[Undesired side effects of tapentadol in comparison to oxycodone. A meta-analysis of randomized controlled comparative studies]

Recent advances in the pharmacotherapy of osteoarthritis

Introduction: Osteoarthritis (OA) is a common debilitating disease affecting the geriatric population. Management of osteoarthritis is a challenge for orthopedicians because till date there has been no such drug that can completely cure the disease or at least retard/arrest the disease progression. In addition to the currently available treatment options for OA like NSAIDs, opioids, nutraceuticals (glucosamine sulphate and chondroitin sulphate), many new drugs are being discovered or repurposed for use in osteoarthritis. Most of these recent drugs aim at retarding the disease progression rather than providing just a symptomatic relief.

Materials and methods: All relevant articles regarding approved new drugs and pipeline drugs for osteoarthritis published between 2012–2021 were analysed. Those included animal studies as well as clinical trials. Some older articles were also referred to, provided they highlighted any significant data. The obtained data were analysed and compiled.

Results and discussion: Broadly the recent drugs for OA can be classified based upon their site of action as (i) drugs targeting articular cartilage, (ii) drugs targeting inflammation, (iii) drugs targeting the subchondral bone, and (iv) drugs for relieving pain. Ranging from in vitro studies to clinical trials, these drugs are in various phases of drug discovery. Early diagnosis of OA and its management with a drug that retards disease progression rather than prescribing just a symptom reliever is very much necessary in the current situation.

Conclusion: Need for new drugs for OA is increasing day by day. More number of clinical trials with larger sample sizes alone can satisfy the need of disease modifying drugs for OA. This review provides a deep insight into all the recent advances in the pharmacotherapy of osteoarthritis.

Graphical abstract:

Investigational drugs for the treatment of osteoarthritis, an update on recent developments

INTRODUCTION

Osteoarthritis (OA) is the leading cause of pain, loss of function, and disability among elderly, with the knee the most affected joint. It is a heterogeneous condition characterized by complex and multifactorial etiologies which contribute to the broad variation in symptoms presentation and treatment responses that OA patients present. This poses a challenge for the development of effective treatment on OA.

AREAS COVERED

This review will discuss recent development of agents for the treatment of OA, updating our previous narrative review published in 2015. They include drugs for controlling local and systemic inflammation, regulating articular cartilage, targeting subchondral bone, and relieving pain.

EXPERT OPINION

Although new OA drugs such as monoclonal antibodies have shown marked effects and favorable tolerance, current treatment options for OA remain limited. The authors believe there is no miracle drug that can be used for all OA patients'; treatment and disease stage is crucial for the effectiveness of drugs. Therefore, early diagnosis, phenotyping OA patients and precise therapy would expedite the development of investigational drugs targeting at symptoms and disease progression of OA.

Tapentadol Extended Release in the Treatment of Severe Chronic Low Back Pain and Osteoarthritis Pain

Tapentadol is a novel pain reliever with apparently synergistic dual mechanisms of action, capable of addressing both nociceptive and neuropathic components of chronic pain. As an effective analgesic with good tolerability, tapentadol may be appropriate for patients suffering from severe chronic pain associated with low back pain (LBP) or osteoarthritis (OA). Efficacy studies of tapentadol in populations of patients with severe chronic LBP or OA pain suggest that tapentadol is non-inferior to oxycodone. Its tolerability, especially with respect to gastrointestinal (GI) side effects, may be better than that of other strong opioids in clinical trials and analyses of multiple trials. Patient satisfaction with tapentadol extended release for chronic noncancer pain syndromes is good. Although tapentadol has an opioid component with abuse liability, it appears to be a difficult opioid for tampering with less appeal to abusers than other opioids. For patients with severe LBP and OA pain, tapentadol appears to hold promise as a safe, effective therapeutic option.

Combatting pain after orthopedic/trauma surgery- perioperative oral extended-release tapentadol vs. extended-release oxycodone/naloxone

BACKGROUND

High post-operative pain scores after "minor" orthopedic/trauma surgery are in part attributed to inadequate prescription of opioid analgesics. Novel concepts aiming to achieve sufficient analgesia while minimizing opioid-related side effects by avoiding fluctuating plasma levels are based on perioperative oral administration of extended-release opioids beginning with the first dose pre-operatively. This is the first study to evaluate analgesic efficacy and side effect rates of extended-release tapentadol compared to oxycodone/naloxone following orthopedic/trauma surgery.

METHODS

This randomized, observer-blinded, active-controlled prospective clinical trial had 2 co-primary endpoints: (1) Analgesic efficacy: Mean pain level on a numeric rating scale (NRS) from 0 to 10 during exercise over 5 days. (2) Safety: Side effect sum score of the following events: Nausea, vomiting, constipation, sedation, vertigo, somnolence. The study was powered to detect superiority of tapentadol for at least one endpoint pending statistical proof of non-inferiority for both endpoints in a first step.

RESULTS

Two hundred sixty-six trauma patients were randomized to receive either tapentadol (n = 133) or oxycodone/naloxone (n = 133). Analgesic efficacy: Mean (±SD) daily pain levels in the first five post-operative days were 2.8 ± 1.3 in both groups. Mean maximum pain intensity during exercise in the first 24 h after surgery was 3.8 ± 1.9 (tapentadol) and 3.8 ± 2.1 (oxycodone/naloxone). Statistically tapentadol was non-inferior but not superior to oxycodone/naloxone.

SAFETY

Vomiting on day 1 occurred in 11%, constipation in 35% of the tapentadol patients and in 16% and 30% of the oxycodone/naloxone patients (p = 0.60 and 0.33), respectively. The incidence of sedation/ vertigo was <10%, that of somnolence <2% in both groups (p > 0.3, respectively). The sum score of side effect events was 51% in the tapentadol vs. 49% in the oxycodone/naloxone group; risk difference 3% [95% CI, -8 to 14%]; p = 0.6). Non-inferiority of tapentadol could not be concluded as the pre-defined non-inferiority margin was exceeded.

CONCLUSIONS

With both concepts, mean maximum pain intensity during exercise within the first 24 h after orthopedic/trauma surgery was reduced to a score of <4. This analgesic efficacy came at the cost of mainly gastro-intestinal side effects. Thus, we now use a prophylaxis against nausea and vomiting and pre-emptive laxatives as part of these concepts.

TRIAL REGISTRATION

https://eudract.ema.europa.eu (EudraCT- Nr. 2011-003238-15 ); October 24th, 2012.

[Incidence of constipation in patients with outpatient opioid therapy]

BACKGROUND

Constipation is a common complication in patients with opioid therapy. Additionally, patient-related risk factors also contribute to the development of constipation and these factors have to be integrated into an individualized treatment plan.

OBJECTIVE

The aim of this study was to assess the incidence of constipation in patients with opioid therapy in an outpatient setting and to analyze the risk factors that contribute to the development of constipation.

MATERIAL AND METHODS

This retrospective cohort study was conducted in two university affiliated outpatient departments at the Charité hospital in Berlin. The trial included all consecutively treated patients with opioid therapy of at least 4 weeks duration. The study was conducted from January 2013 to August 2013. Constipation was defined according to the Rome III criteria.

RESULTS

Out of 1166 screened patients, altogether 171 patients were included with a median duration of opioid therapy of 5 years. The most common diagnoses were back pain, musculoskeletal pain and neuropathic pain. In 14% of the treated patients symptoms of constipation were detected and another 35% needed laxatives for symptom control resulting in an overall incidence of constipation of 49%. The remaining 51% of the patients did not use any laxatives and did not experience symptoms of constipation. Age and dosing of opioid therapy significantly increased the risk of consipation but duration of opioid therapy was not related to the incidence of constipation.

DISCUSSION

The incidence of constipation in this population remains high although a relevant number of patients were intermittently free of symptoms without using laxatives. An individualized therapy plan and patient education seem to be important elements to control opioid-associated constipation.

[Opioids in chronic noncancer pain-are opioids different? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids of at least four week's duration]

BACKGROUND

We updated a systematic review on the comparative efficacy, tolerability and safety of opioids and of their routes of application in chronic noncancer pain (CNCP).

METHODS

We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CNCP. We included randomized head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) of at least 4 week's duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. The quality of evidence was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We included 13 RCTs with 6748 participants. Median study duration was 15 weeks (range 4-56 weeks). Hydromorphone, morphine, oxymorphone and tapentadol were compared to oxycodone; fentanyl to morphine and buprenorphine to tramadol. In pooled analysis, there were no significant differences between the two groups of opioids in terms of mean pain reduction (low-quality evidence), the patient global impression to be much or very much improved outcome (low-quality evidence), physical function (very low-quality evidence), serious adverse events (moderate-quality evidence) or mortality (moderate-quality evidence). There was no significant difference between transdermal and oral application of opioids in terms of mean pain reduction, physical function, serious adverse events, mortality (all low-quality evidence) or dropout due to adverse events (very low-quality).

CONCLUSION

Pooled head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) provide no rational for preferring one opioid and/or administration route over another in the therapy of patients with CNCP. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").

Tapentadol prolonged release for severe chronic cancer-related pain: effectiveness, tolerability, and influence on quality of life of the patients

Background

Clinical trials have shown the efficacy and good tolerability of tapentadol prolonged release (PR) for severe chronic pain of different etiologies. This study investigated the influence of tapentadol PR on pain control and quality of life of patients with severe chronic cancer-related pain in routine clinical practice in Germany.

Patients and methods

During a 3-month observation period, 45 physicians (mainly palliative care specialists) documented dosage and tolerability of tapentadol PR, previous and concomitant analgesic treatment, pain intensity, pain-related restrictions of daily activities and quality of life, and general state of health of 123 patients with chronic cancer-related pain in the context of a prospective noninterventional study.

Results

All patients (mean age 63.9±13.2 years, 93.5% in constant pain) had received analgesic long-term treatment (42.3% strong opioids) prior to the start of tapentadol PR treatment. During the observation period, tapentadol PR significantly reduced the average pain intensity by 2.4 points (from a mean 6.1±1.7 to 3.7±2.0, P<0.001); half of the patients (52%) achieved a pain score ≤3 at the end of observation. At the same time, mental and emotional well-being, pain-related impairments of daily activities, sleep quality, and quality of life improved, while the overall intake of analgesic concomitant medication could be reduced. Improvements in general state of health were significant (P<0.001). Overall, tapentadol PR was well tolerated.

Conclusion

Good pain control with tapentadol PR was accompanied by markedly reduced pain-related mental and physical burden and quality of life improved. Overall, the general state of health of these patients with chronic cancer-related pain improved significantly despite the underlying illness.

Management of severe chronic pain with tapentadol prolonged release - long-term data from pain specialists

BACKGROUND AND OBJECTIVE

Clinical trials have documented the efficacy and good tolerability of tapentadol prolonged released (PR) for severe chronic pain. This study investigated routine long-term administration by pain specialists.

METHODS

The effectiveness analysis included prospective data collected over a 3 month period (cohort I, n = 1457, mean age 61.2 ± 13 years) and over a 12 month period (cohort II, n = 588, 60.1 ± 13.2 years) regarding previous and concomitant analgesic treatment, tapentadol dosage, pain intensity, sleep and quality of life parameters, and tolerability.

RESULTS

Most patients (>77%) had suffered from severe chronic pain for ≥2 years with low back pain the main pain diagnosis (82%); 91% had already received analgesic long-term treatment prior to initiation of tapentadol therapy (42% of those received strong opioids). After 3 month tapentadol treatment, cohort I had experienced a mean pain reduction of 2.4 points (from 6.8 ± 1.6 at baseline) and improvements of 2.1 points in quality of sleep (from 5.8 ± 2.5) and quality of life (from 6.5 ± 2; all p ≤ 0.001). The 12 month tapentadol treatment (cohort II) reduced the mean pain intensity by 3.2 points from 6.7 ± 1.6 at baseline (NRS-11; p ≤ 0.001); 57% of the patients experienced clinically relevant pain relief of ≥50%. At end of observation, 92% attained either their intended pain reduction and/or an additional individual treatment target, both predefined at start of tapentadol therapy. This was accompanied by a significant reduction in pain-related impairments in daily activities and an improvement in quality of life (all p ≤ 0.001). Most frequent side-effects were nausea (6.3% of patients) and dizziness (3.8%) for cohort I, and nausea (1.5%) and constipation (1.2%) for cohort II.

CONCLUSION

Tapentadol PR is effective and well tolerated and can be considered an alternative to classical strong opioids in long-term chronic pain therapy.

LIMITATIONS

The study lacks a control group; assessment under routine practice conditions, however, reflects daily practice clinical management conditions.

Neuropathic cancer pain: What we are dealing with? How to manage it?

Cancer pain is a serious health problem, and imposes a great burden on the lives of patients and their families. Pain can be associated with delay in treatment, denial of treatment, or failure of treatment. If the pain is not treated properly it may impair the quality of life. Neuropathic cancer pain (NCP) is one of the most complex phenomena among cancer pain syndromes. NCP may result from direct damage to nerves due to acute diagnostic/therapeutic interventions. Chronic NCP is the result of treatment complications or malignancy itself. Although the reason for pain is different in NCP and noncancer neuropathic pain, the pathophysiologic mechanisms are similar. Data regarding neuropathic pain are primarily obtained from neuropathic pain studies. Evidence pertaining to NCP is limited. NCP due to chemotherapeutic toxicity is a major problem for physicians. In the past two decades, there have been efforts to standardize NCP treatment in order to provide better medical service. Opioids are the mainstay of cancer pain treatment; however, a new group of therapeutics called coanalgesic drugs has been introduced to pain treatment. These coanalgesics include gabapentinoids (gabapentin, pregabalin), antidepressants (tricyclic antidepressants, duloxetine, and venlafaxine), corticosteroids, bisphosphonates, N-methyl-D-aspartate antagonists, and cannabinoids. Pain can be encountered throughout every step of cancer treatment, and thus all practicing oncologists must be capable of assessing pain, know the possible underlying pathophysiology, and manage it appropriately. The purpose of this review is to discuss neuropathic pain and NCP in detail, the relevance of this topic, clinical features, possible pathology, and treatments of NCP.

[Prescription of high-potency opioids in 2011]

BACKGROUND

The aim of this study was to analyze the prescription of high-potency (WHO step III) opioids with respect to regional differences and to assess the proportion of opioid-naïve new users of transdermal fentanyl.

METHODS

Prescription claims data of the largest single German health fund (BARMER GEK) with 9.1 million insured persons from the year 2011 were used. For new users of transdermal fentanyl who had had no prescription in the preceding 6 months it was studied whether they had received other high-potency or low-potency opioids before.

RESULTS

A total of 18.9 million defined daily doses (DDD) of high-potency opioids were included corresponding to a mean of 208.6 DDD per 100 persons. Significant regional differences were found with lower values in the south, ranging from 145.9 DDD in Baden-Württemberg to 259.5 DDD per 100 persons in Lower Saxony. Fentanyl was the most frequently used step III opioid (40.8% of DDDs) which is nearly only given transdermally. Of the 11,184 patients with new use of transdermal fentanyl 80.7% had received no other high-potency opioid before and 52.9% had received neither low-potency nor high-potency opioids before. The first prescription exceeded the smallest available dose of 12.5 μg/h for over half of the patients starting treatment.

CONCLUSIONS

Although oral morphine, oxycodone and hydromorphone are recommended as first-line step III opioids, transdermal fentanyl seems to be prescribed too often as the first choice and might not be appropriate.

Tapentadol prolonged release for severe chronic pain: results of a noninterventional study involving general practitioners and internists

This noninterventional, prospective study investigated the administration of tapentadol prolonged release (PR; the dosage form described in this article is commercially available in Germany as Palexia retard; Grünenthal GmbH, Aachen) for severe chronic pain in routine clinical practice over a 3-month period. Effectiveness analyses included data from 3134 patients; 1331 received World Health Organization (WHO) Step III pretreatment. A total of 97.8% of patients received long-term analgesic pretreatment (42.5% with strong opioids). Switching to tapentadol PR produced a 3.9-point mean pain reduction (baseline, 7.0 ± 1.5; end of observation, 3.1 ± 1.8; 11-point numerical rating scale; descriptive P value ≤.001); 72.1% of patients experienced clinically relevant pain relief (≥50%) at the end of observation. Significant decreases in pain-related impairment of daily activities and improvements in quality of life (descriptive P value ≤.001) were observed with tapentadol PR with good tolerability. Tapentadol PR was effective for various pain indications in patients previously receiving strong opioids (67.2% achieved clinically relevant pain relief). Tapentadol PR can be considered an alternative therapy to classical opioids for treatment of severe chronic pain.

Mechanistic and functional differentiation of tapentadol and tramadol

INTRODUCTION

Many opioid analgesics share common structural elements; however, minor differences in structure can result in major differences in pharmacological activity, pharmacokinetic profile, and clinical efficacy and tolerability.

AREAS COVERED

This review compares and contrasts the chemistry, pharmacodynamics, pharmacokinetics, and CNS 'functional activity' of tapentadol and tramadol, responsible for their individual clinical utilities.

EXPERT OPINION

The distinct properties of tapentadol and tramadol generate different CNS functional activities, making each drug the prototype of different classes of opioid/nonopioid analgesics. Tramadol's analgesia derives from relatively weak µ-opioid receptor (MOR) agonism, plus norepinephrine and serotonin reuptake inhibition, provided collectively by the enantiomers of the parent drug and a metabolite that is a stronger MOR agonist, but has lower CNS penetration. Tapentadol's MOR agonist activity is several-fold greater than tramadol's, with prominent norepinephrine reuptake inhibition and minimal serotonin effect. Accordingly, tramadol is well-suited for pain conditions for which a strong opioid component is not needed-and it has the benefit of a low abuse potential; whereas tapentadol, a schedule-II controlled substance, is well-suited for pain conditions requiring a strong opioid component-and it has the benefit of greater gastrointestinal tolerability compared to classical strong opioids. Both drugs offer distinct and complementary clinical options.