Comparative study of efficacy and safety of tapentadol versus etoricoxib in mild to moderate grades of chronic osteorthritis of knee

Similar Effects of Exercise Therapy, Nonsteroidal Anti-inflammatory Drugs, and Opioids for Knee Osteoarthritis Pain: A Systematic Review with Network Meta-analysis

OBJECTIVE

To compare the effectiveness of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and exercise therapy for knee osteoarthritis pain.

DESIGN

Systematic review with network meta-analysis.

LITERATURE SEARCH

We searched the databases MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from inception to April 15, 2021. Web of Science was used for citation tracking.

STUDY SELECTION CRITERIA

Randomized controlled trials comparing exercise therapy, NSAIDs, and opioids in any combination for knee osteoarthritis pain.

DATA SYNTHESIS

Network meta-analysis comparing exercise therapy, NSAIDs, opioids, and placebo/control for knee osteoarthritis pain. Additional trials from previous reviews were included to create the external placebo/control anchor.

RESULTS

We included 13 trials (1398 patients) with direct comparisons, supplemented with data from 101 additional trials. The treatment effect of NSAIDs for knee osteoarthritis pain was similar to that of opioids (standardized mean difference [SMD], 0.02; 95% confidence interval [CI], -0.14 to 0.18; Grading of Recommendations, Assessment, Development and Evaluations [GRADE]: low certainty). Exercise therapy had a larger effect than NSAIDs (SMD, 0.54; 95% CI, 0.19 to 0.89; GRADE: very low certainty). No estimate could be made for exercise vs opioids due to the lack of studies. Exercise therapy ranked as the "best" intervention in the network meta-analysis, followed by NSAIDs, opioids, and placebo/control intervention (GRADE: low certainty).

CONCLUSION

Exercise therapy ranked as the best treatment for knee osteoarthritis pain, followed by NSAIDs and opioids. The difference between treatments was small and likely not clinically relevant, and the overall confidence in the ranking was low. The results highlight the limited evidence for comparative effectiveness between exercise therapy, NSAIDs, and opioids for knee osteoarthritis pain. J Orthop Sports Phys Ther 2022;52(4):207-216. doi:10.2519/jospt.2022.10490.

Synopsis of the 2020 US Department of Veterans Affairs/US Department of Defense Clinical Practice Guideline: The Non-Surgical Management of Hip and Knee Osteoarthritis

In July 2020, the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) approved a new joint clinical practice guideline for the non-surgical management of hip and knee osteoarthritis. This synopsis highlights some of the recommendations. In February 2019, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched (ie, Cochrane Database of Systematic Reviews, EMBASE, MEDLINE PreMEDLINE, PubMed, and the Agency for Healthcare Research and Quality website) and evaluated the literature, created a simple 1-page algorithm, and advanced 19 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. This synopsis summarizes key recommendations in all 6 topics covered in the guideline. These topics are diagnosis, self-management, physical therapy, pharmacotherapy, orthobiologics, and complementary and integrative health.

Modulation of sensitization processes in the management of pain and the importance of descending pathways: a role for tapentadol?

Objective: This paper presents and discusses recent evidence on the pathophysiological mechanisms of pain. The role of tapentadol - an opioid characterized by an innovative mechanism of action (i.e. µ-opioid receptor [MOR] agonism and inhibition of noradrenaline [NA] reuptake [NRI]) - in the modulation of pain, and the most recent pharmacological evidence on this molecule (e.g. the µ-load concept) are also presented and commented upon.Methods: Narrative review.Results: Solid evidence has highlighted the importance of central sensitization in the transition from acute to chronic pain. In particular, the noradrenergic system holds a major role in limiting central sensitization and the progression to chronic pain. Therefore, pharmacological modulation of the noradrenergic system appears to be a well-grounded strategy for the control of chronic pain. Tapentadol is characterized by a to-date-unique mechanism of action, since it acts both as a MOR agonist and as an inhibitor of NA reuptake. The synergistic interaction of these two mechanisms allows a strong analgesic effect by acting on both ascending and descending pathways. Of note, the reduced µ-load of tapentadol limits the risk of opioid-related adverse events, such as gastrointestinal disturbances. Moreover, the NA component becomes predominant, at least, in some types of pain, with consequent specific clinical efficacy in the treatment of neuropathic and chronic pain.Conclusions: According to these characteristics, tapentadol appears suitable in the treatment of severe uncontrolled chronic pain characterized by both a nociceptive and a neuropathic component, such as osteoarthritis or back pain.

Modulation of sensitization processes in the management of pain and the importance of descending pathways: a role for tapentadol?

Objective: This paper presents and discusses recent evidence on the pathophysiological mechanisms of pain. The role of tapentadol - an analgesic molecule characterized by an innovative mechanism of action (i.e. µ-opioid receptor [MOR] agonism and inhibition of noradrenaline [NA] reuptake [NRI]) - in the modulation of pain, and the most recent pharmacological evidence on this molecule (e.g. the µ-load concept) are also presented and commented upon.Methods: Narrative review.Results: Solid evidence has highlighted the importance of central sensitization in the transition from acute to chronic pain. In particular, the noradrenergic system holds a major role in limiting central sensitization and the progression to chronic pain. Therefore, pharmacological modulation of the noradrenergic system appears to be a well-grounded strategy for the control of chronic pain. Tapentadol is characterized by a to-date-unique mechanism of action since it acts both as a MOR agonist and as an inhibitor of NA reuptake. The synergistic interaction of these two mechanisms allows a strong analgesic effect by acting on both ascending and descending pathways. Of note, the reduced µ-load of tapentadol has two important consequences: first, it limits the risk of opioid-related adverse events, as well as the risk of dependence; second, the NA component becomes predominant at least in some types of pain with consequent specific clinical efficacy in the treatment of neuropathic and chronic pain.Conclusions: According to these characteristics, tapentadol appears suitable in the treatment of chronic pain conditions characterized by both a nociceptive and a neuropathic component, such as osteoarthritis or back pain.

Toxicity of tapentadol: a systematic review

BACKGROUND

Tapentadol is a novel atypical opioid. Anecdotal evidence suggests that tapentadol has a lower toxicity than conventional opioids.

OBJECTIVES

To evaluate all single-drug mortality due to tapentadol and assess serious adverse events caused by tapentadol.

METHODS

The Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) reporting guidelines, an evidence-based minimum set of items for reporting in systematic reviews, were followed in this systematic review.

RESULTS

 24 peer-reviewed papers were identified. They indicate that tapentadol toxicity can cause mortality and serious adverse effects.

CONCLUSION(S)

At least four confirmed fatalities, and serious adverse effects have been documented for individuals abusing or using tapentadol as prescribed. Serious adverse effects of tapentadol use may include respiratory depression, confusion, coma, hallucination/delusion, seizures, tachycardia, hypertension, agitation, tremor, miosis, hypotension, dyspnea, electrolyte abnormality, atrial fibrillation or severe upper abdominal pain. Tapentadol is unlikely to cause serotonin syndrome. The toxicity of tapentadol is significantly less than pure mu opioids, such as oxycodone.