved by the Region Zealand Committee on Health Research Ethics (SJ-799). Plans for dissemination include publication in peer-reviewed journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER NCT04123873.
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Affiliation(s)
- Joakim Steiness
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Anaesthesiology, Nastved Hospital, Naestved, Denmark
| | - Daniel Hägi-Pedersen
- Department of Anaesthesiology, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - Martin Lindberg-Larsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | | | | | - Peter Lindholm
- Department of Anaesthesiology, Odense University Hospital, Odense, Denmark
| | - Stig Brorson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Zealand University Hospital Koge, Koege, Denmark
| | | | - Torben Beck
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Michael Skettrup
- Department of Orthopaedic Surgery, Gentofte Hospital, Hellerup, Denmark
| | | | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
| | | | - Søren Overgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Zaslansky R. Status quo of pain-related patient reported outcomes and perioperative pain management in 10 415 patients from 10 countries: analysis of registry data. Eur J Pain 2022; 26:2120-2140. [PMID: 35996995 DOI: 10.1002/ejp.2024] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 08/08/2022] [Accepted: 08/14/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Postoperative pain is common at the global level, despite considerable attempts for improvement, reflecting the complexity of offering effective pain relief. In this study, clinicians from Mexico, China, and eight European countries evaluated perioperative pain practices and patient-reported outcomes (PROs) in their hospitals as a basis for carrying out quality improvement (QI) projects in each country. METHODS PAIN OUT, an international perioperative pain registry, provided standardized methodology for assessing management and multi-dimensional PROs on the first postoperative day, in patients undergoing orthopedic, general surgery, obstetric & gynecology or urological procedures. RESULTS Between 2017-2019, data obtained from 10,415 adult patients in 105 wards, qualified for analysis. At the ward level: 50% (median) of patients reported worst pain intensities ≥7/10 NRS, 25% spent ≥50% of the time in severe pain and 20-34% reported severe ratings for pain-related functional and emotional interference. Demographic variables, country and surgical discipline explained a small proportion of the variation in the PROs, leaving about 88% unexplained. Most treatment processes varied considerably between wards. Ward effects accounted for about 7% and 32% of variation in PROs and treatment processes, respectively. CONCLUSIONS This comprehensive evaluation demonstrates that many patients in this international cohort reported poor pain-related PROs on the first postoperative day. PROs and treatments varied greatly. Most of the variance of the PROs could not be explained. The findings served as a basis for devising and implementing QI programs in participating hospitals.
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Affiliation(s)
- Ruth Zaslansky
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
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17
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Hamilton C, Alfille P, Mountjoy J, Bao X. Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review. J Thorac Dis 2022; 14:2276-2296. [PMID: 35813725 PMCID: PMC9264080 DOI: 10.21037/jtd-21-1740] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/24/2022] [Indexed: 12/11/2022]
Abstract
Background and Objective Thoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research. Methods We searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader. Key Content and Findings There is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate. Conclusions The optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.
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Affiliation(s)
- Casey Hamilton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paul Alfille
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremi Mountjoy
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Feldman CA, Fredericks-Younger J, Lu SE, Desjardins PJ, Malmstrom H, Miloro M, Warburton G, Ward B, Ziccardi V, Fine D. The Opioid Analgesic Reduction Study (OARS)-a comparison of opioid vs. non-opioid combination analgesics for management of post-surgical pain: a double-blind randomized clinical trial. Trials 2022; 23:160. [PMID: 35177108 PMCID: PMC8851821 DOI: 10.1186/s13063-022-06064-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 01/29/2022] [Indexed: 12/01/2022] Open
Abstract
Background Everyday people die unnecessarily from opioid overdose-related addiction. Dentists are among the leading prescribers of opioid analgesics. Opioid-seeking behaviors have been linked to receipt of initial opioid prescriptions following the common dental procedure of third molar extraction. With each opioid prescription, a patient’s risk for opioid misuse or abuse increases. With an estimated 56 million tablets of 5 mg hydrocodone annually prescribed after third molar extractions in the USA, 3.5 million young adults may be unnecessarily exposed to opioids by dentists who are inadvertently increasing their patient’s risk for addiction. Methods A double-blind, stratified randomized, multi-center clinical trial has been designed to evaluate whether a combination of over-the-counter non-opioid-containing analgesics is not inferior to the most prescribed opioid analgesic. The impacted 3rd molar extraction model is being used due to the predictable severity of the post-operative pain and generalizability of results. Within each site/clinic and gender type (male/female), patients are randomized to receive either OPIOID (hydrocodone/acetaminophen 5/300 mg) or NON-OPIOID (ibuprofen/acetaminophen 400/500 mg). Outcome data include pain levels, adverse events, overall patient satisfaction, ability to sleep, and ability to perform daily functions. To develop clinical guidelines and a clinical decision-making tool, pain management, extraction difficulty, and the number of tablets taken are being collected, enabling an experimental decision-making tool to be developed. Discussion The proposed methods address the shortcomings of other analgesic studies. Although prior studies have tested short-term effects of single doses of pain medications, patients and their dentists are interested in managing pain for the entire post-operative period, not just the first 12 h. After surgery, patients expect to be able to perform normal daily functions without feeling nauseous or dizzy and they desire a restful sleep at night. Parents of young people are concerned with the risks of opioid use and misuse, related either to treatments received or to subsequent use of leftover pills. Upon successful completion of this clinical trial, dentists, patients, and their families will be better able to make informed decisions regarding post-operative pain management. Trial registration ClinicalTrials.govNCT04452344. Registered on June 20, 2020
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Affiliation(s)
- Cecile A Feldman
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA. .,School of Public Health, Rutgers University, 683 Hoes Lane, Piscataway, NJ, 08854, USA.
| | | | - Shou-En Lu
- School of Public Health, Rutgers University, 683 Hoes Lane, Piscataway, NJ, 08854, USA
| | - Paul J Desjardins
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Hans Malmstrom
- Eastman Institute for Oral Health, University of Rochester, 625 Elmwood Ave, Rochester, NY, 14620, USA
| | - Michael Miloro
- College of Dentistry, University of Illinois, 801 S Paulina St, Room 110 (MC 835), Chicago, IL, 60612, USA
| | - Gary Warburton
- School of Dentistry, University of Maryland, 650 W Baltimore St, Room 1209, Baltimore, MD, 2120, USA
| | - Brent Ward
- School of Dentistry, University of Michigan, 1515 E. Hospital Drive, Ann Arbor, MI, 48109, USA
| | - Vincent Ziccardi
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
| | - Daniel Fine
- School of Dental Medicine, Rutgers University, 110 Bergen Street, Newark, NJ, 07103, USA
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Procedure-Related Access Site Pain Multimodal Management following Percutaneous Cardiac Intervention: A Randomized Control Trial. Pain Res Manag 2022; 2022:6102793. [PMID: 35111274 PMCID: PMC8803434 DOI: 10.1155/2022/6102793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/29/2021] [Indexed: 12/02/2022]
Abstract
Methods 137 patients who underwent PCI procedure via radial artery were randomly assigned (1 : 1) to the control (CG, n = 68) and intervention (IG, n = 65) groups. IG received MPM (paracetamol, ibuprofen, and the arm physiotherapy), CG received pain medication “as needed.” Outcomes were assessed immediately after, 2, 12, 24, and 48 h, 1 week, and 1 and 3 months after PCI. The primary outcome was A-S pain prevalence and pain intensity numeric rating scale (NRS) 0–10. Results Results showed that A-S pain prevalence during the 3-month follow-up period was decreasing. Statistically significant difference between the groups (CG versus IG) was after 24 h (41.2% versus 18.5, p=0.005), 48 h (30.9% versus 1.5%, p ≤ 0.001), 1 week (25% versus 10.8%, p=0.042), 1 month (23.5% versus 7.7%, p=0.017) after the procedure. The mean of the highest pain intensity was after 2 h (IG-2.17 ± 2.07; CG-3.53 ± 2.69) and the lowest 3 months (IG-0.02 ± 0.12; CG-0.09 ± 0.45) after the procedure. A-S pain intensity mean scores were statistically significantly higher in CG during the follow-up period (Wilks' λ = 0.84 F (7,125) = 3.37, p=0.002). Conclusion In conclusion, MPM approach can reduce A-S pain prevalence and pain intensity after PCI. More randomized control studies are needed.
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Häuser W, Fisher E, Perrot S, Moore RA, Makri S, Bidonde J. Non-pharmacological interventions for fibromyalgia (fibromyalgia syndrome) in adults: an overview of Cochrane Reviews. Hippokratia 2022. [DOI: 10.1002/14651858.cd015074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Winfried Häuser
- Department of Psychosomatic Medicine and Psychotherapy; Technische Universität München; München Germany
| | - Emma Fisher
- Cochrane Pain, Palliative and Supportive Care Group; Pain Research Unit, Churchill Hospital; Oxford UK
| | - Serge Perrot
- Service de Médecine Interne et Thérapeutique; Hôtel Dieu, Université Paris Descartes, INSERM U 987; Paris France
| | | | - Souzi Makri
- Cyprus League Against Rheumatism; Nicosia Cyprus
| | - Julia Bidonde
- School of Rehabilitation Science, College of Medicine; University of Saskatchewan; Saskatoon Canada
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21
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Lyngstad G, Skjelbred P, Swanson DM, Skoglund LA. Analgesic effect of oral ibuprofen 400, 600, and 800 mg; paracetamol 500 and 1000 mg; and paracetamol 1000 mg plus 60 mg codeine in acute postoperative pain: a single-dose, randomized, placebo-controlled, and double-blind study. Eur J Clin Pharmacol 2021; 77:1843-1852. [PMID: 34655316 PMCID: PMC8585829 DOI: 10.1007/s00228-021-03231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Effect size estimates of analgesic drugs can be misleading. Ibuprofen (400 mg, 600 mg, 800 mg), paracetamol (1000 mg, 500 mg), paracetamol 1000 mg/codeine 60 mg, and placebo were investigated to establish the multidimensional pharmacodynamic profiles of each drug on acute pain with calculated effect size estimates. METHODS A randomized, double-blind, single-dose, placebo-controlled, parallel-group, single-centre, outpatient, and single-dose study used 350 patients (mean age 25 year, range 18 to 30 years) of homogenous ethnicity after third molar surgery. Primary outcome was sum pain intensity over 6 h. Secondary outcomes were time to analgesic onset, duration of analgesia, time to rescue drug intake, number of patients taking rescue drug, sum pain intensity difference, maximum pain intensity difference, time to maximum pain intensity difference, number needed to treat values, adverse effects, overall drug assessment as patient-reported outcome measure (PROM), and the effect size estimates NNT and NNTp. RESULTS Ibuprofen doses above 400 mg do not significantly increase analgesic effect. Paracetamol has a very flat analgesic dose-response profile. Paracetamol 1000/codeine 60 mg gives similar analgesia as ibuprofen from 400 mg, but has a shorter time to analgesic onset. Active drugs show no significant difference in maximal analgesic effect. Other secondary outcomes support these findings. The frequencies of adverse effects were low, mild to moderate in all active groups. NNT and NTTp values did not coincide well with PROMs. CONCLUSION Ibuprofen doses above 400 mg for acute pain offer limited analgesic gain. Paracetamol 1000 mg/codeine 60 mg is comparable to ibuprofen doses from 400 mg. Calculated effect size estimates and PROM in our study seem not to relate well as clinical analgesic efficacy estimators. TRIAL REGISTRATION NCT00699114.
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Affiliation(s)
- Gaute Lyngstad
- Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Blindern, P. O. Box 1119, N-0317 Nydalen Oslo, Norway
| | - Per Skjelbred
- Department of Maxillofacial Surgery, Oslo University Hospital, P. O. Box 4950, Nydalen N-0424 Oslo, Norway
| | - David M. Swanson
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Blindern, P.O. Box 1122, N-0317 Oslo, Norway
| | - Lasse A. Skoglund
- Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Blindern, P. O. Box 1119, N-0317 Nydalen Oslo, Norway
- Department of Maxillofacial Surgery, Oslo University Hospital, P. O. Box 4950, Nydalen N-0424 Oslo, Norway
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22
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Ferguson MC, Schumann R, Gallagher S, McNicol ED. Single-dose intravenous ibuprofen for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 9:CD013264. [PMID: 34499349 PMCID: PMC8428326 DOI: 10.1002/14651858.cd013264.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous (IV) ibuprofen, compared with placebo or an active comparator, for moderate-to-severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 10 June 2021. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA We included randomized trials that compared a single postoperative dose of intravenous (IV) ibuprofen with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for review inclusion, assessed risk of bias, and extracted data. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a 4- and 6-hour period. Our secondary outcomes were time to, and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants reporting or experiencing any AE, serious AEs (SAEs), and specific NSAID-related or opioid-related AEs. We were not able to carry out any planned meta-analysis. We assessed the certainty of the evidence using GRADE. MAIN RESULTS Only one study met our inclusion criteria, involving 201 total participants, mostly female (mean age 42 years), undergoing primary, unilateral, distal, first metatarsal bunionectomy (with osteotomy and internal fixation). Ibuprofen 300 mg, placebo or acetaminophen 1000 mg was administered intravenously to participants reporting moderate pain intensity the day after surgery. Since we identified only one study for inclusion, we did not perform any quantitative analyses. The study was at low risk of bias for most domains. We downgraded the certainty of the evidence due to serious study limitations, indirectness and imprecision. Ibuprofen versus placebo Findings of the single study found that at both the 4-hour and 6-hour assessment period, the proportion of participants with at least 50% pain relief was 32% (24/76) for those assigned to ibuprofen and 22% (11/50) for those assigned to placebo. These findings produced a risk ratio (RR) of 1.44 (95% confidence interval (CI) 0.77 to 2.66 versus placebo for at least 50% of maximum pain relief over the 4-hour and 6-hour period (very low-certainty evidence). Median time to rescue medication was 101 minutes for ibuprofen and 71 minutes for placebo (1 study, 126 participants; very low-certainty evidence). The number of participants using rescue medication was not reported within the included study. During the study (1 study, 126 participants), 58/76 (76%) of participants assigned to ibuprofen and 39/50 (78%) assigned to placebo reported or experienced any adverse event (AE), (RR 0.98, 95% CI 0.81 to 1.19; low-certainty evidence). No serious AEs (SAEs) were experienced (1 study, 126 participants; very low-certainty evidence). Ibuprofen versus active comparators Ibuprofen (300 mg) was similar to the active comparator, IV acetaminophen (1000 mg) at 4 hours and 6 hours (1 study, 126 participants). For those assigned to active control (acetaminophen), the proportion of participants with at least 50% pain relief was 35% (26/75) at 4 hours and 31% (23/75) at 6 hours. At 4 hours, these findings produced a RR of 0.91 (95% CI 0.58 to 1.43; very low-certainty evidence) versus active comparator (acetaminophen). At 6 hours, these findings produced a RR of 1.03 (95% CI 0.64 to 1.66; very low-certainty evidence) versus active comparator (acetaminophen). Median time to rescue medication was 101 minutes for ibuprofen and 125 minutes for the active comparator, acetaminophen (1 study, 151 participants; very low-certainty evidence). The number of participants using rescue medication was not reported within the included study. During the study, 8/76 (76%) of participants assigned to ibuprofen and 45/75 (60%) assigned to active control (acetaminophen) reported or experienced any AE, (RR 1.27, 95% CI 1.02 to 1.59; very low-certainty evidence). No SAEs were experienced (1 study, 151 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the suggestion that IV ibuprofen is effective and safe for acute postoperative pain in adults.
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Affiliation(s)
- McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, Illinois, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Sean Gallagher
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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Herzig SJ, Anderson TS, Jung Y, Ngo L, Kim DH, McCarthy EP. Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study. PLoS Med 2021; 18:e1003804. [PMID: 34570810 PMCID: PMC8504723 DOI: 10.1371/journal.pmed.1003804] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 10/11/2021] [Accepted: 09/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although analgesics are initiated on hospital discharge in millions of adults each year, studies quantifying the risks of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) among older adults during this transition are limited. We sought to determine the incidence and risk of post-discharge adverse events among older adults with an opioid claim in the week after hospital discharge, compared to those with NSAID claims only. METHODS AND FINDINGS We performed a retrospective cohort study using a national sample of Medicare beneficiaries age 65 and older, hospitalized in United States hospitals in 2016. We excluded beneficiaries admitted from or discharged to a facility. We derived a propensity score that included over 100 factors potentially related to the choice of analgesic, including demographics, diagnoses, surgeries, and medication coadministrations. Using 3:1 propensity matching, beneficiaries with an opioid claim in the week after hospital discharge (with or without NSAID claims) were matched to beneficiaries with an NSAID claim only. Primary outcomes included death, healthcare utilization (emergency department [ED] visits and rehospitalization), and a composite of known adverse effects of opioids or NSAIDs (fall/fracture, delirium, nausea/vomiting, complications of slowed colonic motility, acute renal failure, and gastritis/duodenitis) within 30 days of discharge. After propensity matching, there were 13,385 beneficiaries in the opioid cohort and 4,677 in the NSAID cohort (mean age: 74 years, 57% female). Beneficiaries receiving opioids had a higher incidence of death (1.8% versus 1.1%; relative risk [RR] 1.7 [1.3 to 2.3], p < 0.001, number needed to harm [NNH] 125), healthcare utilization (19.0% versus 17.4%; RR 1.1 [1.02 to 1.2], p = 0.02, NNH 59), and any potential adverse effect (25.2% versus 21.3%; RR 1.2 [1.1 to 1.3], p < 0.001, NNH 26), compared to those with an NSAID claim only. Specifically, they had higher relative risk of fall/fracture (4.5% versus 3.4%; RR 1.3 [1.1 to 1.6], p = 0.002), nausea/vomiting (9.2% versus 7.3%; RR 1.3 [1.1 to 1.4], p < 0.001), and slowed colonic motility (8.0% versus 6.2%; RR 1.3 [1.1 to 1.4], p < 0.001). Risks of delirium, acute renal failure, and gastritis/duodenitis did not differ between groups. The main limitation of our study is the observational nature of the data and possibility of residual confounding. CONCLUSIONS Older adults filling an opioid prescription in the week after hospital discharge were at higher risk for mortality and other post-discharge adverse outcomes compared to those filling an NSAID prescription only.
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Affiliation(s)
- Shoshana J. Herzig
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Timothy S. Anderson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Long Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dae H. Kim
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United States of America
| | - Ellen P. McCarthy
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United States of America
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Moore RA, Fisher E, Häuser W, Bell RF, Perrot S, Bidonde J, Makri S, Straube S. Pharmacological therapies for fibromyalgia (fibromyalgia syndrome) in adults - an overview of Cochrane Reviews. Hippokratia 2021. [DOI: 10.1002/14651858.cd013151.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Emma Fisher
- Cochrane Pain, Palliative and Supportive Care Group; Pain Research Unit, Churchill Hospital; Oxford UK
| | - Winfried Häuser
- Department of Psychosomatic Medicine and Psychotherapy; Technische Universität München; München Germany
| | - Rae Frances Bell
- Emerita, Regional Centre of Excellence in Palliative Care; Haukeland University Hospital; Bergen Norway
| | - Serge Perrot
- Service de Médecine Interne et Thérapeutique; Hôtel Dieu, Université Paris Descartes, INSERM U 987; Paris France
| | - Julia Bidonde
- School of Rehabilitation Science, College of Medicine; University of Saskatchewan; Saskatoon Canada
| | - Souzi Makri
- Cyprus League Against Rheumatism; Nicosia Cyprus
| | - Sebastian Straube
- Department of Medicine, Division of Preventive Medicine; University of Alberta; Edmonton Canada
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Shikh EV, Khaytovich ED, Perkov AV. Clinical and pharmacological approaches to the choice of a drug for a tension-type headache relief. TERAPEVT ARKH 2021; 93:862-868. [DOI: 10.26442/00403660.2021.08.200920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 11/22/2022]
Abstract
The article goes to describe clinical and pharmacological approaches to choosing a drug with an optimal efficacy/safety profile, providing the necessary analgesic effect in tension-type headache. TRPV1 brain receptors are considered the main action point of the mediator.
Aim. The purpose of this study is a comparative analysis of the pharmacodynamic and pharmacokinetic parameters of ibuprofen and paracetamol as a part of fixed dose combination and as monotherapy in tension type headaches.
Materials and methods. Comparative dissolution kinetics test; Comparative analysis of pharmacokinetic parameters using the PubMed/MEDLINE database.
Results. The median Tmax of ibuprofen as a part of a fixed-dose combination and as a monotherapy is 75 minutes. The median Tmax of paracetamol is 30 min when taken in a fixed dose combination and 40 min as a monotherapy. In patients who received the fixed dose combination, the concentration of ibuprofen in the blood plasma after 10 minutes 6.64 g/ml-1; after 20 minutes 16.81 g/ml-1, while when taken in the same dose in as a monotherapy, respectively, 0.58 and 9.00 g/ml-1. The mean plasma concentrations of paracetamol after 10 and 20 minutes in patients receiving the fixed combination were 5.43 and 14.54 g/ml-1, respectively, compared with 0.33 and 9.19 g/ml-1 for paracetamol as monotherapy. dissolution kinetics test of the Paracytolgin: after 5 minutes, 20% of paracetamol passed into the solution in a system with a pH of 1.2; in a system with a pH of 4.5 36.4%; in a system with a pH of 6.8 33.5%; after 10 minutes, respectively 68.5, 98.0 and 89.6%. After 15 minutes, almost complete dissolution was noted in all systems: 98.5, 98.8 and 100.5%, respectively.
Discussion. The combination of ibuprofen and paracetamol makes it possible to enhance the analgesic effect as a result of additive action by the help of central mechanisms. The fixed dose combination of ibuprofen and paracetamol significantly increases the rate of absorption of paracetamol, which has potential therapeutic benefits in terms of a faster analgesias onset.
Conclusion. The fixed dose combination of ibuprofen and paracetamol provides faster and long-term anaesthesia with a comparatively lower dosage of each analgesic.
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Serrano Afonso A, Carnaval T, Videla Cés S. Combination Therapy for Neuropathic Pain: A Review of Recent Evidence. J Clin Med 2021; 10:jcm10163533. [PMID: 34441829 PMCID: PMC8396869 DOI: 10.3390/jcm10163533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 12/19/2022] Open
Abstract
Pharmacological treatment is not very effective for neuropathic pain (NP). A progressive decrease in the estimated effect of NP drugs has been reported, giving rise to an increase in the use of the multimodal analgesic approach. We performed a new independent review to assess whether more and better-quality evidence has become available since the last systematic review. We evaluated the efficacy, tolerability, and safety of double-blinded randomized controlled trials involving only adult participants and comparing combination therapy (CT: ≥2 drugs) with a placebo and/or at least one other comparator with an NP indication. The primary outcome assessed was the proportion of participants reporting ≥50% pain reductions from baseline. The secondary outcome assessed was the proportion of drop-outs due to treatment-emergent adverse events. After removing duplicates, 2323 citations were screened, with 164 articles assessed for eligibility, from which 16 were included for qualitative analysis. From the latter, only five lasted for at least 12 weeks and only six complied with the required data for complete analysis. CT has been adopted for years without robust evidence. Efforts have been made to achieve better-quality evidence, but the quality has not improved over the years. In this regard, guidelines for NP should attempt to make recommendations about CT research, prioritizing which combinations to analyze.
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Affiliation(s)
- Ancor Serrano Afonso
- Department of Anesthesiology, Resuscitation and Pain Management, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain
- Correspondence:
| | - Thiago Carnaval
- Department of Clinical Pharmacology, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain;
| | - Sebastià Videla Cés
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, 08907 L’Hospitalet de Llobregat, Spain;
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Freo U, Ruocco C, Valerio A, Scagnol I, Nisoli E. Paracetamol: A Review of Guideline Recommendations. J Clin Med 2021; 10:jcm10153420. [PMID: 34362203 PMCID: PMC8347233 DOI: 10.3390/jcm10153420] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/11/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023] Open
Abstract
Musculoskeletal pain conditions are age-related, leading contributors to chronic pain and pain-related disability, which are expected to rise with the rapid global population aging. Current medical treatments provide only partial relief. Furthermore, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in young and otherwise healthy individuals but are often contraindicated in elderly and frail patients. As a result of its favorable safety and tolerability record, paracetamol has long been the most common drug for treating pain. Strikingly, recent reports questioned its therapeutic value and safety. This review aims to present guideline recommendations. Paracetamol has been assessed in different conditions and demonstrated therapeutic efficacy on both acute and chronic pain. It is active as a single agent and is additive or synergistic with NSAIDs and opioids, improving their efficacy and safety. However, a lack of significant efficacy and hepatic toxicity have also been reported. Fast dissolving formulations of paracetamol provide superior and more extended pain relief that is similar to intravenous paracetamol. A dose reduction is recommended in patients with liver disease or malnourished. Genotyping may improve efficacy and safety. Within the current trend toward the minimization of opioid analgesia, it is consistently included in multimodal, non-opioid, or opioid-sparing therapies. Paracetamol is being recommended by guidelines as a first or second-line drug for acute pain and chronic pain, especially for patients with limited therapeutic options and for the elderly.
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Affiliation(s)
- Ulderico Freo
- Anesthesiology and Intensive Care, Department of Medicine—DIMED, University of Padua, 35122 Padua, Italy;
- Correspondence: ; Tel.: +39-049-821-3090
| | - Chiara Ruocco
- Center for the Study and Research on Obesity, Department of Biomedical Technology and Translational Medicine, University of Milan, 20129 Milan, Italy; (C.R.); (E.N.)
| | - Alessandra Valerio
- Department of Molecular and Translational Medicine, University of Brescia, 25100 Brescia, Italy;
| | - Irene Scagnol
- Anesthesiology and Intensive Care, Department of Medicine—DIMED, University of Padua, 35122 Padua, Italy;
| | - Enzo Nisoli
- Center for the Study and Research on Obesity, Department of Biomedical Technology and Translational Medicine, University of Milan, 20129 Milan, Italy; (C.R.); (E.N.)
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[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]. Schmerz 2021; 35:265-281. [PMID: 34076782 DOI: 10.1007/s00482-021-00566-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics. METHODS An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process. RESULTS The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs. CONCLUSION The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.
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Stamer UM, Erlenwein J, Freys SM, Stammschulte T, Stichtenoth D, Wirz S. [Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]. Anaesthesist 2021; 70:689-705. [PMID: 34282481 DOI: 10.1007/s00101-021-01010-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics. METHODS An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process. RESULTS The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs. CONCLUSION The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.
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Affiliation(s)
- Ulrike M Stamer
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz.
- Arbeitskreis Akutschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland.
| | - Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Wissenschaftlicher Arbeitskreis Schmerzmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V., Nürnberg, Deutschland
| | - Stephan M Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Deutschland
- Chirurgische Arbeitsgemeinschaft Akutschmerz, Deutsche Gesellschaft für Chirurgie e.V., Berlin, Deutschland
| | - Thomas Stammschulte
- , Bern, Schweiz
- ehemalige Institution Arzneimittelkommission der deutschen Ärzteschaft, Berlin, Deutschland
| | - Dirk Stichtenoth
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stefan Wirz
- Abteilung für Anästhesie, Interdisziplinäre Intensivmedizin, Schmerzmedizin/Palliativmedizin, Zentrum für Schmerzmedizin, Weaningzentrum, CURA - GFO-Kliniken Bonn, Bad Honnef, Deutschland
- Arbeitskreis Tumorschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland
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Xiang C, Pan M, Shen Q, Hu S, Feng Z, Feng Q, Yang C. Clinical Consumption of Compound Opioid Analgesics in China: A Retrospective Analysis of National Data 2015-2018. Biol Pharm Bull 2021; 44:1316-1322. [PMID: 34219120 DOI: 10.1248/bpb.b21-00347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Compound opioid analgesics (COA) are widely used for cancer pain relief, but few studies investigated the use of that. We aimed to report the characteristics and trend of COA consumption in different regions and health facilities in China. The procurement data of two types of COA, compound codeine phosphate (CCP) and oxycodone and acetaminophen (OAA), in all medical institutions of 20 provinces from 2015 to 2018 were used. Data were presented as defined daily dose for statistical purpose (SDDD) and expenditures per million inhabitants per day. The annual consumption of COA and ratio of two combinations were compared among regions and institutions. We found, during 2015-2018, COA consumption increased at an average rate of 7.32% in SDDD and 19.19% in expenditures, while OAA accounted for most of the consumption. Highest COA consumption appeared in Northern China, with 121.72 SDDD and 1689.87 RMB (2015), whereas the lowest COA consumption was only 11.28 SDDD appearing in Southern China. The ratio of OAA and CCP (in SDDD) was highest in Southern China (53.14 in 2018), whereas lowest in West North (0.37 in 2018). In terms of institutions, tertiary had the highest COA consumption, with 16.74 SDDD and 292.73 RMB (2018). The SDDD of OAA was 27.44 times of that of CCP in tertiary, while it was only 0.11 in primary. Overall, COA consumption is on an upward trend and different among regions and health institutions in either amount or types of COA. These findings call for establishment of COA management regulations.
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Affiliation(s)
- Cheng Xiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Mengyuan Pan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Qian Shen
- The Second Affiliated Hospital, Xi'an Jiaotong University
| | - Shuchen Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Zhitong Feng
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
| | - Qinqin Feng
- Department of Pharmacy, No. 521 Hospital of Norinco Group
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University.,Center for Drug Safety and Policy Research, Xi'an Jiaotong University
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Stamer UM, Erlenwein J, Freys SM, Stammschulte T, Stichtenoth D, Wirz S. [Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]. Chirurg 2021; 92:647-663. [PMID: 34037807 PMCID: PMC8241738 DOI: 10.1007/s00104-021-01421-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/17/2022]
Abstract
Hintergrund Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe. Methodik Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet. Ergebnisse Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden. Schlussfolgerung Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden. Zusatzmaterial online Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.
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Affiliation(s)
- Ulrike M Stamer
- Universitätsklinik für Anästhesiologie und Schmerztherapie, Inselspital, Universität Bern, Freiburgstrasse, 3010, Bern, Schweiz. .,Arbeitskreis Akutschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland.
| | - Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Deutschland.,Wissenschaftlicher Arbeitskreis Schmerzmedizin, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V., Nürnberg, Deutschland
| | - Stephan M Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Deutschland.,Chirurgische Arbeitsgemeinschaft Akutschmerz, Deutsche Gesellschaft für Chirurgie e.V., Berlin, Deutschland
| | - Thomas Stammschulte
- , Bern, Schweiz.,ehemalige Institution Arzneimittelkommission der deutschen Ärzteschaft, Berlin, Deutschland
| | - Dirk Stichtenoth
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stefan Wirz
- Abteilung für Anästhesie, Interdisziplinäre Intensivmedizin, Schmerzmedizin/Palliativmedizin, Zentrum für Schmerzmedizin, Weaningzentrum, CURA - GFO-Kliniken Bonn, Bad Honnef, Deutschland.,Arbeitskreis Tumorschmerz, Deutsche Schmerzgesellschaft e.V., Berlin, Deutschland
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McNicol ED, Ferguson MC, Schumann R. Single-dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database Syst Rev 2021; 5:CD013263. [PMID: 33998669 PMCID: PMC8127532 DOI: 10.1002/14651858.cd013263.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative pain is common and may be severe. Postoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) reduces patient opioid requirements and, in turn, may reduce the incidence and severity of opioid-induced adverse events (AEs). OBJECTIVES To assess the analgesic efficacy and adverse effects of single-dose intravenous ketorolac, compared with placebo or an active comparator, for moderate to severe postoperative pain in adults. SEARCH METHODS We searched the following databases without language restrictions: CENTRAL, MEDLINE, Embase and LILACS on 20 April 2020. We checked clinical trials registers and reference lists of retrieved articles for additional studies. SELECTION CRITERIA Randomized double-blind trials that compared a single postoperative dose of intravenous ketorolac with placebo or another active treatment, for treating acute postoperative pain in adults following any surgery. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was the number of participants in each arm achieving at least 50% pain relief over a four- and six-hour period. Our secondary outcomes were time to and number of participants using rescue medication; withdrawals due to lack of efficacy, adverse events (AEs), and for any other cause; and number of participants experiencing any AE, serious AEs (SAEs), and NSAID-related or opioid-related AEs. For subgroup analysis, we planned to analyze different doses of parenteral ketorolac separately and to analyze results based on the type of surgery performed. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, involving 1905 participants undergoing various surgeries (pelvic/abdominal, dental, and orthopedic), with 17 to 83 participants receiving intravenous ketorolac in each study. Mean study population ages ranged from 22.5 years to 67.4 years. Most studies administered a dose of ketorolac of 30 mg; one study assessed 15 mg, and another administered 60 mg. Most studies had an unclear risk of bias for some domains, particularly allocation concealment and blinding, and a high risk of bias due to small sample size. The overall certainty of evidence for each outcome ranged from very low to moderate. Reasons for downgrading certainty included serious study limitations, inconsistency and imprecision. Ketorolac versus placebo Very low-certainty evidence from eight studies (658 participants) suggests that ketorolac results in a large increase in the number of participants achieving at least 50% pain relief over four hours compared to placebo, but the evidence is very uncertain (risk ratio (RR) 2.81, 95% confidence interval (CI) 1.80 to 4.37). The number needed to treat for one additional participant to benefit (NNTB) was 2.4 (95% CI 1.8 to 3.7). Low-certainty evidence from 10 studies (914 participants) demonstrates that ketorolac may result in a large increase in the number of participants achieving at least 50% pain relief over six hours compared to placebo (RR 3.26, 95% CI 1.93 to 5.51). The NNTB was 2.5 (95% CI 1.9 to 3.7). Among secondary outcomes, for time to rescue medication, moderate-certainty evidence comparing intravenous ketorolac versus placebo demonstrated a mean median of 271 minutes for ketorolac versus 104 minutes for placebo (6 studies, 633 participants). For the number of participants using rescue medication, very low-certainty evidence from five studies (417 participants) compared ketorolac with placebo. The RR was 0.60 (95% CI 0.36 to 1.00), that is, it did not demonstrate a difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with placebo (74% versus 65%; 8 studies, 810 participants; RR 1.09, 95% CI 1.00 to 1.19; number needed to treat for an additional harmful event (NNTH) 16.7, 95% CI 8.3 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from eight studies (703 participants) did not demonstrate a difference in rates between ketorolac and placebo (RR 0.62, 95% CI 0.13 to 3.03). Ketorolac versus NSAIDs Ketorolac was compared to parecoxib in four studies and diclofenac in two studies. For our primary outcome, over both four and six hours there was no evidence of a difference between intravenous ketorolac and another NSAID (low-certainty and moderate-certainty evidence, respectively). Over four hours, four studies (337 participants) produced an RR of 1.04 (95% CI 0.89 to 1.21) and over six hours, six studies (603 participants) produced an RR of 1.06 (95% CI 0.95 to 1.19). For time to rescue medication, low-certainty evidence from four studies (427 participants) suggested that participants receiving ketorolac waited an extra 35 minutes (mean median 331 minutes versus 296 minutes). For the number of participants using rescue medication, very low-certainty evidence from three studies (260 participants) compared ketorolac with another NSAID. The RR was 0.90 (95% CI 0.58 to 1.40), that is, there may be little or no difference between groups. Ketorolac probably results in a slight increase in total adverse event rates compared with another NSAID (76% versus 68%, 5 studies, 516 participants; RR 1.11, 95% CI 1.00 to 1.23; NNTH 12.5, 95% CI 6.7 to infinite, moderate-certainty evidence). Serious AEs were rare. Low-certainty evidence from five studies (530 participants) did not demonstrate a difference in rates between ketorolac and another NSAID (RR 3.18, 95% CI 0.13 to 76.99). Only one of the five studies reported a single serious AE. AUTHORS' CONCLUSIONS The amount and certainty of evidence for the use of intravenous ketorolac as a treatment for postoperative pain varies across efficacy and safety outcomes and amongst comparators, from very low to moderate. The available evidence indicates that postoperative intravenous ketorolac administration may offer substantial pain relief for most patients, but further research may impact this estimate. Adverse events appear to occur at a slightly higher rate in comparison to placebo and to other NSAIDs. Insufficient information is available to assess whether intravenous ketorolac has a different rate of gastrointestinal or surgical-site bleeding, renal dysfunction, or cardiovascular events versus other NSAIDs. There was a lack of studies in cardiovascular surgeries and in elderly populations who may be at increased risk for adverse events.
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Affiliation(s)
- Ewan D McNicol
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - McKenzie C Ferguson
- Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, USA
| | - Roman Schumann
- Department of Anesthesia, Critical Care and Pain Medicine, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
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Franco-de la Torre L, Figueroa-Fernández NP, Franco-González DL, Alonso-Castro ÁJ, Rivera-Luna F, Isiordia-Espinoza MA. A Meta-Analysis of the Analgesic Efficacy of Single-Doses of Ibuprofen Compared to Traditional Non-Opioid Analgesics Following Third Molar Surgery. Pharmaceuticals (Basel) 2021; 14:ph14040360. [PMID: 33919715 PMCID: PMC8070746 DOI: 10.3390/ph14040360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 04/08/2021] [Indexed: 01/10/2023] Open
Abstract
The purpose of this systematic review was to determine the analgesic efficacy and adverse effects of ibuprofen in comparison with other traditional non-opioid analgesics after third molar surgery. A total of 17 full texts were identified in PubMed and assessed using the Cochrane Collaboration’s risk of bias tool by two independent researchers. The sum of pain intensity differences, total pain relief, the overall evaluation, the number of patients requiring rescue analgesics, and adverse effects were collected. Data were analyzed using the Review Manager Software 5.3. for Windows. A total of 15 articles met the criteria. The qualitative and quantitative analysis showed that ibuprofen is more effective to relieve post-operative dental pain than acetaminophen, meclofenamate, aceclofenac, bromfenac, and aspirin. Moreover, ibuprofen and traditional non-steroidal anti-inflammatory drugs have a similar safety profile. In conclusion, ibuprofen 400 mg appears to have good analgesic efficacy and a safety profile similar to other traditional non-steroidal anti-inflammatory drugs after third molar surgery.
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Affiliation(s)
- Lorenzo Franco-de la Torre
- Instituto de Investigación en Ciencias Médicas, Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos 47620, Mexico; (L.F.-d.l.T.); (D.L.F.-G.)
| | - Norma Patricia Figueroa-Fernández
- Departamento de Cirugía Oral y Maxilofacial, Facultad de Odontología, Universidad Autónoma de Baja California, Campus Mexicali 21040, Mexico; (N.P.F.-F.); (F.R.-L.)
| | - Diana Laura Franco-González
- Instituto de Investigación en Ciencias Médicas, Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos 47620, Mexico; (L.F.-d.l.T.); (D.L.F.-G.)
| | - Ángel Josabad Alonso-Castro
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato 36250, Mexico;
| | - Federico Rivera-Luna
- Departamento de Cirugía Oral y Maxilofacial, Facultad de Odontología, Universidad Autónoma de Baja California, Campus Mexicali 21040, Mexico; (N.P.F.-F.); (F.R.-L.)
| | - Mario Alberto Isiordia-Espinoza
- Instituto de Investigación en Ciencias Médicas, Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos 47620, Mexico; (L.F.-d.l.T.); (D.L.F.-G.)
- Correspondence: ; Tel.: +52-378-119-5786
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Management of Acute Pain Due to Traumatic Injury in Patients with Chronic Pain and Pre-injury Opioid Use. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sittl R, Bäumler P, Stumvoll AM, Irnich D, Zwißler B. [Considerations concerning the perioperative use of metamizole]. Anaesthesist 2020; 68:530-537. [PMID: 31435718 DOI: 10.1007/s00101-019-00637-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The non-opioid analgesic metamizole (dipyrone) is approved for the treatment of severe pain and is often used in the perioperative period. As it can cause agranulocytosis, a severe adverse event, its perioperative administration is controversially discussed. OBJECTIVE Is there enough evidence for a high risk of metamizol-induced agranulocytosis (MIA)? What are the consequences of its perioperative use with respect to the risk profiles of alternative analgesics? MATERIAL AND METHODS Rapid review of the literature on the risk of MIA and adverse effects of non-opioid analgesics. RESULTS The incidence of MIA is estimated to be one case per million inhabitants per year. The risk seems low compared to other drugs associated with a risk of agranulocytosis, such as antithyroid drugs and ticlopidine. The risk profile of metamizole concerning hepatotoxicity, nephrotoxicity, bleeding and cardiovascular adverse effects is favorable compared to other non-opioid analgesics. None of the non-opioid analgesics are licensed to be administered intraoperatively. CONCLUSION The perioperative use of metamizole is possible after a thorough evaluation of the indications as it provides good analgesia with a generally favorable side effect profile and is administered intravenously. The risk of agranulocytosis is small but needs to be mentioned during patient informed consent in order to optimize early recognition. Intraoperative administration aims at reducing the expected severe postoperative pain. A documentation and justification for the evaluation of the indications are recommended.
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Affiliation(s)
- R Sittl
- Interdisziplinäre Schmerzambulanz, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Pettenkoferstr. 8a, 80336, München, Deutschland
| | - P Bäumler
- Interdisziplinäre Schmerzambulanz, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Pettenkoferstr. 8a, 80336, München, Deutschland
| | - A-M Stumvoll
- Interdisziplinäre Schmerzambulanz, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Pettenkoferstr. 8a, 80336, München, Deutschland
| | - D Irnich
- Interdisziplinäre Schmerzambulanz, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - B Zwißler
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Andreasen RA, Kristensen LE, Baraliakos X, Strand V, Mease PJ, de Wit M, Ellingsen T, Hansen IMJ, Kirkham J, Wells GA, Tugwell P, Maxwell L, Boers M, Egstrup K, Christensen R. Assessing the effect of interventions for axial spondyloarthritis according to the endorsed ASAS/OMERACT core outcome set: a meta-research study of trials included in Cochrane reviews. Arthritis Res Ther 2020; 22:177. [PMID: 32711571 PMCID: PMC7382035 DOI: 10.1186/s13075-020-02262-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/06/2020] [Indexed: 12/24/2022] Open
Abstract
The Assessment of SpondyloArthritis international Society (ASAS) has defined core sets for (i) symptom-modifying anti-rheumatic drugs (SM-ARD), (ii) clinical record keeping, and (iii) disease-controlling anti-rheumatic therapy (DC-ART). These include the following domains for all three core sets: “physical function,” “pain,” “spinal mobility,” “spinal stiffness,” and “patient’s global assessment” (PGA). The core set for clinical record keeping further includes the domains “peripheral joints/entheses” and “acute phase reactants,” and the core set for DC-ART further includes the domains “fatigue” and “spine radiographs/hip radiographs.” The Outcome Measures in Rheumatology (OMERACT) endorsed the core sets in 1998. Using empirical evidence from axSpA trials, we investigated the efficacy (i.e., net benefit) according to the ASAS/OMERACT core outcome set for axSpA across all interventions tested in trials included in subsequent Cochrane reviews. For all continuous scales, we combined data using the standardized mean difference (SMD) to meta-analyze outcomes involving the same domains. Also, through meta-regression analysis, we examined the effect of the separate SMD measures (independent variables) on the primary endpoint (log [OR], dependent variable) across all trials. Based on 11 eligible Cochrane reviews, from these, 85 articles were screened; we included 43 trials with 63 randomized comparisons. Mean (SD) number of ASAS/OMERACT core outcome domains measured for SM-ARD/physical therapy trials was 4.2 (1.7). Six trials assessed all proposed domains. Mean (SD) for number of core outcome domains for DC-ART trials was 5.8 (1.7). No trials assessed all nine domains. Eight trials (16%) were judged to have inadequate (i.e., high risk of) selective outcome reporting bias. The most responsible core domains for achieving success in meeting the primary objective per trial were pain, OR (95% CI) 5.19 (2.28, 11.77), and PGA, OR (95% CI) 1.87 (1.14, 3.07). In conclusion, selective outcome reporting (and “missing data”) should be reduced by encouraging the use of the endorsed ASAS/OMERACT outcome domains in clinical trials. Overall outcome reporting was good for SM-ARD/physical therapy trials and poor for DC-ART trials. Our findings suggest that both PGA and pain provide a valuable holistic construct for the assessment of improvement beyond more objective measures of spinal inflammation.
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Affiliation(s)
- Rikke A Andreasen
- Department of Medicine, Section of Rheumatology, Odense University Hospital, Svendborg and University of Southern Denmark, Odense, Denmark.,Musculoskeletal Statistics Unit, the Parker Institute, Bispebjerg and Frederiksberg Hospital, University Hospital, Copenhagen F, Denmark
| | - Lars E Kristensen
- Musculoskeletal Statistics Unit, the Parker Institute, Bispebjerg and Frederiksberg Hospital, University Hospital, Copenhagen F, Denmark
| | | | - Vibeke Strand
- Division Immunology/Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Philip J Mease
- Swedish Medical Centre/Providence St. Joseph Health and University of Washington, Seattle, USA
| | | | - Torkell Ellingsen
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Inger Marie J Hansen
- Department of Medicine, Section of Rheumatology, Odense University Hospital, Svendborg and University of Southern Denmark, Odense, Denmark
| | - Jamie Kirkham
- Centre for Biostatistics, Manchester Academic Health Science, Manchester, UK
| | - George A Wells
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tugwell
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lara Maxwell
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Maarten Boers
- Department of Epidemiology & Biostatistics, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Kenneth Egstrup
- Cardiovascular Research Unit, Odense University Hospital, Svendborg, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, the Parker Institute, Bispebjerg and Frederiksberg Hospital, University Hospital, Copenhagen F, Denmark. .,Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark.
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Ohnesorge H, Günther V, Grünewald M, Maass N, Alkatout İ. Postoperative pain management in obstetrics and gynecology. J Turk Ger Gynecol Assoc 2020; 21:287-297. [PMID: 32500680 PMCID: PMC7726464 DOI: 10.4274/jtgga.galenos.2020.2020.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficiency and quality of postoperative pain management may be considered unsatisfactory in Europe, as well as in the United States. Notwithstanding our better understanding of the physiology of pain and the development of new analgesia procedures, the improvement in satisfaction of patients has not be enhanced to the same degree. Obstetrics and gynecology are no exception to this statement. In fact, obstetrics and gynecology are surgical departments in which patients experience the greatest severity of postoperative pain. Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics, supplemented with regional analgesia procedures and/or peripheral nerve blockades and, in some cases, the administration of other pain-relieving pharmaceutical agents. Based on the existing body of evidence, it would be appropriate to develop procedure-related concepts of analgesia. The concepts are based on the special circumstances of the respective department, and the scheme of analgesia is aligned to the respective interventions. Generally, however, a surgeon’s individual experience in dealing with the procedures and substances could be more significant than the theoretical advantages demonstrated in preceding investigations.
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Affiliation(s)
- Henning Ohnesorge
- Clinic of Anesthesiology and Operative Intensive Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Veronika Günther
- Clinic of Obstetrics and Gynecology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Matthias Grünewald
- Clinic of Anesthesiology and Operative Intensive Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Nicolai Maass
- Clinic of Obstetrics and Gynecology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - İbrahim Alkatout
- Clinic of Obstetrics and Gynecology, University Medical Center Schleswig-Holstein, Kiel, Germany
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Förderreuther S, Lampert A, Hitier S, Lange R, Weiser T. The Impact of Baseline Pain Intensity on the Analgesic Efficacy of Ibuprofen/Caffeine in Patients with Acute Postoperative Dental Pain: Post Hoc Subgroup Analysis of a Randomised Controlled Trial. Adv Ther 2020; 37:2976-2987. [PMID: 32333328 PMCID: PMC7467437 DOI: 10.1007/s12325-020-01297-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Indexed: 02/05/2023]
Abstract
Introduction A fixed dose combination (FDC) of ibuprofen 400 mg and caffeine 100 mg has been shown to be more effective than ibuprofen 400 mg alone for the treatment of acute postoperative dental pain in a phase III randomised controlled trial. A post hoc subgroup analysis of the primary data from an active-/placebo-controlled, double-blind, single-centre, parallel-group study was conducted in patients with moderate or severe baseline pain. Methods After dental surgery, patients with moderate or severe pain, which was determined on a 4-point verbal rating scale (‘no pain’ to ‘severe pain’), received a single dose of ibuprofen 400 mg/caffeine 100 mg FDC, ibuprofen 400 mg, caffeine 100 mg or placebo. Pain relief (PAR) and pain intensity were assessed 0.25, 0.5, 0.75, 1, 1.5, 2, 3, 4, 5, 6, 7 and 8 h after administration of study medication. The primary study endpoint was the time-weighted sum of PAR and pain intensity difference (PID) from pre-dose baseline, summed for all post-dose assessment times from 0 to 8 h (SPRID0–8h). Results There were 237 patients with moderate pain and 325 with severe pain at baseline. SPRID0–8h was significantly improved with the FDC versus ibuprofen, caffeine and placebo in the moderate and severe pain subgroups. Adjusted mean SPRID0–8h difference for the FDC versus ibuprofen was 18.19 (p < 0.0001) for patients with moderate pain and 7.70 (p = 0.0409) for patients with severe pain. With the exception of the 7-h measurement in patients with moderate pain, PID was significantly improved with the FDC versus ibuprofen at all measured time points from 0.5 to 8 h. In the severe pain subgroup, PID was significantly improved for the FDC versus ibuprofen from 0.5 to 3 h post-dose, but was not significantly different thereafter. Conclusion The enhanced analgesic efficacy of ibuprofen/caffeine FDC versus ibuprofen is most pronounced in patients with moderate intensity pain at baseline, and also evident in patients with severe baseline pain. Trial Registration ClinicalTrials.gov identifier, NCT01929031. The non-steroidal anti-inflammatory drug (NSAID) ibuprofen is commonly used to relieve mild to moderate pain. Research suggests that combining ibuprofen with caffeine can increase the analgesic efficacy. Previously, a randomised, double-blind, placebo-controlled study showed that this ibuprofen/caffeine combination was significantly more effective than ibuprofen alone for relieving pain after dental surgery (wisdom tooth removal). Patients in that study had moderate or severe pain, so the researchers conducted another analysis of the study data to investigate how well the ibuprofen/caffeine combination worked in patients with moderate pain and in patients with severe pain. The study found that a single dose of ibuprofen/caffeine was significantly more effective than ibuprofen alone in patients with moderate pain and in those with severe pain. The analgesic effects of ibuprofen/caffeine were more marked in patients with moderate pain than in those with severe pain. This indicates that ibuprofen/caffeine is an effective pain reliever for patients with moderate pain, and to a lesser extent in patients with severe pain.
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Affiliation(s)
| | - Anette Lampert
- Medical Consumer Health Care, Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
| | - Simon Hitier
- Global Medical Consumer Health Care, Sanofi-Aventis Groupe, Gentilly, France
| | - Robert Lange
- Global Medical Affairs, Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
| | - Thomas Weiser
- Medical Consumer Health Care, Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
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Richards GC. Treating postoperative pain? Avoid tramadol, long-acting opioid analgesics and long-term use. BMJ Evid Based Med 2020; 25:110-111. [PMID: 31420352 DOI: 10.1136/bmjebm-2019-111236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Georgia C Richards
- Center for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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40
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Kyselovič J, Koscova E, Lampert A, Weiser T. A Randomized, Double-Blind, Placebo-Controlled Trial of Ibuprofen Lysinate in Comparison to Ibuprofen Acid for Acute Postoperative Dental Pain. Pain Ther 2020; 9:249-259. [PMID: 31912434 PMCID: PMC7203382 DOI: 10.1007/s40122-019-00148-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Ibuprofen acid is poorly soluble in the stomach, thus reaching maximum plasma levels at approximately 90 min post-dose. Ibuprofen lysinate has been developed to accelerate absorption of ibuprofen to shorten the time to analgesic efficacy. This study compared analgesic efficacy and onset of effect of a single dose of ibuprofen lysinate or ibuprofen acid in patients undergoing third molar extraction. METHODS Randomized, double-blind, placebo-controlled, multi-center, parallel-group single-dose study. Adults (18-60 years) undergoing extraction of ≥ 1 third molar were randomized 2:2:1 to ibuprofen lysinate, ibuprofen acid, or placebo postoperatively. Pain relief (PAR, 5-point scale, 0 = none to 4 = complete pain relief) and pain intensity (PI, 100 mm visual analog scale) were assessed between 15 and 360 min post-dose. The primary endpoint was the weighted sum of PAR scores at 6 h (TOTPAR). Time to onset of effect, global assessment of efficacy, and adverse events were also assessed. RESULTS Overall, 351 patients received ibuprofen lysinate (N = 141), ibuprofen acid (N = 139), or placebo (N = 71). Both active treatments significantly reduced pain compared with placebo, from 15 min post-dose to 6 h (TOTPAR: ibuprofen lysinate: 19.57; ibuprofen acid: 19.96; placebo: 8.27). Ibuprofen lysinate was significantly more effective than placebo, but non-inferior to ibuprofen acid, at providing pain relief over 6 h. There was no significant difference between ibuprofen lysinate and ibuprofen acid for onset of analgesia. Both ibuprofen formulations were well tolerated; all adverse events were mild to moderate and considered unrelated to treatment. CONCLUSIONS A single dose of ibuprofen lysinate is non-inferior to ibuprofen acid in terms of analgesic efficacy, onset of action, and tolerability in patients who have recently undergone dental surgery. TRIAL REGISTRATION EudraCT No. 2006-006942-33. Plain language summary available for this article.
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Affiliation(s)
- Ján Kyselovič
- Clinical Research Unit, 5th Department of Internal Medicine, Medical Faculty of Comenius University, University Hospital, Bratislava, Slovak Republic
| | - Eva Koscova
- CHC Medical Affairs, Eastern Europe Zone, Sanofi-Aventis Pharma Slovakia s.r.o, Bratislava, Slovak Republic
| | - Anette Lampert
- Medical CHC, Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
| | - Thomas Weiser
- Medical CHC, Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany.
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41
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Stamos A, Drum M, Reader A, Nusstein J, Fowler S, Beck M. An Evaluation of Ibuprofen Versus Ibuprofen/Acetaminophen for Postoperative Endodontic Pain in Patients With Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis. Anesth Prog 2020; 66:192-201. [PMID: 31891295 DOI: 10.2344/anpr-66-03-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The purpose of this investigation was to compare ibuprofen versus an ibuprofen/acetaminophen combination for postoperative pain control in a patient model specific to teeth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis. One hundred and two patients presenting with moderate to severe pain from a maxillary or mandibular posterior tooth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis were included. Following local anesthetic administration, complete endodontic cleaning and shaping was performed. Patients were randomly assigned to receive identically appearing tablets of ibuprofen 200 mg or a combination of ibuprofen 200 mg/acetaminophen 216.7 mg with instructions to take 3 tablets every 6 hours as needed for pain. Patients were also given a prescription for an escape medication to take if the study medications did not adequately control their pain. A 4-day diary was used to record pain ratings and medication use. Moderate to severe pain was experienced by 59-61% of the patients on postoperative day 1 and 50-57% of the patients on day 2, with the pain ratings decreasing over the next 2 days. There were no statistically significant differences between the 2 groups in postoperative pain, percussion pain, or medication use. There was no difference between ibuprofen and the combination of ibuprofen/acetaminophen in the reduction of postoperative pain following endodontic debridement in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.
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Affiliation(s)
- Alex Stamos
- Former Graduate Student in Endodontics, The Ohio State University
| | - Melissa Drum
- Professor and Graduate Program Director, Division of Endodontics, The Ohio State University
| | - Al Reader
- Emeritus Professor, Division of Endodontics, The Ohio State University
| | - John Nusstein
- Professor and Chair, Division of Endodontics, The Ohio State University
| | - Sara Fowler
- Assistant Professor and Predoctoral Director, Division of Endodontics, The Ohio State University
| | - Mike Beck
- Emeritus Associate Professor, Division of Biosciences, The Ohio State University
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42
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Joshi S, Shetty Y, Panchal R, Patankar P, Salgaonkar S, Rawat R, Natu A. An observational study to evaluate the prescription pattern of analgesics used in the perioperative period in a tertiary care hospital. Perspect Clin Res 2020; 12:165-170. [PMID: 34386382 PMCID: PMC8323566 DOI: 10.4103/picr.picr_87_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/14/2019] [Accepted: 11/24/2019] [Indexed: 12/02/2022] Open
Abstract
Background and Aims: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. There are limited observational prescription pattern studies of analgesics in perioperative period in tertiary care hospitals for which this study was carried out in orthopedic, general surgery, and plastic surgery departments. The primary aim was to study the prescription pattern of analgesics in the perioperative period with the secondary aim to study the specific use of opioids and pain relief using the Visual Analog Scale (VAS). Methods: A total of 250, 250, and 100 patients were taken from orthopedic, general surgery, and plastic surgery departments, respectively. The analgesics commonly used in preoperative, intraoperative, and postoperative period were observed. The use of opioids in the perioperative period, the number of fixed drug combinations used, the number of generic drug prescription, and pain relief postoperatively were also observed. The analysis was done using descriptive statistics. Results: Total analgesics prescribed were 1168, 117, and 369 in orthopedic, general surgery, and plastic surgery departments, respectively, and were maximum in the intraoperative period. Most commonly used analgesic in the preoperative and postoperative period was paracetamol and that in intraoperative period was fentanyl. Nonsteroidal anti-inflammatory drugs (NSAIDs) were mainly prescribed by the general surgery department in postoperative period. The amount of pain in postoperative period after treatment with analgesics was mild to moderate as per the VAS. Conclusion: This study revealed that in preoperative and postoperative period, the most common analgesic used is paracetamol. In the intraoperative period, maximum patients received fentanyl. Diclofenac is an established NSAID used in the management of acute and chronic pain states. In our study, we found that the usage of paracetamol was more than NSAIDs and the usage of opioid was maximum during intraoperative period.
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Affiliation(s)
- Shirish Joshi
- Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Yashashri Shetty
- Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Roshni Panchal
- Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Panini Patankar
- Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sweta Salgaonkar
- Department of Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rishabh Rawat
- Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anuya Natu
- Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Miano TA, Shashaty MGS, Yang W, Brown JR, Zuppa A, Hennessy S. Effect of Renin-Angiotensin System Inhibitors on the Comparative Nephrotoxicity of NSAIDs and Opioids during Hospitalization. ACTA ACUST UNITED AC 2020; 1:604-613. [PMID: 33163971 DOI: 10.34067/kid.0001432020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDS) are increasingly important alternatives to opioids for analgesia during hospitalization as health systems implement opioid-minimization initiatives. Increasing NSAID use may increase AKI rates, particularly in patients with predisposing risk factors. Inconclusive data in outpatient populations suggests that NSAID nephrotoxicity is magnified by renin-angiotensin system inhibitors (RAS-I). No studies have tested this in hospitalized patients. Methods Retrospective, active-comparator cohort study of patients admitted to four hospitals in Philadelphia, Pennsylvania. To minimize confounding by indication, NSAIDs were compared to oxycodone, and RAS-I were compared to amlodipine. We tested synergistic NSAID+RAS-I nephrotoxicity by comparing the difference in AKI rate between NSAID versus oxycodone in patients treated with RAS-I to the difference in AKI rate between NSAID versus oxycodone in patients treated with amlodipine. In a secondary analysis, we restricted the cohort to patients with baseline diuretic treatment. AKI rates were adjusted for 71 baseline characteristics with inverse probability of treatment-weighted Poisson regression. Results The analysis included 25,571 patients who received a median of 2.4 days of analgesia. The overall AKI rate was 23.6 per 1000 days. The rate difference (RD) for NSAID versus oxycodone in patients treated with amlodipine was 4.1 per 1000 days (95% CI, -2.8 to 11.1), and the rate difference for NSAID versus oxycodone in patients treated with RAS-I was 5.9 per 1000 days (95% CI, 1.9 to 10.1), resulting in a nonsignificant interaction estimate: 1.85 excess AKI events per 1000 days (95% CI, -6.23 to 9.92). Analysis in patients treated with diuretics produced a higher, albeit nonsignificant, interaction estimate: 9.89 excess AKI events per 1000 days (95% CI, -5.04 to 24.83). Conclusions Synergistic nephrotoxicity was not observed with short-term NSAID+RAS-I treatment in the absence of concomitant diuretics, suggesting that RAS-I treatment may not be a reason to choose opioids in lieu of NSAIDs in this population. Synergistic nephrotoxicity cannot be ruled out in patients treated with diuretics.
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Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.,Department of Epidemiology, Geisel School of Medicine, Hanover, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine, Hanover, New Hampshire
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Hersh EV, Moore PA, Grosser T, Polomano RC, Farrar JT, Saraghi M, Juska SA, Mitchell CH, Theken KN. Nonsteroidal Anti-Inflammatory Drugs and Opioids in Postsurgical Dental Pain. J Dent Res 2020; 99:777-786. [PMID: 32286125 DOI: 10.1177/0022034520914254] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Postsurgical dental pain is mainly driven by inflammation, particularly through the generation of prostaglandins via the cyclooxygenase system. Thus, it is no surprise that numerous randomized placebo-controlled trials studying acute pain following the surgical extraction of impacted third molars have demonstrated the remarkable efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, etodolac, diclofenac, and ketorolac in this prototypic condition of acute inflammatory pain. Combining an optimal dose of an NSAID with an appropriate dose of acetaminophen appears to further enhance analgesic efficacy and potentially reduce the need for opioids. In addition to being on average inferior to NSAIDs as analgesics in postsurgical dental pain, opioids produce a higher incidence of side effects in dental outpatients, including dizziness, drowsiness, psychomotor impairment, nausea/vomiting, and constipation. Unused opioids are also subject to misuse and diversion, and they may cause addiction. Despite these risks, some dental surgical outpatients may benefit from a 1- or 2-d course of opioids added to their NSAID regimen. NSAID use may carry significant risks in certain patient populations, in which a short course of an acetaminophen/opioid combination may provide a more favorable benefit versus risk ratio than an NSAID regimen.
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Affiliation(s)
- E V Hersh
- Department of Oral Surgery and Pharmacology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - P A Moore
- Department of Dental Public Health, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, USA
| | - T Grosser
- Institute of Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - R C Polomano
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - J T Farrar
- Departments of Epidemiology/Biostatistics and Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - M Saraghi
- Department of Dentistry/Oral and Maxillofacial Surgery, Jacobi Medical Center, Bronx, New York City, NY, USA
| | - S A Juska
- Institute of Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - C H Mitchell
- Department of Basic and Translational Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - K N Theken
- Institute of Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Pergolizzi JV, Magnusson P, LeQuang JA, Gharibo C, Varrassi G. The pharmacological management of dental pain. Expert Opin Pharmacother 2020; 21:591-601. [PMID: 32027199 DOI: 10.1080/14656566.2020.1718651] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: Dental pain is primarily treated by dentists and emergency medicine clinicians and may occur because of insult to the tooth or oral surgery. The dental impaction pain model (DIPM) has been widely used in clinical studies of analgesic agents and is generalizable to many other forms of pain.Areas Covered: The authors discuss the DIPM, which has allowed for important head-to-head studies of analgesic agents, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations. Postsurgical dental pain follows a predictable trajectory over the course of one to 3 days. Dental pain may have odontic origin or may be referred pain from other areas of the body.Expert opinion: Pain following oral surgery has sometimes been treated with longer-than-necessary courses of opioid therapy. Postsurgical dental pain may be moderate to severe but typically resolves in a day or two after the extraction. Opioid monotherapy, rarely used in dentistry but combination therapy (opioid plus acetaminophen or an NSAID), was sometimes used as well as nonopioid analgesic monotherapy. The dental impaction pain model has been valuable in the study of analgesics but does not address all painful conditions, for example, pain with a neuropathic component.
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Affiliation(s)
| | - Peter Magnusson
- Centre for Research and Development, Uppsala/Region, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet, Stockholm, Sweden
| | | | - Christopher Gharibo
- Anesthesiology, Pain Medicine, and Orthopedics, New York University Langone Health, New York, NY, USA
| | - Giustino Varrassi
- Paolo Procacci Foundation, Roma, Italy.,World Institute of Pain, Winston-Salem, NC, USA
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46
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El-Kefraoui C, Olleik G, Chay MA, Kouyoumdjian A, Nguyen-Powanda P, Rajabiyazdi F, Do U, Derksen A, Landry T, Amar-Zifkin A, Ramanakumar AV, Martel MO, Baldini G, Feldman L, Fiore JF. Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e035443. [PMID: 32014880 PMCID: PMC7045253 DOI: 10.1136/bmjopen-2019-035443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/16/2019] [Accepted: 01/02/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Excessive prescribing after surgery has contributed to a public health crisis of opioid addiction and overdose in North America. However, the value of prescribing opioids to manage postoperative pain after surgical discharge remains unclear. We propose a systematic review and meta-analysis to assess the extent to which opioid analgesia impact postoperative pain intensity and adverse events in comparison to opioid-free analgesia in patients discharged after surgery. METHODS AND ANALYSIS Major electronic databases (MEDLINE, Embase, Cochrane Library, Scopus, AMED, BIOSIS, CINAHL and PsycINFO) will be searched for multi-dose randomised-trials examining the comparative effectiveness of opioid versus opioid-free analgesia after surgical discharge. Studies published from January 1990 to July 2019 will be targeted, with no language restrictions. The search will be re-run before manuscript submission to include most recent literature. We will consider studies involving patients undergoing minor and major surgery. Teams of reviewers will, independently and in duplicate, assess eligibility, extract data and evaluate risk of bias. Our main outcomes of interest are pain intensity and postoperative vomiting. Study results will be pooled using random effects models. When trials report outcomes for a common domain (eg, pain intensity) using different scales, we will convert effect sizes to a common standard metric (eg, Visual Analogue Scale). Minimally important clinical differences reported in previous literature will be considered when interpreting results. Subgroup analyses defined a priori will be conducted to explore heterogeneity. Risk of bias will be assessed according to the Cochrane Collaboration's Risk of Bias Tool 2.0. The quality of evidence for all outcomes will be evaluated using the GRADE rating system. ETHICS AND DISSEMINATION Ethical approval is not required since this is a systematic review of published studies. Our results will be published in a peer-reviewed journal and presented at relevant conferences. Further knowledge dissemination will be sought via public and patient organisations focussed on pain and opioid-related harms.
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Affiliation(s)
- Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Ghadeer Olleik
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Marc-Aurele Chay
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Araz Kouyoumdjian
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Fateme Rajabiyazdi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Alexa Derksen
- Child Health and Human Development Program, McGill University, Montreal, Quebec, Canada
- Clinical Research Institute of Montreal, Montreal, Quebec, Canada
| | - Tara Landry
- Bibliothèque de la Santé, Universite de Montreal, Montreal, Quebec, Canada
| | | | | | | | - Gabriele Baldini
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Liane Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Surgery, McGill University, Montreal, Quebec, Canada
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47
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Jang Y, Kim M, Hwang SW. Molecular mechanisms underlying the actions of arachidonic acid-derived prostaglandins on peripheral nociception. J Neuroinflammation 2020; 17:30. [PMID: 31969159 PMCID: PMC6975075 DOI: 10.1186/s12974-020-1703-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/06/2020] [Indexed: 12/30/2022] Open
Abstract
Arachidonic acid-derived prostaglandins not only contribute to the development of inflammation as intercellular pro-inflammatory mediators, but also promote the excitability of the peripheral somatosensory system, contributing to pain exacerbation. Peripheral tissues undergo many forms of diseases that are frequently accompanied by inflammation. The somatosensory nerves innervating the inflamed areas experience heightened excitability and generate and transmit pain signals. Extensive studies have been carried out to elucidate how prostaglandins play their roles for such signaling at the cellular and molecular levels. Here, we briefly summarize the roles of arachidonic acid-derived prostaglandins, focusing on four prostaglandins and one thromboxane, particularly in terms of their actions on afferent nociceptors. We discuss the biosynthesis of the prostaglandins, their specific action sites, the pathological alteration of the expression levels of related proteins, the neuronal outcomes of receptor stimulation, their correlation with behavioral nociception, and the pharmacological efficacy of their regulators. This overview will help to a better understanding of the pathological roles that prostaglandins play in the somatosensory system and to a finding of critical molecular contributors to normalizing pain.
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Affiliation(s)
- Yongwoo Jang
- Department of Psychiatry and Program in Neuroscience, McLean Hospital, Harvard Medical School, Belmont, MA, 02478, USA.,Department of Biomedical Engineering, Hanyang University, Seoul, 04763, South Korea
| | - Minseok Kim
- Department of Biomedical Sciences, Korea University, Seoul, 02841, South Korea
| | - Sun Wook Hwang
- Department of Biomedical Sciences, Korea University, Seoul, 02841, South Korea. .,Department of Physiology, College of Medicine, Korea University, Seoul, 02841, South Korea.
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48
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Nourwali I, Namnakani A, Almutairi M, Alaufi A, Aljohani Y, Kassim S. Loxoprofen Sodium Versus Diclofenac Potassium for Post-Dental Extraction Pain Relief: A Randomized, Triple-Blind, Clinical Trial. Dent J (Basel) 2019; 8:dj8010002. [PMID: 31881670 PMCID: PMC7148446 DOI: 10.3390/dj8010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 11/16/2022] Open
Abstract
One of the most common post-operative complications of tooth extraction is pain. Oral analgesics, namely loxoprofen sodium and diclofenac potassium, are often prescribed; however, the efficacy of these drugs irrespective of gender and type of extraction has not been tested. Therefore, this study aimed to compare the efficacy of these two drugs in post-dental extraction pain relief among male and female patients in cases of simple and surgical tooth extraction. A single-center, triple-blind, randomized clinical trial was conducted among 100 male and female patients who underwent tooth extraction at Taibah University Dental College and Hospital in Al-Madinah, Saudi Arabia. The patients reported their pain post-operatively after 6 hours and every 12 h for 3 days using the Verbal Descriptor Scale (e.g., "no pain", "mild pain"). Descriptive statistics and chi-square tests were run to analyze the data. An equal number of patients received either the drug loxoprofen sodium or diclofenac potassium and completed the study follow-up. Patients allocated to the diclofenac potassium drug group after 36 h were statistically significantly in their reporting of "no pain" and "mild pain" compared to patients allocated to the loxoprofen sodium group (86% vs. 66%, respectively; p = 0.019), irrespective of gender or type of tooth extraction. However, both groups demonstrated comparable (p > 0.05) post-operative pain relief over the other aforementioned allocated time intervals. In conclusion, the diclofenac potassium group had slightly better control over post-operative pain than the group receiving loxoprofen sodium.
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Affiliation(s)
- Ibrahim Nourwali
- Department of Oral and Maxillofacial Surgery, Taibah University Dental College & Hospital, Naif Ibn Abdulaziz Road, Al-Madinah Al-Munawwarah 42353, Saudi Arabia
- Correspondence: ; Tel.: +966-505-539-489
| | - Arwa Namnakani
- Interns, Taibah University Dental College & Hospital, Naif Ibn Abdulaziz Road, Al-Madinah Al-Munawwarah 42353, Saudi Arabia; (A.N.); (M.A.); (A.A.); (Y.A.)
| | - Majd Almutairi
- Interns, Taibah University Dental College & Hospital, Naif Ibn Abdulaziz Road, Al-Madinah Al-Munawwarah 42353, Saudi Arabia; (A.N.); (M.A.); (A.A.); (Y.A.)
| | - Anas Alaufi
- Interns, Taibah University Dental College & Hospital, Naif Ibn Abdulaziz Road, Al-Madinah Al-Munawwarah 42353, Saudi Arabia; (A.N.); (M.A.); (A.A.); (Y.A.)
| | - Yasser Aljohani
- Interns, Taibah University Dental College & Hospital, Naif Ibn Abdulaziz Road, Al-Madinah Al-Munawwarah 42353, Saudi Arabia; (A.N.); (M.A.); (A.A.); (Y.A.)
| | - Saba Kassim
- Department of Preventive Dental Sciences, Taibah University Dental College & Hospital, Prince, Naif Ibn Abdulaziz Road, Al-Madinah Al-Munawwarah 42353, Saudi Arabia; or
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49
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Abstract
After intensive care unit (ICU) treatment, the recollection of experienced pain is one of the most burdensome aftermaths. In addition, pain has several negative physiological consequences. The majority of patients report moderate to severe pain while being treated on an ICU, often caused by diagnostic or therapeutic procedures. Pain and its functional consequences during ICU treatment should therefore be systematically recorded and treated. Due to their high analgesic potency, pharmacological pain therapy focuses on opioids; however, gastrointestinal motility disturbance and development of tolerance are disadvantages. When applying non-opioids, such as non-steroidal anti-inflammatory drugs (NSAID) and paracetamol, attention should be paid to their possible organ toxicity. Ketamine and α2-antagonists can complement the analgesic concept. Analogous to its perioperative administration, intravenous lidocaine in intensive care seems acceptable because of a favorable impact on opioid requirements and gastrointestinal motility. When using regional anesthesia the positive therapeutic effect and the possible complications need to be carefully weighed. Non-pharmaceutical procedures, especially transcutaneous electrical nerve stimulation (TENS), have proven successful in postoperative pain management. Even if only limited data from intensive care are available, a therapeutic attempt seems justifiable because of the low risk of complications.
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Affiliation(s)
- Katharina Rose
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - Winfried Meißner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland.
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50
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Zhou S, Zou H, Chen G, Huang G. Synthesis and Biological Activities of Chemical Drugs for the Treatment of Rheumatoid Arthritis. Top Curr Chem (Cham) 2019; 377:28. [DOI: 10.1007/s41061-019-0252-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/10/2019] [Indexed: 12/12/2022]
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