Ibuprofen liquigel for oral surgery pain

Pharmacological Management of Acute Endodontic Pain

Pain associated with infections of the tooth pulp and periapical tissues is intense and often the most common reason for patients seeking emergency dental care. Effective management of acute dental pain requires a deep understanding of pain mechanisms, which enables accurate diagnosis and definitive treatment. While drugs are only used as an adjunct to definitive dental treatment, a thorough understanding of their mechanism of action and effectiveness enables clinicians to effectively control intra-operative and post-operative pain and prevent persistent pain. This review describes how pain is detected, processed, and perceived. It also provides information on evidence-based strategies on the use of different classes of drugs to effectively manage endodontic pain.

A Meta-Analysis of the Analgesic Efficacy of Single-Doses of Ibuprofen Compared to Traditional Non-Opioid Analgesics Following Third Molar Surgery

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.

Evaluation of Fixed-Dose Combinations of Ibuprofen and Acetaminophen in the Treatment of Postsurgical Dental Pain: A Pilot, Dose-Ranging, Randomized Study

Introduction

Ibuprofen and acetaminophen provide analgesia via different mechanisms of action and do not exhibit drug–drug interactions; therefore, combining low doses of each may provide greater efficacy without compromising safety.

Objectives

The present study assessed the analgesic efficacy of fixed-dose combinations (FDCs) of ibuprofen/acetaminophen (IBU/APAP) compared with ibuprofen 400 mg and placebo.

Methods

This 12-h, double-blind, proof-of-concept study compared three FDCs of IBU/APAP (200 mg/500 mg, 250 mg/500 mg, and 300 mg/500 mg) with ibuprofen 400 mg and placebo in patients with moderate-to-severe pain following third molar extraction. The primary endpoint was the time-weighted sum of pain relief and pain intensity difference scores from 0 to 8 h after dosing (SPRID[4]_0–8). Time to meaningful pain relief (TMPR), duration of pain relief, and adverse events (AEs) were also assessed.

Results

In total, 394 patients were randomized. All active treatments were superior to placebo for SPRID[4]_0–8 (all p < 0.001) but not significantly different from ibuprofen 400 mg. Median TMPR with FDCs and ibuprofen (44.5–54.1 and 56.2 min, respectively) was faster than with placebo (> 720 min; all p < 0.001 vs. placebo). Duration of pain relief was similar with the FDCs and ibuprofen 400 mg (9.7 –11.1 h) and longer than with placebo (1.6 h; all p < 0.001). AE incidence was comparable with all treatments.

Conclusion

Each IBU/APAP FDC provided analgesic efficacy comparable to that with ibuprofen 400 mg and superior to that with placebo. Each FDC provided MPR in < 1 h, duration of pain relief > 9 h, and tolerability similar to that with ibuprofen and placebo.

ClinicalTrials.gov Registration

NCT01559259

Electronic supplementary material

The online version of this article (10.1007/s40268-020-00310-7) contains supplementary material, which is available to authorized users.

Nonsteroidal Anti-Inflammatory Drugs and Opioids in Postsurgical Dental Pain

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.

API ionic liquids: probing the effect of counterion structure on physical form and lipid solubility

Lipid based formulations (LBFs) are extensively utilised as an enabling technology in drug delivery. The use of ionic liquids (ILs) or lipophilic salts (LS) in drug delivery has also garnered considerable interest due to unique solubility properties. Conversion of active pharmaceutical ingredients (API) to ILs by pairing with an appropriately lipophilic counterion has been shown to decrease melting point of the salt complex and improve solubility in LBFs. However, the relationship between the structure of the counterion, the physicochemical properties of the resulting salts and solubility in LBFs has not been systematically explored. This study investigates the relationship between alkyl sulfate counterion structure and melting temperature (T m or T g) in addition to LBF solubility, utilizing cinnarizine and lumefantrine as model weakly basic APIs. Three series of structurally diverse alkyl sulfate counterions were chosen to probe this relationship. Pairing cinnarizine and lumefantrine with a majority of these alkyl sulfate counterions resulted in a reduction in melting temperature and enhanced solubility in model medium chain and long chain LBFs. The chain length of the alkyl sulfate plays a crucial role in performance, and consistently branched alkyl sulfate counterions perform better than straight chain alkyl sulfate counterions, as predicted. Most interestingly, trends in counterion performance were found to be consistent across two APIs with disparate chemical structures. The findings from this study will facilitate the design of counterions which enhance solubility of ionisable drugs and unlock the potential to develop compounds previously restrained by poor solubility.

A randomized, placebo- and active-controlled, multi-country, multi-center parallel group trial to evaluate the efficacy and safety of a fixed-dose combination of 400 mg ibuprofen and 100 mg caffeine compared with ibuprofen 400 mg and placebo in patients with acute lower back or neck pain

Background

Ibuprofen is a well-established analgesic for acute pain symptoms. In several acute pain models, caffeine has demonstrated an analgesic adjuvant effect. This randomized trial (NCT03003000) was designed to compare the efficacy of a fixed-dose combination of ibuprofen and caffeine with ibuprofen or placebo for the treatment of acute lower back/neck pain.

Methods

Patients with acute lower back/neck pain resulting in pain on movement (POM) ≥5 on a 10-point numerical rating scale were randomized 2:2:1 to receive orally, three times daily for 6 days, 400 mg ibuprofen+100 mg caffeine, 400 mg ibuprofen or placebo, respectively. The primary endpoint was change in POM_WP (POM triggering highest pain score at baseline [worst procedure]) between baseline and the morning of day 2. Key secondary endpoints included POM_WP area under curve (AUC) between baseline and the morning of day 4 (POM_WPAUC_72h) and day 6 (POM_WPAUC_120h).

Results

In total, 635 patients were randomized (256 ibuprofen + caffeine: 253 ibuprofen: 126 placebo). Active treatments exhibited similar reductions in POM_WP, with an adjusted mean reduction of 1.998 (standard error [SE]: 0.1042) between baseline and day 2 for ibuprofen, 1.869 (SE: 0.1030) for ibuprofen + caffeine and 1.712 (SE: 0.1422) for placebo. Similar results were observed for POM_WPAUC_72h and POM_WPAUC_120h. Safety and tolerability was as expected.

Conclusion

A decrease in lower back/neck pain, indicated by reduced POM_WP, was shown in all active treatment arms; however, treatment effects were small versus placebo. Ibuprofen plus caffeine was not superior to ibuprofen alone or placebo for the treatment of acute lower back/neck pain in this setting.

Variability in the Analgesic Response to Ibuprofen Is Associated With Cyclooxygenase Activation in Inflammatory Pain

The mechanisms underlying interindividual variability in analgesic efficacy of nonsteroidal anti‐inflammatory drugs (NSAIDs) are not well understood. Therefore, we performed pain phenotyping, functional neuroimaging, pharmacokinetic/pharmacodynamic assessments, inflammation biomarkers, and gene expression profiling in healthy subjects who underwent surgical extraction of bony impacted third molars and were treated with ibuprofen (400 mg; N = 19) or placebo (N = 10). Analgesic efficacy was not associated with demographic or clinical characteristics, ibuprofen pharmacokinetics, or the degree of cyclooxygenase inhibition by ibuprofen. Compared with partial responders to ibuprofen (N = 9, required rescue medication within the dosing interval), complete responders (N = 10, no rescue medication) exhibited greater induction of urinary prostaglandin metabolites and serum tumor necrosis factor‐α and interleukin 8. Differentially expressed genes in peripheral blood mononuclear cells were enriched for inflammation‐related pathways. These findings suggest that a less pronounced activation of the inflammatory prostanoid system is associated with insufficient pain relief on ibuprofen alone and the need for additional therapeutic intervention.

Unlocking the full potential of lipid-based formulations using lipophilic salt/ionic liquid forms

Lipid-based formulations (LBF) are widely used by industry and accepted by the regulatory authorities for oral drug delivery in the pharmaceutical and consumer healthcare market. Innovation in the LBF field is however needed in order to meet the demands of modern drugs, their more challenging problem statements and growing needs for achieving optimal pharmacokinetics (i.e., no food-effects, low variability) on approval. This review describes a new lipophilic salt / ionic liquid approach in combination with LBF, and how this salt strategy can be used to better tailor the properties of a drug to LBFs. The potential advantages of lipophilic salts are discussed in the context of dose escalation studies during toxicological evaluation, reducing the pill burden, increasing drug absorption of new drugs and in life-cycle management. Commentary on lipophilic salt synthesis, scale-up, LBF design and the regulatory aspects are also provided. These topics are discussed in the broad context of bringing the widely recognized advantages of LBFs to a broader spectrum of drugs.

A Proof-of-concept Study Using Quantitative Sensory Threshold Analysis to Compare Two Intraoral Topical Anesthetics

PURPOSE

CTY-5339A is an investigational topical anesthetic spray containing 14% benzocaine/2% tetracaine in a metered canister. Each spray delivers ∼0.2 mL of solution. This double-blind, randomized, crossover study compared the local anesthetic effect of CTY-5339A versus 14% benzocaine alone by using 2 quantitative sensory threshold experimental pain paradigms on the maxillary gingiva: pin prick test pain intensity (PPT PI) and heat pain threshold (HPT).

METHODS

American Society of Anesthesiology Class 1 and 2 subjects (N = 50) were enrolled in this study. To qualify for the study, subjects were tested on the anterior maxillary gingiva with both PPT and HPT. Subjects had to report a PPT PI of ≥3 on a 0 to 10 numeric pain intensity scale on 1 of 2 consecutive pin pricks separated by 10 s, with at least one score ≥4. After PPT, mean HPT following 2 ramps in the same location had to be ≤ 46.5 °C, with each ramp beginning at 35 °C and an automatic cutoff of 50.6 °C. For treatment visits, subjects were randomly administered either 1 spray of CTY-5339A or 14% benzocaine to the anterior maxillary gingiva within 3 weeks of screening and then the alternative treatment 5 days to 2 weeks later. PPT PI and HPT were recorded immediately before drug application. After drug administration, PPT PI was recorded every minute through 5 min. Commencing at 5 min, PPT PI and HPT were recorded every 5 min through 60 min. For assessment of methemoglobin concentrations, venous blood (5 mL) was drawn from the antecubital fossa both before and 60 min after drug application. Oxygen saturation was recorded via pulse oximetry at baseline and every 10 min.

FINDINGS

The AUCs for pain intensity difference from 0-30 and 0-60 min after PPT and HPT differences were significantly greater (P < 0.0001) for CTY-5339A compared with 14% benzocaine. Multiple time points on the time-action curves for PPT PI difference and HPT difference statistically (P < 0.05) favored CTY-5399A. Methemoglobin and oxygen saturation levels did not change compared with baseline after dosing with either treatment.

IMPLICATIONS

Recommended doses of CTY-5339A provided significantly more profound and sustained local anesthesia than 14% benzocaine when applied to the maxillary gingiva. Significant changes in methemoglobin or oxygen saturation concentrations did not occur for either drug. ClinicalTrials.gov identifier: NCT03233737.

Variability in analgesic response to non-steroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used agents for the treatment of acute and chronic pain. However, it has long been recognized that there is substantial inter-individual variability in the analgesic response to NSAIDs, reflecting the complex interplay between mechanisms of pain, differences between distinct NSAIDs, and patient-specific factors such as genetic variation. This review summarizes the current knowledge regarding how these factors contribute to variability in the analgesic response to NSAIDs.

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial

BACKGROUND

Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal.

METHODS

We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher's exact p=0.11).

CONCLUSION

Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.

Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth, a Cochrane systematic review

This paper compares the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth. In this systematic review only randomised controlled double-blinded clinical trials were included. We calculated the proportion of patients with at least 50% pain relief at 2 and 6 hours post dosing, along with the proportion of participants using rescue medication at 6 and 8 hours. Adverse events were also analysed. Data was meta-analysed where possible. Seven studies were included with a total of 2,241 participants enrolled. Ibuprofen 400 mg is superior to 1,000 mg paracetamol with a risk ratio for at least 50% pain relief at 6 hours of 1.47 (95% confidence interval [CI] 1.28 to 1.69). For the combined drug, the risk ratio for at least 50% maximum pain relief over 6 hours is 1.77 (95% CI 1.32 to 2.39) based on total pain relief (TOTPAR) data. There is high quality evidence that ibuprofen is superior to paracetamol. The novel combination drug shows encouraging results when compared to the single drugs (based on two trials).

Ibuprofen sodium is absorbed faster than standard Ibuprofen tablets: results of two open-label, randomized, crossover pharmacokinetic studies

Background

A novel ibuprofen (IBU) formulation, Advil^® Film-Coated Tablets (IBU_Na), was developed.

Objective

Pharmacokinetic comparison of IBU_Na versus other IBU formulations.

Study Design

Two randomized, single-dose, open-label, five-way crossover pharmacokinetic studies.

Setting

Inpatient research clinic.

Subjects

Seventy-one healthy adult volunteers.

Intervention

Study 1: In three periods, fasted subjects received 400-mg IBU dose equivalents as IBU_Na 2 × 256 mg, Advil^® Liqui-Gels^® (IBU_LG) 2 × 200 mg, and Motrin^® IB (IBU_Mot) 2 × 200 mg tablets. In two periods following a high-fat breakfast, subjects received 400-mg IBU dose equivalents as IBU_Na 2 × 256 mg and IBU_LG 2 × 200 mg. Study 2: In five study periods, fasted subjects received 400-mg IBU dose equivalents as IBU_Na 2 × 256 mg, Advil^® FastGel^® (IBU_FG) 2 × 200 mg, Nurofen^® (IBU_Nur) 2 × 200 mg, Advil^® (IBU_Adv) 2 × 200 mg, and Nurofen^® Express containing IBU lysinate (IBU_Lys) 2 × 342 mg.

Main Outcome Measure

Log-transformed area under the plasma concentration versus time curve to last observable concentration (AUC_L) and maximum plasma concentration (C_max) were the primary pharmacokinetic parameters; time to maximum measured plasma concentration (T_max) was analyzed post hoc.

Results

IBU_Na was bioequivalent to IBU_LG (fasted and fed) and IBU_FG and IBU_Lys (fasted) for rate (C_max) and extent (AUC_L) of IBU absorption. After fasting, AUC_L was bioequivalent for IBU_Na and IBU_Mot, IBU_Adv, and IBU_Nur, but C_max occurred significantly earlier with IBU_Na. After fasting, median IBU_NaT_max was comparable to that for IBU_LG, IBU_FG, and IBU_Lys, but was much shorter than that for IBU_Mot, IBU_Nur, and IBU_Adv. Food slowed absorption of IBU_Na and IBU_LG similarly. All treatments were tolerated similarly.

Conclusion

IBU_Na is absorbed faster but to a similar extent as standard IBU formulations.

Acute pain: a multifaceted challenge - the role of nimesulide

BACKGROUND

This article summarizes the outcome from an international consensus meeting, which took place in Vienna on 4 November 2014.

SCOPE

The aim of the meeting was to provide the state of the art on the pathophysiology and treatment of acute pain with special emphasis on nimesulide, a non-steroidal anti-inflammatory drug (NSAID) indicated for the treatment of acute pain and primary dysmenorrhea. Besides the data on the mechanisms of acute inflammatory pain and on the efficacy and safety of nimesulide in patients affected by different forms of acute pain, the clinical experience of attending experts was discussed based on selected case reports.

RESULTS

The members of this consensus group recognized that nimesulide is a NSAID highly effective in the treatment of several painful situations with an acute inflammatory component including primary dysmenorrhea. Although safety concerns regarding nimesulide have emerged in recent years, both robust new epidemiological data and clinical experience confirm a positive benefit/risk profile of nimesulide in the treatment of several forms of acute pain.

CONCLUSIONS

The members of this international consensus group concluded that nimesulide, when used appropriately, remains a particularly valuable and safe option for the treatment of several conditions characterized by the presence of acute inflammatory pain because of the rapid onset of the analgesic action, and the positive evidence-based benefit/risk profile.

Onset of analgesia and efficacy of ibuprofen sodium in postsurgical dental pain: a randomized, placebo-controlled study versus standard ibuprofen

Objectives:

A novel, immediate-release tablet formulation of ibuprofen (IBU) sodium dihydrate, Advil Film Coated Tablets (IBU_Na), has been developed that is absorbed faster than standard IBU tablets. The objective of the current study was to compare the efficacy and onset of analgesia of this new formulation with standard IBU tablets after a single dose.

Materials and Methods:

Patients (N=316) with at least moderate baseline postsurgical dental pain were randomized to 400 mg IBU_Na, Advil (IBU_Adv), Motrin (IBU_Mot), or placebo. Primary endpoints were time-weighted sum of pain relief (PR) and pain intensity differences over 8 hours (SPRID 0-8) and time to onset of meaningful pain relief (TMPR) measured by the double-stopwatch method.

Results:

SPRID 0-8 was significantly greater for IBU_Na and the other active treatments versus placebo (P<0.001). IBU_Na had a significantly earlier TMPR versus placebo, pooled IBU_Adv/IBU_Mot, and IBU_Mot (P<0.001 for all), and a marginally faster TMPR (P=0.075) versus IBU_Adv. Results for secondary endpoints were similar. Adverse events were comparable across treatment groups, with gastrointestinal disorders being most frequently reported. Most adverse events were mild or moderate.

Discussion:

This novel formulation of IBU_Na provided superior overall PR compared with placebo and more rapid onset of analgesic effect compared with standard IBU tablets. Rapid PR is important in the treatment of acute pain, including dental pain, and this IBU_Na formulation represents a new treatment option for rapid PR.

The Efficacy and Clinical Safety of Various Analgesic Combinations for Post-Operative Pain after Third Molar Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To run a systematic review and meta-analysis of randomized clinical trials aiming to answer the clinical question "which analgesic combination and dosage is potentially the most effective and safe for acute post-operative pain control after third molar surgery?".

MATERIALS AND METHODS

A systematic search of computer databases and journals was performed. The search and the evaluations of articles were performed by 2 independent reviewers in 3 rounds. Randomized clinical trials related to analgesic combinations for acute post-operative pain control after lower third molar surgery that matched the selection criteria were evaluated to enter in the final review.

RESULTS

Fourteen studies with 3521 subjects, with 10 groups (17 dosages) of analgesic combinations were included in the final review. The analgesic efficacy were presented by the objective pain measurements including sum of pain intensity at 6 hours (SPID6) and total pain relief at 6 hours (TOTPAR6). The SPID6 scores and TOTPAR6 scores of the reported analgesic combinations were ranged from 1.46 to 6.44 and 3.24 - 10.3, respectively. Ibuprofen 400mg with oxycodone HCL 5mg had superior efficacy (SPID6: 6.44, TOTPAR6: 9.31). Nausea was the most common adverse effect, with prevalence ranging from 0-55%. Ibuprofen 200mg with caffeine 100mg or 200mg had a reasonable analgesic effect with fewer side effects.

CONCLUSION

This systematic review and meta-analysis may help clinicians in their choices of prescribing an analgesic combination for acute post-operative pain control after lower third molar surgery. It was found in this systematic review Ibuprofen 400mg combined with oxycodone HCL 5mg has superior analgesic efficacy when compared to the other analgesic combinations included in this study.

Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice

BACKGROUND

Effective and safe drug therapy for the management of acute postoperative pain has relied on orally administered analgesics such as ibuprofen, naproxen and acetaminophen, or N-acetyl-p-aminophenol (APAP), as well as combination formulations containing opioids such as hydrocodone with APAP. The combination of ibuprofen and APAP has been advocated in the last few years as an alternative therapy for postoperative pain management. The authors conducted a critical analysis to evaluate the scientific evidence for using the ibuprofen-APAP combination and propose clinical treatment recommendations for its use in managing acute postoperative pain in dentistry.

TYPES OF STUDIES REVIEWED

The authors used quantitative evidence-based reviews published by the Cochrane Collaboration to determine the relative analgesic efficacy and safety of combining ibuprofen and APAP. They found additional articles by searching the Ovid MEDLINE, PubMed and ClinicalTrials.gov databases.

CONCLUSIONS

The results of the quantitative systematic reviews indicated that the ibuprofen-APAP combination may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations. In addition, the authors found several randomized controlled trials that also indicated that the ibuprofen-APAP combination provided greater pain relief than did ibuprofen or APAP alone after third-molar extractions. The adverse effects associated with the combination were similar to those of the individual component drugs. Practical Implications. Combining ibuprofen with APAP provides dentists with an additional therapeutic strategy for managing acute postoperative dental pain. This combination has been reported to provide greater analgesia without significantly increasing the adverse effects that often are associated with opioid-containing analgesic combinations. When making stepwise recommendations for the management of acute postoperative dental pain, dentists should consider including ibuprofen-APAP combination therapy.

An evaluation of 10 percent and 20 percent benzocaine gels in patients with acute toothaches: efficacy, tolerability and compliance with label dose administration directions

BACKGROUND

The authors evaluated the efficacy and tolerability of 10 percent and 20 percent benzocaine gels compared with those of a vehicle (placebo) gel for the temporary relief of toothache pain. They also assessed the compliance with the label dose administration directions on the part of participants with toothache pain.

METHODS

Under double-masked conditions, 576 participants self-applied study gel to an open tooth cavity and surrounding oral tissues. Participants evaluated their pain intensity and pain relief for 120 minutes. The authors determined the amount of gel the participants applied.

RESULTS

The responders' rates (the primary efficacy parameter), defined as the percentage of participants who had an improvement in pain intensity as exhibited by a pain score reduction of at least one unit on the dental pain scale from baseline for two consecutive assessments any time between the five- and 20-minute points, were 87.3 percent, 80.7 percent and 70.4 percent, respectively, for 20 percent benzocaine gel, 10 percent benzocaine gel and vehicle gel. Both benzocaine gels were significantly (P ≤ .05) better than vehicle gel; the 20 percent benzocaine gel also was significantly (P ≤ .05) better than the 10 percent benzocaine gel. The mean amount of gel applied was 235.6 milligrams, with 88.2 percent of participants applying 400 mg or less.

CONCLUSIONS

Both 10 percent and 20 percent benzocaine gels were more efficacious than the vehicle gel, and the 20 percent benzocaine gel was more efficacious than the 10 percent benzocaine gel. All treatments were well tolerated by participants. Practical Implications. Patients can use 10 percent and 20 percent benzocaine gels to temporarily treat toothache pain safely.

Content analysis of false and misleading claims in television advertising for prescription and nonprescription drugs

BACKGROUND

False and misleading advertising for drugs can harm consumers and the healthcare system, and previous research has demonstrated that physician-targeted drug advertisements may be misleading. However, there is a dearth of research comparing consumer-targeted drug advertising to evidence to evaluate whether misleading or false information is being presented in these ads.

OBJECTIVE

To compare claims in consumer-targeted television drug advertising to evidence, in order to evaluate the frequency of false or misleading television drug advertising targeted to consumers.

DESIGN

A content analysis of a cross-section of television advertisements for prescription and nonprescription drugs aired from 2008 through 2010. We analyzed commercial segments containing prescription and nonprescription drug advertisements randomly selected from the Vanderbilt Television News Archive, a census of national news broadcasts.

MAIN MEASURES

For each advertisement, the most-emphasized claim in each ad was identified based on claim iteration, mode of communication, duration and placement. This claim was then compared to evidence by trained coders, and categorized as being objectively true, potentially misleading, or false. Potentially misleading claims omitted important information, exaggerated information, made lifestyle associations, or expressed opinions. False claims were factually false or unsubstantiated.

KEY RESULTS

Of the most emphasized claims in prescription (n = 84) and nonprescription (n = 84) drug advertisements, 33 % were objectively true, 57 % were potentially misleading and 10 % were false. In prescription drug ads, there were more objectively true claims (43 %) and fewer false claims (2 %) than in nonprescription drug ads (23 % objectively true, 7 % false). There were similar numbers of potentially misleading claims in prescription (55 %) and nonprescription (61 %) drug ads.

CONCLUSIONS

Potentially misleading claims are prevalent throughout consumer-targeted prescription and nonprescription drug advertising on television. These results are in conflict with proponents who argue the social value of drug advertising is found in informing consumers about drugs.

Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth

BACKGROUND

Both paracetamol and ibuprofen are commonly used analgesics for the relief of pain following the surgical removal of lower wisdom teeth (third molars). In 2010, a novel analgesic (marketed as Nuromol) containing both paracetamol and ibuprofen in the same tablet was launched in the United Kingdom, this drug has shown promising results to date and we have chosen to also compare the combined drug with the single drugs using this model. In this review we investigated the optimal doses of both paracetamol and ibuprofen via comparison of both and via comparison with the novel combined drug. We have taken into account the side effect profile of the study drugs. This review will help oral surgeons to decide on which analgesic to prescribe following wisdom tooth removal.

OBJECTIVES

To compare the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth, at different doses and administered postoperatively.

SEARCH METHODS

We searched the Cochrane Oral Health Group'sTrials Register (to 20 May 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4); MEDLINE via OVID (1946 to 20 May 2013); EMBASE via OVID (1980 to 20 May 2013) and the metaRegister of Controlled Trials (to 20 May 2013). We checked the bibliographies of relevant clinical trials and review articles for further studies. We wrote to authors of the identified randomised controlled trials (RCTs), and searched personal references in an attempt to identify unpublished or ongoing RCTs. No language restriction was applied to the searches of the electronic databases.

SELECTION CRITERIA

Only randomised controlled double-blinded clinical trials were included. Cross-over studies were included provided there was a wash out period of at least 14 days. There had to be a direct comparison in the trial of two or more of the trial drugs at any dosage. All trials used the third molar pain model.

DATA COLLECTION AND ANALYSIS

All trials identified were scanned independently and in duplicate by two review authors, any disagreements were resolved by discussion, or if necessary a third review author was consulted. The proportion of patients with at least 50% pain relief (based on total pain relief (TOTPAR) and summed pain intensity difference (SPID) data) was calculated for all three drugs at both two and six hours postdosing and meta-analysed for comparison. The proportion of participants using rescue medication over both six and eight hours was also collated and compared. The number of patients experiencing adverse events or the total number of adverse events reported or both were analysed for comparison.

MAIN RESULTS

Seven studies were included, they were all parallel-group studies, two studies were assessed as at low risk of bias and three at high risk of bias; two were considered to have unclear bias in their methodology. A total of 2241 participants were enrolled in these trials.Ibuprofen was found to be a superior analgesic to paracetamol at several doses with high quality evidence suggesting that ibuprofen 400 mg is superior to 1000 mg paracetamol based on pain relief (estimated from TOTPAR data) and the use of rescue medication meta-analyses. The risk ratio for at least 50% pain relief (based on TOTPAR) at six hours was 1.47 (95% confidence interval (CI) 1.28 to 1.69; five trials) favouring 400 mg ibuprofen over 1000 mg paracetamol, and the risk ratio for not using rescue medication (also favouring ibuprofen) was 1.50 (95% CI 1.25 to 1.79; four trials).The combined drug showed promising results, with a risk ratio for at least 50% of the maximum pain relief over six hours of 1.77 (95% CI 1.32 to 2.39) (paracetamol 1000 mg and ibuprofen 400 mg) (one trial; moderate quality evidence), and risk ratio not using rescue medication 1.60 (95% CI 1.36 to 1.88) (two trials; moderate quality evidence).The information available regarding adverse events from the studies (including nausea, vomiting, headaches and dizziness) indicated that they were comparable between the treatment groups. However, we could not formally analyse the data as it was not possible to work out how many adverse events there were in total.

AUTHORS' CONCLUSIONS

There is high quality evidence that ibuprofen is superior to paracetamol at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively. The majority of this evidence (five out of six trials) compared ibuprofen 400 mg with paracetamol 1000 mg, these are the most frequently prescribed doses in clinical practice. The novel combination drug is showing encouraging results based on the outcomes from two trials when compared to the single drugs.

Perioperative use of etoricoxib reduces pain and opioid side-effects after total abdominal hysterectomy: a double-blind, randomized, placebo-controlled phase III study

OBJECTIVE

To evaluate the effects of two different doses of etoricoxib delivered perioperatively compared with placebo and standard pain management on pain at rest, pain with mobilization, and use of additional morphine/opioids postoperatively.

RESEARCH DESIGN AND METHODS

In this double-blind, placebo-controlled, randomized clinical trial, we evaluated postoperative pain following total abdominal hysterectomy over 5 days in patients receiving placebo or etoricoxib administered 90 min prior to surgery and continuing postoperatively. Patients were randomly assigned to receive either placebo (n = 144), etoricoxib 90 mg/day (n = 142), or etoricoxib 120 mg/day (n = 144). Average Pain Intensity at Rest over days 1-3 (0- to 10-point numerical rating scale [NRS]) was the primary efficacy endpoint. Secondary endpoints included Average Pain Intensity upon Sitting, Standing, and Walking over days 1-3 (0- to 10-point NRS) as well as Average Total Daily Dose of Morphine over days 1-3.

CLINICAL TRIAL REGISTRATION

This trial is registered on www.clinicaltrials.gov (NCT00788710).

RESULTS

The least squares (LS) means (95% CI) for the primary endpoint were 3.26 (2.96, 3.55); 2.46 (2.16, 2.76); and 2.40 (2.11, 2.69) for placebo, etoricoxib 90 mg, and etoricoxib 120 mg, respectively, significantly different for both etoricoxib doses versus placebo (p < 0.001). Patients on etoricoxib 90 mg and 120 mg required ~30% less morphine per day than those on placebo (p < 0.001), which led to more rapid bowel recovery in the active treatment groups by ~10 hours vs. placebo. A greater proportion of patients on etoricoxib (10-30% greater than placebo) achieved mild levels of pain with movement, defined as pain ≤3/10.

LIMITATIONS

A key limitation for this study was that movement-evoked pain measurements were not designated as primary endpoints.

CONCLUSION

In patients undergoing total abdominal hysterectomy, etoricoxib 90 mg and 120 mg dosed preoperatively and then continued postoperatively significantly reduces both resting and movement-related pain, as well as reduced opioid (morphine) consumption that led to more rapid bowel recovery.

Double-blind, placebo-controlled, randomized pilot study of cerebral blood flow patterns employing SPECT imaging in dental postsurgical pain patients with and without pain relief

BACKGROUND

Single-photon emission computed tomography (SPECT) has been employed in the study of altered regional cerebral blood flow (CBF) in experimental and chronic pain. CBF patterns have not been evaluated in patients with acute postoperative pain.

OBJECTIVE

The purpose of this pilot study was to employ SPECT to measure CBF distribution associated with postoperative dental pain and to compare these CBF patterns to subsequent images in the same patients who were experiencing pain relief versus continued or worsening pain who had received active or placebo analgesic interventions. The primary outcome measure was the percentage change in blood flow in various regions of interest.

METHODS

Twenty-two healthy individuals (10 males and 12 females, age range 20-29 years) who underwent the removal of ≥1 partial or full bony impacted mandibular third molars were evaluated for pain intensity as the local anesthesia dissipated, employing a 0 to10 numeric rating scale (0 = no pain; 10 = worst imaginable). When the subjects' pain level reached ≥4/10, they were injected intravenously with 260 MBq of technetium Tc 99m bicisate (ethyl cysteinate dimer). Under double-blind conditions and 10 minutes before being placed in the SPECT scanner, the first 10 subjects were randomized to receive intravenous ketorolac 15 mg or saline while the remaining 12 subjects were randomized to receive by mouth either ibuprofen 400 mg, ibuprofen 200 mg, acetaminophen 1000 mg, or placebo. One hour after drug administration, subjects were reevaluated for pain, injected with 925 MBq of technetium Tc 99m bicisate, given rescue medication if required, and then rescanned. CBF ratios were obtained for regions of interest and by normalizing to average whole brain activity.

RESULTS

Subjects generally had a moderate degree (mean [SD], 7.3% [4.0%]) of thalamic asymmetry on initial scans with pain; after treatment, subjects reporting worsening pain regardless of the intervention had higher thalamic asymmetry (8.1% vs 2.8%) than those reporting relief of pain. Subjects who reported reduced pain after the intervention had significantly different (P < 0.05) mean CBF changes compared with those reporting worsening pain in the left prefrontal cortex, left sensorimotor area, right anterior cingulate, and right caudate.

CONCLUSIONS

Acute postoperative dental pain was associated with moderate thalamic asymmetry that improved following successful pain management. Sustained or worsening pain was associated with increased CBF in brain regions associated with pain pathways, whereas pain relief was associated with decreased activity in the same areas.

Efficacy and Safety of Ibuprofen and Acetaminophen in Children and Adults: A Meta-Analysis and Qualitative Review

Objective:

To evaluate the analgesic and antipyretic efficacy and safety of ibuprofen compared to acetaminophen in children and adults.

Data Sources:

Literature searches were performed using PubMed/MEDLINE (through August 2009) and EMBASE (through January 2008) and were restricted to the English language. In PubMed/MEDLINE, search terms used were ibuprofen, acetaminophen, paracetamol, clinical trials, and randomized controlled trials. EMBASE search terms included ibuprofen and acetaminophen, restricted to human and clinical trials.

Study Selection And Data Extraction:

All English-language articles identified from the data sources were reviewed. Multiple review articles were studied for any pertinent references and this yielded additional articles. Only articles that directly compared ibuprofen and acetaminophen were eligible for this review.

Data Synthesis:

Eighty-five studies that directly compared ibuprofen to acetaminophen were identified; 54 contained analgesic efficacy data, 35 contained antipyretic/temperature reduction data, and 66 contained safety data (some articles contained more than 1 type of data). Qualitative review of the literature revealed that, for the most part, ibuprofen was more efficacious than acetaminophen for the treatment of pain and fever in both pediatric and adult populations, and that these 2 drugs were equally safe. Meta-analyses on the subset of randomized clinical trial articles that reported sufficient quantitative information to calculate either an odds ratio (adverse event [AE]) or standardized mean difference (pain and fever) confirmed the qualitative results for adult (standardized mean difference [SMD] 0.69; 95% CI 0.57 to 0.81) and pediatric (SMD 0.28; 95% CI 0.10 to 0.46) pain at 2 hours postdose and pediatric fever (SMD 0.26; 95% CI 0.10 to 0.41) at 4 hours postdose. Conclusions regarding adult fever/temperature reduction could not be made due to a lack of evaluable data. The combined odds ratio for the proportion of adult subjects experiencing at least 1 AE slightly favored ibuprofen; however, the difference was not statistically significant (1.12; 95% CI 1.00 to 1.25). No significant difference between drugs in AE incidence was found for pediatric patients (0.82; 95% CI 0.60 to 1.12).

Conclusions:

Ibuprofen is as or more efficacious than acetaminophen for the treatment of pain and fever in adult and pediatric populations and is equally safe.

The value of the dental impaction pain model in drug development

The modern version of the Dental Impaction Pain Model (DIPM) was developed in the mid-1970s. Since that time, several hundred studies have been conducted by numerous investigators. Today it is arguably the most utilized of all the acute pain models. Its popularity is due to the success rate of the studies, fast subject entry, and cost effectiveness. The surgical procedure is extremely standardized, and the surgery requires either minimal or no use of CNS depressant anesthetics. The methodology is similar to that utilized in other acute pain models; however, the DIPM is much more versatile than most other models. The model can be easily adapted to perform multiple-dose studies, pharmacokinetics/pharmacodynamics (PK/PD) correlations, preemptive interventions, and sleep-pain studies. A few investigators have even developed microdialysis techniques, wherein they insert probes into extraction sockets to collect exudates for measuring biochemical mediators of pain or drug levels at the site of injury. In many instances, an accomplished site can complete a study of several hundred subjects in approximately 3 months. There are studies in the literature that have incorporated up to six treatment arms in one study and clearly separated the drugs from each other. The exquisite assay sensitivity is due to the homogeneity of the study population, the predictable level and appropriate intensity of the postsurgical pain, and the minimizing of variability by using only one or two study centers. The DIPM has been employed to evaluate NSAIDs (both nonselective and selective Cox inhibitors), opioids and combination analgesics, as well as some investigational drugs with unique mechanisms of action. The model is particularly useful for proof-of-concept studies that require dose-ranging and profiling the time-effect curve for efficacy including onset, peak effect, and duration of analgesic activity.

Single dose oral ibuprofen for acute postoperative pain in adults

BACKGROUND

This review updates a 1999 Cochrane review showing that ibuprofen at various doses was effective in postoperative pain in single dose studies designed to demonstrate analgesic efficacy. New studies have since been published. Ibuprofen is one of the most widely used non-steroidal anti-inflammatory (NSAID) analgesics both by prescription and as an over-the-counter medicine. Ibuprofen is used for acute and chronic painful conditions.

OBJECTIVES

To assess analgesic efficacy of ibuprofen in single oral doses for moderate and severe postoperative pain in adults.

SEARCH STRATEGY

We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to May 2009.

SELECTION CRITERIA

Randomised, double blind, placebo-controlled trials of single dose orally administered ibuprofen (any formulation) in adults with moderate to severe acute postoperative pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number-needed-to-treat-to-benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals were collected.

MAIN RESULTS

Seventy-two studies compared ibuprofen and placebo (9186 participants). Studies were predominantly of high reporting quality, and the bulk of the information concerned ibuprofen 200 mg and 400 mg. For at least 50% pain relief compared with placebo the NNT for ibuprofen 200 mg (2690 participants) was 2.7 (2.5 to 3.0) and for ibuprofen 400 mg (6475 participants) it was 2.5 (2.4 to 2.6). The proportion with at least 50% pain relief was 46% with 200 mg and 54% with 400 mg. Remedication within 6 hours was less frequent with higher doses, with 48% remedicating with 200 mg and 42% with 400 mg. The median time to remedication was 4.7 hours with 200 mg and 5.4 hours with 400 mg. Sensitivity analysis indicated that pain model and ibuprofen formulation may both affect the result, with dental impaction models and soluble ibuprofen salts producing better efficacy estimates. Adverse events were uncommon, and not different from placebo.

AUTHORS' CONCLUSIONS

The very substantial amount of high quality evidence demonstrates that ibuprofen is an effective analgesic in treating postoperative pain. NNTs for 200 mg and 400 mg ibuprofen did not change significantly from the previous review even when a substantial amount of new information was added. New information is provided on remedication.

Rationale for faster oral delivery to overcome the pathophysiology associated with dental pain--biopharmaceutic and pharmacokinetic challenges

Recent published evidences on ibuprofen and meloxicam confirm the need of faster oral drug absorption to overcome the pathophysiological conditions associated with dental pain (due to excessive vagal nerve suppression) in order to provide relief in acute pain management. While the communication provides relevant case studies to support the hypothesis in both dental pain and migraine attacks, it also provides biopharmaceutical and pharmacokinetic challenges of developing such a strategy for faster oral drug absorption. It is envisaged that the unmet need in this area, to overcome the pathophsiological barriers, should provide impetus for further research exploration in formulation strategies and biopharmaceutical/pharmacokinetic integration.

Reversal of soft-tissue local anesthesia with phentolamine mesylate in adolescents and adults

BACKGROUND

The authors conducted two multicenter, randomized, double-blinded, controlled Phase III clinical trials to study the efficacy and safety of phentolamine mesylate (PM) in shortening the duration and burden of soft-tissue anesthesia. The study involved 484 subjects who received one of four commercially available local anesthetic solutions containing vasoconstrictors for restorative or scaling procedures.

METHODS

On completion of the dental procedure, subjects randomly received a PM or a sham injection (an injection in which a needle does not penetrate the soft tissue) in the same site as the local anesthetic injection. The investigators measured the duration of soft-tissue anesthesia by using standardized lip- and tongue-tapping procedures every five minutes for five hours. They also evaluated functional measures and subject-perceived altered function, sensation, appearance and safety.

RESULTS

Median recovery times in the lower lip and tongue for subjects in the PM group were 70 minutes and 60 minutes, respectively. Median recovery times in the lower lip and tongue for subjects in the sham group were 155 minutes and 125 minutes, respectively. Upper lip median recovery times were 50 minutes for subjects in the PM group and 133 minutes for subjects in the sham group. These differences were significant (P < .0001). Recovery from actual functional deficits and subject-perceived altered function, sensation and appearance also showed significant differences between the PM and the sham groups.

CONCLUSIONS

PM was efficacious and safe in reducing the duration of local anesthetic- induced soft-tissue numbness and its associated functional deficits.

CLINICAL IMPLICATIONS

Clinicians can use PM to accelerate reversal of soft-tissue anesthesia and the associated functional deficits.

Single dose oral paracetamol (acetaminophen) for postoperative pain in adults

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 1, 2004 - this original review had been split from a previous title on 'Single dose paracetamol (acetaminophen) with and without codeine for postoperative pain'. The last version of this review concluded that paracetamol is an effective analgesic for postoperative pain, but additional trials have since been published. This review sought to evaluate the efficacy and safety of paracetamol using current data, and to compare the findings with other analgesics evaluated in the same way.

OBJECTIVES

To assess the efficacy of single dose oral paracetamol for the treatment of acute postoperative pain.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, the Oxford Pain Relief Database and reference lists of articles to update an existing version of the review in July 2008.

SELECTION CRITERIA

Randomised, double-blind, placebo-controlled clinical trials of paracetamol for acute postoperative pain in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Area under the "pain relief versus time" curve was used to derive the proportion of participants with paracetamol or placebo experiencing at least 50% pain relief over four to six hours, using validated equations. Number-needed-to-treat-to-benefit (NNT) was calculated, with 95% confidence intervals (CI). The proportion of participants using rescue analgesia over a specified time period, and time to use, were sought as measures of duration of analgesia. Information on adverse events and withdrawals was also collected.

MAIN RESULTS

Fifty-one studies, with 5762 participants, were included: 3277 participants were treated with a single oral dose of paracetamol and 2425 with placebo. About half of participants treated with paracetamol at standard doses achieved at least 50% pain relief over four to six hours, compared with about 20% treated with placebo. NNTs for at least 50% pain relief over four to six hours following a single dose of paracetamol were as follows: 500 mg NNT 3.5 (2.7 to 4.8); 600 to 650 mg NNT 4.6 (3.9 to 5.5); 975 to 1000 mg NNT 3.6 (3.4 to 4.0). There was no dose response. Sensitivity analysis showed no significant effect of trial size or quality on this outcome.About half of participants needed additional analgesia over four to six hours, compared with about 70% with placebo. Five people would need to be treated with 1000 mg paracetamol, the most commonly used dose, to prevent one needing rescue medication over four to six hours, who would have needed it with placebo. Adverse event reporting was inconsistent and often incomplete. Reported adverse events were mainly mild and transient, and occurred at similar rates with 1000 mg paracetamol and placebo. No serious adverse events were reported. Withdrawals due to adverse events were uncommon and occurred in both paracetamol and placebo treatment arms.

AUTHORS' CONCLUSIONS

A single dose of paracetamol provides effective analgesia for about half of patients with acute postoperative pain, for a period of about four hours, and is associated with few, mainly mild, adverse events.

Paracetamol for pain relief after surgical removal of lower wisdom teeth

BACKGROUND

Paracetamol has been commonly used for the relief of postoperative pain following oral surgery. In this review we investigated the optimal dose of paracetamol and the optimal time for drug administration to provide pain relief, taking into account the side effects of different doses of the drug. This will inform dentists and their patients of the best strategy for pain relief after the surgical removal of wisdom teeth.

OBJECTIVES

To assess the beneficial and harmful effects of paracetamol for pain relief after surgical removal of lower wisdom teeth, compared to placebo, at different doses and administered postoperatively.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register; the Cochrane Pain, Palliative and Supportive Care Group's Trials Register; CENTRAL; MEDLINE; EMBASE and the Current Controlled Trials Register. Handsearching included several dental journals. We checked the bibliographies of relevant clinical trials and review articles for studies outside the handsearched journals. We wrote to authors of the identified randomised controlled trials (RCTs), to manufacturers of analgesic pharmaceuticals, we searched personal references in an attempt to identify unpublished or ongoing RCTs. No language restriction was applied. The last electronic search was conducted on 24th August 2006.

SELECTION CRITERIA

Randomised, parallel group, placebo controlled, double blind clinical trials of paracetamol for acute pain, following third molar surgery.

DATA COLLECTION AND ANALYSIS

All trials identified were scanned independently and in duplicate by two review authors, any disagreements were resolved by discussion, or if necessary a third review author was consulted. The proportion of patients with at least 50% pain relief was calculated for both paracetamol and placebo. The number of patients experiencing adverse events, and/or the total number of adverse events reported were analysed.

MAIN RESULTS

Twenty-one trials met the inclusion criteria. A total of 2048 patients were initially enrolled in the trials (1148 received paracetamol, and 892 the placebo) and of these 1968 (96%) were included in the meta-analysis (1133 received paracetamol, and 835 the placebo). Paracetamol provided a statistically significant benefit when compared with placebo for pain relief and pain intensity at both 4 and 6 hours. Most studies were found to have moderate risk of bias, with poorly reported allocation concealment being the main problem. Risk ratio values for pain relief at 4 hours 2.85 (95% confidence interval (CI) 1.89 to 4.29), and at 6 hours 3.32 (95% CI 1.88 to 5.87). A statistically significant benefit was also found between up to 1000 mg and 1000 mg doses, the higher the dose giving greater benefit for each measure at both time points. There was no statistically significant difference between the number of patients who reported adverse events, overall this being 19% in the paracetamol group and 16% in the placebo group.

AUTHORS' CONCLUSIONS

Paracetamol is a safe, effective drug for the treatment of postoperative pain following the surgical removal of lower wisdom teeth.

Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains

STUDY OBJECTIVE

To compare acetaminophen extended release 1,300 mg 3 times daily and ibuprofen 400 mg 3 times daily for treatment of signs and symptoms of grade I or II lateral ankle sprains.

METHODS

Patients (N=260) 18 years or older and with grade I or II lateral ankle sprains were randomized to receive acetaminophen extended release 1,300 mg 3 times daily or ibuprofen 400 mg 3 times daily for 9 days. Primary endpoint was change from baseline at day 4 in pain on walking. Other endpoints included change from baseline at day 9 in pain on walking; change from baseline at days 4 and 9 in ability to walk and ankle swelling, bruising, and range of motion; satisfaction with treatment on days 4 and 9; percentage of patients with positive anterior drawer test on day 4; and time to resume normal activity. Safety assessments consisted of reported adverse events. This study had a noninferiority design in which the hypothesis was that acetaminophen extended release was not inferior to ibuprofen for treatment of signs and symptoms of grade I or II lateral ankle sprains.

RESULTS

The difference in least squares means (acetaminophen extended release, ibuprofen) with respect to the primary endpoint within the per-protocol population was -0.88; acetaminophen extended release was comparable to ibuprofen for the primary endpoint because the upper limit (3.26) of the 1-sided 95% confidence interval (CI) for the difference in least squares means did not exceed the noninferiority limit of 6.90. The intention-to-treat population was used to test the second step of the 2-step testing process because the null hypothesis was rejected in the noninferiority test. For this analysis, the difference between acetaminophen extended release and ibuprofen in the least squares mean change from baseline for the primary endpoint was -1.63 (not significant). Results showed that acetaminophen extended release was noninferior to ibuprofen with respect to the secondary endpoints. No serious drug-related adverse events were reported. The most common adverse events, reported by 6.5% of patients, were in the gastrointestinal system (mainly nausea and upper abdominal pain).

CONCLUSION

Acetaminophen extended release 3,900 mg daily was comparable to ibuprofen 1,200 mg daily for treatment of grade I or II lateral ankle sprains. Both treatments were well tolerated.

Dose-response in direct comparisons of different doses of aspirin, ibuprofen and paracetamol (acetaminophen) in analgesic studies

AIMS

Establishing the dose-response relationship for clinically useful doses of aspirin, ibuprofen and paracetamol has been difficult. Indirect comparison from meta-analysis is compromised by too little information at some doses.

METHODS

A systematic review of randomized, double-blind trials in acute pain comparing different doses of aspirin, ibuprofen and paracetamol was therefore undertaken.

RESULTS

Fifty trials were found. Numerical superiority of higher over lower dose was found by the original authors in 37/50 trials (74%) and statistical superiority in 11/50 (22%). Twenty-eight trials had design, quality and data reporting characteristics to allow pooling of common doses; in 3/28 (11%) of the individual trials our calculations showed statistical superiority of higher over lower dose. Pooled comparison of 1000/1200 mg aspirin over 500/600 mg was statistically superior, with a number-needed-to-treat (NNT) for higher over lower dose of 16 (8 to > 100). Pooled comparison of 400 mg ibuprofen over 200 mg was statistically superior, with an NNT for higher over lower dose of 10 (6-23). Pooled comparison of 1000 mg paracetamol over 500 mg was statistically superior, with an NNT for higher over lower dose of 9 (6-20).

CONCLUSIONS

Use of trials making direct comparison of two different doses of target drugs revealed the underlying dose-response curve for clinical analgesia.

Drugs for pain management in dentistry

Pain is one of the most common reasons patients seek dental treatment. It may be due to many different diseases/conditions or it may occur after treatment. Dentists must be able to diagnose the source of pain and have strategies for its management. The '3-D's' principle--diagnosis, dental treatment and drugs--should be used to manage pain. The first, and most important, step is to diagnose the condition causing the pain and identify what caused that condition. Appropriate dental treatment should then be undertaken to remove the cause of the condition as this usually provides rapid resolution of the symptoms. Drugs should only be used as an adjunct to the dental treatment. Most painful problems that require analgesics will be due to inflammation. Pain management drugs include non-narcotic analgesics (e.g., non-steroidal anti-inflammatory drugs, paracetamol, etc) or opioids (i.e., narcotics). Non-steroidal anti-inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti-inflammatory and analgesic action. The most common NSAIDs are aspirin and ibuprofen. Paracetamol gives very effective analgesia but has little anti-inflammatory action. The opioids are powerful analgesics but have significant side effects and therefore they should be reserved for severe pain only. The most commonly-used opioid is codeine, usually in combination with paracetamol. Corticosteroids can also be used for managing inflammation but their use in dentistry is limited to a few very specific situations.

Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence?

Number needed to treat (NNT) values have been recommended and used to assess efficacy of analgesics for acute pain management. However, the data analysed come from a variety of procedures, which may potentially hinder the interpretation of the NNT value for specific procedures. We reanalysed available NNT data with acetaminophen in relation to the magnitude of surgical injury. Acetaminophen was less effective for pain relief after orthopaedic procedures than after dental procedures. The relative risk ratio for more than 50% pain relief, compared with placebo, was only 1.87 compared with 3.77 (P<0.05). Although NNT can give a valuable overview of efficacy, this concept is not necessarily applicable to all types of surgery. We suggest that estimates of NNT should be related to specific surgical procedures.

Combination oxycodone 5 mg/ibuprofen 400 mg for the treatment of postoperative pain: A double-blind, placebo- and active-controlled parallel-group study

OBJECTIVE

This study compared the efficacy and safety of a single dose of oxycodone 5 mg/ibuprofen 400 mg versus its individual components and placebo in a third-molar extraction model.

METHODS

In this multicenter, double-blind, double-dummy, parallel-group investigation, subjects with moderate to severe pain within 5 hours after extraction of > or =2 ipsilateral bony impacted third molars were randomized to single doses of oxycodone 5 mg/ibuprofen 400 mg, ibuprofen 400 mg, oxycodone 5 mg, or placebo. Primary efficacy variables were the sum of pain intensity difference over 6 hours (SP1D6) and total pain relief through 6 hours (TOTPAR6). The pharmacokinetics of oxycodone and ibuprofen, alone and in combination, were also determined in a subset of patients.

RESULTS

A total of 498 subjects were randomized to treatment (187 to oxycodone 5 mg/ibuprofen 400 mg, 186 to ibuprofen 400 mg, 63 to oxycodone 5 mg, and 62 to placebo). Baseline demographics were generally similar among treatment groups, despite differences in sex (P = 0.041) and race (P = 0.023). Combination therapy was associated with greater analgesia than ibuprofen alone, oxycodone alone, or placebo (mean [SE] TOTPAR6: 13.3 [0.52], 12.2 [0.52], 4.3 [0.82], and 4.2 [0.83], respectively [P < 0.001 vs oxycodone or placebo, P = 0.012 vs ibuprofen]; mean [SE] SP1D6: 6.54 [0.42], 5.41 [0.44], 0.14 [0.60], and 0.32 [0.59], respectively [P < 0.001 vs oxycodone or placebo, P = 0.002 vs ibuprofen]). Combination therapy was well tolerated. Pharmacokinetic results implied no interaction between oxycodone and ibuprofen.

CONCLUSIONS

In this study, a single dose of oxycodone 5 mg/ibuprofen 400 mg was fast-acting, effective, and well tolerated in subjects with moderate to severe pain after dental surgery. Oxycodone 5 mg alone did not provide an efficacy benefit over placebo in this study.

Dose-ranging analgesic study of Prosorb diclofenac potassium in postsurgical dental pain

BACKGROUND

ProSorb diclofenac potassium (K) is a novel, liquid-filled rapid-dispersion formulation of the nonsteroidal anti-inflammatory drug diclofenac, placed into soft gelatin capsules. Its time to maximal plasma drug concentration has been shown to be approximately half, and its maximal plasma drug concentration nearly twice, that of immediate-release diclofenac K tablets.

OBJECTIVE

This study compared the analgesic dose-response relationship and tolerability of 3 doses of ProSorb diclofenac K and placebo in the treatment of pain after dental impaction surgery.

METHODS

This randomized, double-blind, double-dummy, placebo-controlled parallel-group study was conducted at 6 centers across the United States. Patients aged 18 to 65 years with moderate or severe pain after the removal of > or =1 impacted mandibular third molar were randomly assigned to receive a single dose of ProSorb diclofenac K 25, 50, or 100 mg or placebo. Pain intensity and relief were assessed up to 6 hours after dosing. Rescue treatment was allowed after 1 hour. Efficacy end points included the summed pain intensity difference over 3 and 6 hours (SPID3 and 6); total pain relief at 3 and 6 hours (TOTPAR3 and 6); median times to onset of perceptible and meaningful relief (analgesic onset) and rescue medication use (analgesic duration); and cumulative percentage of patients using rescue medication. Tolerability was assessed using vital sign measurements and spontaneous reporting of adverse events.

RESULTS

A total of 265 patients (154 women, 111 men; mean age, 23.3 years) were enrolled. All 3 ProSorb diclofenac K groups showed higher SPID6 and TOTPAR6 scores and longer median times to rescue medication use than the placebo group (all, P < 0.001). For these end points, a dose-response relationship was evident between the 100-mg dose and the 25- and 50-mg doses (P < or = 0.05); the 25- and 50-mg doses were similar. In the diclofenac groups, median onset times for first perceptible (< or =22.5 min) and meaningful (< or =53.0 min) relief were significantly more rapid than placebo (P < or = 0.01). Proportions of patients requiring rescue analgesic were < or =50.8% with diclofenac compared with 79.4% with placebo. Proportions of patients assigning a global evaluation of good or better was > or =68% with diclofenac compared with 21% for placebo. Tolerability was similar across all treatment groups.

CONCLUSION

In this study of patients treated for pain following dental impaction surgery, single doses of ProSorb diclofenac K 25, 50, and 100 mg were more efficacious than placebo with respect to reduction of pain. All 3 doses provided a rapid analgesic onset and were well tolerated.

Single dose oral paracetamol (acetaminophen) for postoperative pain

BACKGROUND

Paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the relief of mild and moderate pain arising from headache, musculoskeletal conditions and dysmenorrhoea. A prior Cochrane systematic review concluded that paracetamol is also effective for postoperative pain, but additional trials have since been published. This review sought to evaluate the efficacy and safety of paracetamol using current data, and to compare the findings with other analgesics evaluated in the same way.

OBJECTIVES

To assess the efficacy of single dose oral paracetamol for the treatment of acute postoperative pain.

SEARCH STRATEGY

We searched the Cochrane Library (Issue 3, 2002), the trials register of the Cochrane Pain, Palliative and Supportive Care group (November 2002); MEDLINE (1966 to May 1996); PubMed (1996 to August 2001); EMBASE (1980 to 1996); the Oxford Pain Relief Database (1950 to 1994); and reference lists of articles in order to update an existing version of the review.

SELECTION CRITERIA

Randomised, double-blind, placebo-controlled clinical trials of paracetamol for acute postoperative pain in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. The area under the 'pain relief versus time' curve was used to derive the proportion of patients with paracetamol or placebo experiencing least 50% pain relief over four to six hours using validated equations. The number-needed-to-treat (NNT) was calculated using 95% confidence intervals. Information on adverse effects was also collected.

MAIN RESULTS

Forty-seven reports that enrolled 4186 patients (2561 patients were treated with a single oral dose of paracetamol and 1625 with placebo) met the inclusion criteria and were included in the analyses. The NNTs for at least 50% pain relief over four to six hours following a single dose of paracetamol were as follows: 325 mg NNT 3.8 (2.2 to 13.3); 500 mg NNT 3.5 (2.7 to 4.8); 600/650 mg NNT 4.6 (3.9 to 5.5); 975/1000 mg NNT 3.8 (3.4 to 4.4); and 1500 mg NNT 3.7 (2.3 to 9.5). Sub-group analysis showed no significant differences between smaller and larger trials, or lower and higher quality trials. Drug-related study withdrawals were rarely reported. Studies reported a variable incidence of adverse effects that were generally mild and transient. There were no statistically significant differences in the frequency of reported adverse effects between paracetamol 975/1000 mg and placebo.

REVIEWER'S CONCLUSIONS

Single doses of paracetamol are effective analgesics for acute postoperative pain and give rise to few adverse effects.

Safety and efficacy of a traditional herbal medicine (Throat Coat) in symptomatic temporary relief of pain in patients with acute pharyngitis: a multicenter, prospective, randomized, double-blinded, placebo-controlled study

OBJECTIVE

To investigate the safety and efficacy of Throat Coat) (Traditional Medicinals,) Sebastopol, CA), a traditional demulcent herbal tea, in comparison with a placebo tea in the symptomatic treatment of acute pharyngitis.

DESIGN

Multicenter, prospective, randomized, double-blinded, placebo-controlled, two-armed, parallel-group clinical trial.

SETTINGS

Three primary care clinics in Duluth, MN, Madison, WI, and Middleton, WI.

SUBJECTS

Patients of both genders (>or=18 years of age) with clinical diagnoses of acute pharyngitis.

INTERVENTIONS

Patients (n = 60) were randomly assigned to receive 5-8 oz of Throat Coat (n = 30) or a placebo (n = 30), four to six times daily. The study period was 2 to 7 days with a window for the follow-up visit of 2-10 days accounting for the variable duration of sore throat symptoms.

OUTCOME MEASURES

Primary efficacy parameter: sum of pain intensity differences (SPID) for pain in throat on swallowing, calculated as the area under the curve (AUC) of pain intensity difference scores (assessed at 1 minute, 5 minutes, 10 minutes, 15 minutes, 20 minutes, and 30 minutes after treatment). Secondary efficacy parameter: total pain relief (TOTPAR), calculated as the AUC from time 0 (baseline) to 30 minutes of pain relief (assessed at 1 minute, 5 minutes, 10 minutes, 15 minutes, 20 minutes, and 30 minutes).

RESULTS

Compared to placebo, intensity of throat pain when swallowing was significantly reduced by Throat Coat in intention to treat and valid for efficacy analysis (VEA). Significant differences in change from baseline pain were observed at 5 min (p = 0.007), 10 min (p = 0.005), 15 minutes (p = 0.01), 20 minutes (p = 0.05), and 30 minutes (p = 0.04) after completion of the first dose (VEA analysis). There was a statistically significant improvement of SPID in the Throat Coat-treated group: Least square means +/- standard error of the means (SEM) of SPID were -16.5 +/- 13.9 in the placebo group and -43.8 +/- 11.9 in the Throat Coat-treated group (p = 0.012). TOTPAR was also significantly higher in the Throat Coat-treated group: Least square means +/- SEM of TOTPAR were 32.4 +/- 12.8 in the placebo group and 53.6 +/- 10.9 in the Throat Coat-treated group (p = 0.031). This study shows that Throat Coat is significantly superior to placebo and provided a rapid, temporary relief of sore throat pain in patients with pharyngitis.