Acceptability and efficacy of two associations of paracetamol with a central analgesic (dextropropoxyphene or codeine): comparison in osteoarthritis

Comparative risk-benefit profiles of weak opioids in the treatment of osteoarthritis: a network meta-analysis of randomized controlled trials

BACKGROUND

Despite their poor tolerance, weak opioids are still the most commonly-prescribed medicine for osteoarthritis (OA)-related pain. The objective of this network meta-analysis was to comparatively examine the efficacy and safety of weak opioids in OA treatment.

METHODS

Databases including PubMed, Embase, Cochrane Library and Web of Science were searched from inception to August 5, 2020 to retrieve randomized controlled trials (RCTs) comparing weak opioids with placebo or between one another in OA patients. Bayesian network meta-analysis was performed on the following outcomes of interest, namely the change-from-baseline score in pain relief, gastrointestinal (GI) adverse events (AEs), central nervous system (CNS) AEs, and total number of AEs (i.e., the number of subjects experiencing any AE for at least once) during follow-up.

RESULTS

A total of 14 RCTs involving four types of weak opioids were included in this meta-analysis. Compared to placebo, tramadol (standardized mean difference [SMD] = -0.34, 95% credible interval [CrI]: -0.53 to -0.18) and codeine (SMD = -0.39, 95% CrI: -0.79 to -0.04) were effective for pain relief, but involved a higher risk of GI AEs, CNS AEs and total number of AEs. Dextropropoxyphene demonstrated a significantly lower risk of GI AEs (OR = 0.28, 95%CrI: 0.17 to 0.51), CNS AEs (OR = 0.29, 95%CrI: 0.11 to 0.78) and total number of AEs (OR = 0.35, 95%CrI: 0.15 to 0.82) compared to codeine. Dihydrocodeine had a better safety profile in CNS AEs (SUCRA = 64.8%) and total number of AEs (SUCRA = 66.6%).

CONCLUSIONS

The results of the present study confirmed that tramadol and codeine were effective drugs for the treatment of OA, but involved considerable safety issues. Dextropropoxyphene and dihydrocodeine exhibited a relatively good safety profile but their efficacy still warrant further investigation.

Reporting rate of adverse drug reactions to the French pharmacovigilance system with three step 2 analgesic drugs: dextropropoxyphene, tramadol and codeine (in combination with paracetamol)

AIMS

Three 'weak' opioid analgesics in association with paracetamol are marketed in France as step 2 analgesics: dextropropoxyphene, tramadol and codeine. These combinations are involved in several adverse drug reactions (ADRs), but no data are available about their comparative reporting rate. The aim was to compare the reporting rate of ADRs between tramadol/paracetamol (TRM+P), codeine/paracetamol (COD+P) and dextropropoxyphene/paracetamol (DXP+P).

METHODS

All spontaneous reports submitted to the French Pharmacovigilance Database from 1 January 1987 to 31 December 2006 suspected to be induced by one of the three step 2 analgesic combinations (DXP+P, TRM+P, COD+P) were extracted. Their consumption for the same period was obtained from the French Drug Agency. The number of ADRs, serious ADRs and different organ classes of ADRs were compared according to their consumption. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each variable using DXP+P as reference.

RESULTS

The reporting rate of ADRs was calculated as 24.9/100 000 person-years for DXP+P, 44.5/100 000 person-years for TRM+P and 12.5/100 000 person-years for COD+P. The reporting rate (OR 0.56, 95% CI 0.50, 0.63) and 'seriousness>>' (OR 0.65, 95% CI 0.53, 0.80) of ADRs were significantly higher with TRM+P than with DXP+P. However, hepatobiliary ADRs were significantly more frequent with the DXP+P combination (OR 2.62, 95% CI 1.59, 4.37). In contrast, the reporting rate (OR 1.99, 95% CI 1.82, 2.18) and 'seriousness' (OR 2.64, 95% CI 2.24, 3.11) of ADRs were significantly higher with DXP+P than with COD+P.

CONCLUSIONS

Among the three step 2 analgesic combinations, reporting rate and 'seriousness' of ADRs are the highest with TRM+P and the lowest with COD+P. Our study suggests that the safety profile of DXP+P is worst than that of COD+P.

Oral treatment options for degenerative joint disease--presence and future

Alleviation of pain and inhibition of inflammation are the primary goals of pharmacotherapy of osteoarthritis (OA). These therapeutic goals can almost always be accomplished by the use of analgesics and nonsteroidal anti-inflammatory drugs (NSAID). One of the main problems of NSAIDs is their gastrointestinal toxicity, for which a prophylactic medication should be considered particularly amongst risk groups. Recent studies have shown that COX-2-selective and maybe also non-selective NSAIDs increase the cardiovascular risk so that their application is getting now drastically restricted. Pharmacological results published until now suggest that a clinically relevant minor analgesic and/or anti-inflammatory effect can be attained with the use of some of the SYmptomatic Slow Acting Drugs in OA (SYSADOAs). However, no clinical studies exist, which can positively confirm prevention, slowing down or reversal of any advanced joint cartilage destruction by any individual medication. Disease modifying therapy is still in its infancy; discovery and development of novel therapeutic targets and agents are an extremely difficult task, currently challenging many pharmaceutical companies and academic institutions.

Dextropropoxyphene: safety and efficacy in older patients

Dextropropoxyphene, alone or in combination with acetaminophen (paracetamol), is among the most frequently prescribed opioid analgesics in the elderly in the US despite the American Geriatric Society recommendation that its use should be restricted. However, this recommendation is based on expert opinion in an apparent absence of data. Accordingly, we conducted a literature search which identified nine studies that reported efficacy and safety data for dextropropoxyphene in predominantly older patients (> or = 55 years of age). These studies were evaluated to assess the efficacy and safety of dextropropoxyphene compared with other opioids and to evaluate whether safety and tolerability differed in older versus younger patients. The efficacy of dextropropoxyphene appeared to be similar to that of other analgesics, and its safety was comparable to that of other opioid analgesics. Although the adverse event profile suggests that elderly patients might have more frequent gastrointestinal and CNS complaints than younger patients treated with dextropropoxyphene, the frequency of reports appears similar to that of other opioids. The incidences of dizziness and somnolence were not significantly greater in older patients (1-2% and 0-21%, respectively) than in younger patients (8% and 13%, respectively). The absence of clinical studies directly addressing the safety and tolerability of dextropropoxyphene in elderly patients (>65 years of age) versus younger patients encumbers assessment of the validity of restricting its use in the elderly. Careful outcomes research is needed to assess the effectiveness and safety of dextropropoxyphene in older patients and to develop evidence-based risk/benefit prescribing criteria for use of this drug in this age group.

Does paracetamol (acetaminophen) reduce the pain of osteoarthritis? A meta-analysis of randomised controlled trials

OBJECTIVE

To assess the best available evidence for efficacy of paracetamol (acetaminophen) in the treatment of osteoarthritis (OA).

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

Medline, Embase, Scientific Citation Index, CINAHL, Cochrane Library, and conference abstracts in the past 2 years from the British Society for Rheumatology, the European League Against Rheumatism, the American College of Rheumatology, and the Osteoarthritis Research Society International.

SUBJECTS

10 RCTs including 1712 patients with either symptomatic OA of the knee (6 trials) or hip/knee (3 trials) or multiple joints (1 trial).

MAIN OUTCOME MEASURES

(a). effect size (ES) for pain, stiffness, and functional scores from baseline to end point; (b). rate ratio (RR) and number needed to treat for clinical response rate and patient preference for treatment.

RESULTS

Paracetamol was effective in relieving pain due to OA (ES = 0.21, 95% confidence interval (CI) 0.02 to 0.41). Non-steroidal anti-inflammatory drugs (NSAIDs) were better than paracetamol for pain relief (ES = 0.20, 95% CI 0.10 to 0.30). Clinical response rate was higher with NSAIDs than with paracetamol (RR = 1.24, 95% CI 1.08 to 1.41), and the number of patients who preferred NSAIDs was more than twice the number of those preferring paracetamol (RR = 2.46, 95% CI 1.51 to 4.12). NSAIDs were associated with more frequent gastrointestinal discomfort than paracetamol (RR = 1.35, 95% CI 1.05 to 1.75).

CONCLUSION

Paracetamol is an effective agent for pain relief due to OA. Although safer, it is less effective than NSAIDs. For safety reasons paracetamol should be the first line treatment, with NSAIDs reserved for those who do not respond.

Guidelines for management of osteoarthritis published by the American College of Rheumatology and the European League Against Rheumatism: why are they so different?

Because of different methodology the ACR and EULAR guidelines differ significantly in their recommendations despite an identical evidence base. Guidelines that use a strictly evidence-based approach are less likely to incur bias than those that rely more on expert consensus. Although expert consensus is useful in areas in which there are little trial data, clear delineation should be made between evidence-based statements and expert opinion. Following the dissemination of guidelines for the management of OA, emphasis should now be placed on discussion and implementation of the recommendations and subsequent revision of guidelines as new evidence comes to light.

A new role for opioids in the treatment of arthritis

Arthritis, rheumatic diseases, spinal and peripheral joint disorders share in common a legacy of chronic pain. At the turn of the millennium, nonsteroidal anti-inflammatories (NSAIDs) had replaced aspirin as the agents most commonly used to deal with rheumatic symptoms, including pain. Paracetamol (acetaminophen) was the most common alternative analgesic for minor pain. Opioids were most commonly used on an ad-lib basis, usually for 'breakthrough' pain. However, neurobiological research has confirmed the basis for 24-hour around-the-clock complete suppression of chronic nonmalignant pain. This avoids the 'wind up' that leads to intractable pain progression. Proper monitoring, in the absence of the end organ toxicity seen with NSAIDs, allows a change in direction to opioids for arthritis for more severe pain. This requires understanding the responsibilities of maintaining opioids, in properly selected patients, based upon host response and informed consent. Under such circumstances, evidence-based trials support the use of stronger opioids in recalcitrant chronic pain of arthritis. Thus, we endeavour to better fulfill our Oath of Hippocrates: 'to relieve pain and suffering'.

Treatment of chronic pain in osteoarthritis: do opioids have a clinical role?

Pain is the most prominent symptom and clinical finding in osteoarthritis (OA). Acetaminophen and nonsteroidal anti-inflammatory drug (NSAID) therapy are the mainstays of OA analgesia, but other drug and non-drug therapy, joint injections, and surgery may be needed to provide reasonable quality of life. Regularly scheduled, low-dose opioids can produce good relief of chronic nonmalignant pain including pain caused by OA. This paper reviews the potential risks and benefits of opioids, the evidence supporting their use in OA pain, and guidelines for their use in OA pain.

Risk-benefit assessment of opioids in chronic noncancer pain

Opioids have been accepted as appropriate treatment for acute and cancer pain, but their role in the management of chronic nonmalignant pain is the subject of much debate, mainly due to concerns about waning efficacy, the potential for neuropsychological impairment and the development of drug addiction. Controlled clinical trials demonstrated that opioids may be effective in both nociceptive and neuropathic noncancer pain, although the former responded more consistently than the latter. Gastrointestinal and CNS adverse effects were frequent in most studies. Observational studies have generated contradictory findings regarding efficacy and safety as well as the risk of drug addiction in patients with chronic noncancer pain receiving long term opioid therapy. However, they suggest that opioids may be effective in individual cases, whichever the pathophysiological mechanism of pain. Taken together, the available data indicate that the outcomes associated with opioid therapy vary markedly across patients experiencing chronic nonmalignant pain. The main consensus is that a subset of these patients may gain substantial benefit from opioid analgesics without requiring rapidly escalating doses or developing intolerable adverse effects or drug addiction. Prescribing guidelines have been developed to assist practitioners in selecting the appropriate patients and ensuring an acceptable risk : benefit ratio of opioid therapy. Finally, it must be emphasised that chronic pain is a complex entity wherein analgesics, including opioids, are only part of the treatment.

The use of analgesics in the management of pain in rheumatic diseases

Pain is the most common complaint of patients who see rheumatologists. In this article, the current treatment options for pain are reviewed; these include acetaminophen, nonsteroidal anti-inflammatory drugs, new specific cyclooxygenase-2 inhibitors, opioid analgesics, centrally acting muscle relaxants, antidepressants, and topical analgesics and counterirritants. The doses of medication and known adverse effects of these medications are highlighted.

Codeine and oxycodone use in patients with chronic rheumatic disease pain

OBJECTIVE

Opioid treatment of chronic rheumatic disease pain is controversial because of concerns regarding efficacy, toxicity, tolerance, dependence, and abuse. This study examined opioid use in a cohort of patients with pain due to defined rheumatic diseases.

METHODS

Opioid use was studied retrospectively in a cohort of 644 rheumatology clinic patients. Computerized pharmacy records identified patients who had been prescribed opioids during the previous 3 years. Medical records were reviewed to determine reasons for opioid dosage escalations. Patients were interviewed to determine efficacy, frequency and types of side effects, and history of alcohol or street-drug abuse.

RESULTS

Opioid prescriptions were found in the 3-year pharmacy database for 290 of 644 clinic patients: 153 for <3 consecutive months and 137 for > or =3 months. All opioid-treated patients received codeine and/or oxycodone. In this cohort, 133 patients in each opioid-treated group and 76 of the 354 non-opioid-treated control patients were studied. Opioids significantly reduced rheumatic disease pain severity scores from 8.2 to 3.6 (on a 0-10 scale) (P < 0.001). Mild side effects were reported in 38%; nausea, dyspepsia, constipation, and sedation were the most common. The mean +/-SD initial dosage was 2.1+/-1.7 30-mg codeine equivalents/day, the mean peak was 3.4+/-3.3 per day, and the mean current dose was 2.7+/-2.0 per day. Dosage escalations occurred in 32 patients and were attributable to worsening of the underlying painful condition or a medical complication thereof in all but 4 patients, who also displayed other abuse behaviors. Abuse behaviors were not more frequent in those with or without a history of abuse/ addiction.

CONCLUSION

Prolonged treatment of rheumatic disease pain with codeine or oxycodone was effective in reducing pain severity and was associated with only mild toxicity. Doses were stable for prolonged periods of time, with escalations of the opioid dose almost always related to worsening of the painful condition or a complication thereof, rather than the development of tolerance to opioids. Doubts or concerns about opioid efficacy, toxicity, tolerance, and abuse or addiction should no longer be used to justify withholding opioids from patients with well-defined rheumatic disease pain.