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de Liyis BG, Sutedja JC, Tjandra DC, Widha Putri NLPS, Gunawan MFB, Karuniamaya CP, Barus JFA, Pinzon RT, Widyadharma IPE. Serotonin norepinephrine reuptake inhibitors in managing neuropathic pain following spinal and non-spinal surgery: A systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2024; 239:108223. [PMID: 38484604 DOI: 10.1016/j.clineuro.2024.108223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/19/2024] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND While serotonin norepinephrine reuptake inhibitors (SNRIs) offer promise in managing Post-surgical neuropathic pain (PSNP), uncertainties remain. This study aims to evaluate the effectiveness and adverse events of SNRIs in managing PSNP. METHODS Systematic searches of PubMed, Embase, and Cochrane databases up to January 1st 2023 identified randomized controlled trials (RCTs) comparing SNRIs to placebo for PSNP. The primary outcome measures were pain at rest and adverse events post-surgery. Subgroup analyses were conducted based on surgical type and specific SNRIs. RESULTS A total of 19 RCTs, encompassing 1440 participants (719 in the SNRI group vs 721 in the placebo group), met the inclusion criteria and were included. The pooled results demonstrated that pain scores were significantly lower in patients treated with SNRIs at 2 hours (MD:-0.26; 95%CI: -0.47 to -0.04; p=0.02), 6 hours (MD:-0.68; 95%CI: -1.01 to -0.34; p<0.0001), 24 hours (MD:-0.54; 95%CI: -0.99 to -0.09; p=0.02), and 48 hours (MD:-0.66; 95%CI: -1.23 to -0.10; p=0.02) post-surgery. In terms of adverse events, dizziness (OR:2.53; 95%CI: 1.34-4.78; p=0.004) and dry mouth (OR:2.21; 95%CI: 1.25-3.92; p=0.007) were significantly higher in the SNRIs group. Subgroup analysis showed that SNRI was found to significantly lower the 24-hour pain score after spinal surgery (MD:-0.45; 95%CI: -0.84 to -0.05; p=0.03). Duloxetine (MD:-0.63; 95%CI: -1.15 to -0.11; p=0.02) had a significant effect in lowering the 24-hour pain score at rest compared to placebo, whereas venlafaxine did not. CONCLUSIONS SNRIs yielded considerable pain score reductions across multiple post-surgical intervals, although accompanied by an increased incidence of dizziness and dry mouth.
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Affiliation(s)
| | | | | | | | | | | | - Jimmy Fransisco Abadinta Barus
- Department of Neurology, School of Medicine and Health Science, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Rizaldi Taslim Pinzon
- Department of Neurology, Duta Wacana University School of Medicine, Yogyakarta, Indonesia
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Harder T, Harder J, Baum G, Cox C, Harder J, Hernandez E, MacKay B. Antineuropathic Pain Management After Orthopedic Surgery: A Systematic Review. Orthop Rev (Pavia) 2024; 16:93012. [PMID: 38505138 PMCID: PMC10950197 DOI: 10.52965/001c.93012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/03/2023] [Indexed: 03/21/2024] Open
Abstract
Background The opioid crisis has become a present concern in the medical field. In an effort to address these complications, antineuropathic pain medications have been considered as alternatives to prescribed opioids. Objective This review focuses on the analgesic effects of neuromodulators, such as gabapentin, duloxetine, and pregabalin, that provide room for less dependence on narcotic analgesics following orthopedic surgery. Methods During the database searches, 1,033 records were identified as a preliminary result. After duplicates were removed, an initial screen of each article was completed which identified records to be removed due to absence of a full-text article. Articles were excluded if they were not either prospective or retrospective, showcased an irrelevant medication (such as tricyclic antidepressants) which are not pertinent to this review, or deemed to be unrelated to the topic. Results Ultimately, 19 articles were selected. Three different drugs, gabapentin, pregabalin, and duloxetine, were analyzed to compile data on the effectiveness of preventing opioid overuse and addiction following hand surgery. This review identifies potential evidence that peri-operative gabapentin, pregabalin, and duloxetine administration decreases post-operative pain and lowers opioid dependency. Conclusion Gabapentin, pregabalin, and duloxetine have potential to further decrease post-operative pain and lower opioid dependency. This review creates an opening for further research in hand surgery to assess an updated protocol for pain management to reduce opioid dependency.
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Affiliation(s)
| | | | - Gracie Baum
- Orthopaedic Surgery Texas Tech University Health Sciences Center
| | - Cameron Cox
- Orthopaedic Surgery Texas Tech University Health Sciences Center
| | - Justin Harder
- Orthopaedic Surgery Texas Tech University Health Sciences Center
| | - Evan Hernandez
- Community, Family, and Addiction Sciences Texas Tech University
- Department of Orthopaedic Hand Surgery Texas Tech University Health Sciences Center
| | - Brendan MacKay
- Orthopaedic Surgery Texas Tech University Health Sciences Center
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Noshahr RM, Kouhestani E, Dibamehr M, Alshohaib M. The effect of duloxetine on postoperative pain and opium consumption in spine surgery: A systematic review. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100303. [PMID: 38235484 PMCID: PMC10793159 DOI: 10.1016/j.xnsj.2023.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024]
Abstract
Background Postoperative pain after spinal surgery is a major problem that can impact patients' quality of life. Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI) with analgesic effect in different pain disorders. In this study, we aim to evaluate the safety and analgesic effect of duloxetine on acute and chronic pain following spine surgery. Methods A systematic search was completed on MEDLINE, PsycINFO, and Embase through OVID from inception to April 2023 to find relevant articles. We used Cochrane methodology to evaluate the bias of included studies. Investigated outcomes included postoperative pain, opioid consumption, and adverse events. Results Seven articles involving 487 participants were included in our systematic review. Out of 7 papers, 5 were randomized clinical trials, 1 was a pilot trial and 1 was a retrospective observational study. The results of these studies indicated the analgesic effect of duloxetine on postoperative pain, which was measured using numeric rating scale, verbal numeric scale, brief pain inventory, and visual analogue scale. Duloxetine was generally safe without serious adverse events. The most common reported adverse events included headache, nausea, vomiting, itching, dizziness, and drowsiness. Conclusions Duloxetine may be an effective treatment option for postoperative pain following spine surgery, but further rigorously designed and well-controlled randomized trials are required.
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Affiliation(s)
- Reza Minaei Noshahr
- Department of Orthopedic Surgery, Shahid Beheshti University of Medical Sciences, Velenjak Street, Tehran, Iran
- Bone Joint and Related Tissues Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Shariati street, Tehran, Iran
| | - Emad Kouhestani
- Department of Orthopedic Surgery, Shahid Beheshti University of Medical Sciences, Velenjak Street, Tehran, Iran
- Bone Joint and Related Tissues Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Shariati street, Tehran, Iran
| | - Mohsen Dibamehr
- Bone Joint and Related Tissues Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Shariati street, Tehran, Iran
| | - Muntadhar Alshohaib
- Department of Orthopedic Surgery, Shahid Beheshti University of Medical Sciences, Velenjak Street, Tehran, Iran
- Bone Joint and Related Tissues Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Shariati street, Tehran, Iran
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Siemian JN, Woodhouse K, Liu DH, Zhang Y, Li JX. The imidazoline I 2 receptor agonist 2-BFI reduces abuse-related effects of morphine: self-administration and drug discrimination. Psychopharmacology (Berl) 2024; 241:479-487. [PMID: 38159161 DOI: 10.1007/s00213-023-06524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
RATIONALE Increasing evidence shows that imidazoline I2 receptor agonists enhance opioid-induced analgesia, suggesting that the combination of I2 receptor agonists with opioids could be a favorable strategy for pain control. However, the effect of I2 receptor agonists on the abuse liability of opioids is unknown. This study examined the impact of the I2 receptor agonist 2-BFI on some abuse-related behavioral effects of the opioid morphine in rats. OBJECTIVES The von Frey filament test was used to determine the antinociceptive effects of 2-BFI (intravenous, i.v.) in a rat model of complete Freund's adjuvant (CFA)-induced inflammatory pain. IV self-administration was used to assess the reinforcing effects of 2-BFI alone and to assess the effects of non-contingent injections of 2-BFI (i.p.) on morphine self-administration. A two-lever drug discrimination paradigm in which rats were trained to discriminate 3.2 mg/kg morphine (i.p.) from saline was used to examine whether 2-BFI or another I2 receptor agonist 2-(4,5-dihydroimidazol-2-yl)quinoline hydrochloride (BU224) affected the discriminative stimulus effects of morphine. RESULTS 2-BFI could not maintain reliable self-administration behavior in rats with no pain or CFA-treated inflammatory pain. However, pretreatment with 2-BFI (i.p.) produced dose-dependent decreases in the dose-effect curve of morphine self-administration. Both 2-BFI and BU224 did not substitute for morphine but significantly attenuated the discriminative stimulus effects of morphine. CONCLUSIONS These results suggest that I2 receptor agonists do not enhance, but in fact appear to decrease, the abuse liability of opioids, further supporting the potential utility of I2 receptor agonist-opioid combination therapy for pain control.
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Affiliation(s)
- Justin N Siemian
- Department of Pharmacology and Toxicology, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kristen Woodhouse
- Department of Pharmacology and Toxicology, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | | | - Yanan Zhang
- Research Triangle Institute, Research Triangle Park, NC, USA
| | - Jun-Xu Li
- Department of Pharmacology and Toxicology, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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Zaid HHG, Hua X, Huang Y, Chen B, Jichuan Z, Yang G. Perioperative duloxetine improves postoperative outcomes after anterior talofibular ligament repair for chronic lateral ankle instability for patients with depression: A prospective randomized clinical trial. Orthop Traumatol Surg Res 2024:103837. [PMID: 38355009 DOI: 10.1016/j.otsr.2024.103837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/27/2024] [Accepted: 02/08/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Recent studies have indicated that depression is associated with persistent postoperative pain and decreased satisfaction following foot and ankle surgery. This study aimed to evaluate the effect of perioperative duloxetine on postoperative outcomes of anterior talofibular ligament (ATFL) surgical repair for chronic ankle instability (CAI) in patients with depression. We further sought to evaluate patients' satisfaction and side effects related to duloxetine. MATERIAL AND METHODS Patients undergoing ATFL repair were screened for depression preoperatively with the Patient Health Questionnaire (PHQ-9). Among 249 patients who underwent arthroscopic or open surgical Brostrom repair of the ATFL, 120 patients were identified as being "possibly depressed" and were included in the study. Sixty patients were randomly assigned to the duloxetine group (one day preoperatively and for 6 weeks postoperatively), and the other sixty were randomized to the placebo group. Painkillers and opioid consumption, pain scores, and patient satisfaction were recorded at 12, 24, 48, and 72hours postoperatively and at follow-up visits 1, 3, and 6 months after surgery. Patient-reported outcome measures (PROMs) were assessed preoperatively and at 3, 6, 12 and 24 months postoperatively. Duloxetine-related side effects such as nausea/vomiting and fatigue were also recorded. RESULTS The patients in the duloxetine group reported a significantly longer time to rescue analgesic and reduced opioid requirements (including celecoxib, pregabalin, acetaminophen, and tramadol). The patients experienced decreased pain intensity and greater satisfaction with their pain management at 24, 48, 72h and 1 and 3 months after surgery (p<0.05). The duloxetine group also had significantly better clinical and functional outcomes at 3 and 6 months of follow-up compared to the placebo group (p<0.05). The occurrence and rate of symptoms of duloxetine side effects were not significant. DISCUSSION Depression is an important factor to consider and address because its presence before surgery can predict poor postoperative outcomes, including more severe postoperative pain, persistent postoperative pain, and increased consumption of painkillers and opioids. CONCLUSION Perioperative administration of duloxetine following ATFL repair for CAI in patients with depression increased the time to first postoperative rescue analgesic request and reduced both opioid consumption and postoperative pain. This approach also led to a high level of patient satisfaction. In addition, duloxetine improved the quality of recovery without leading to significant side effects. LEVEL OF EVIDENCE I; prospective randomized controlled trial.
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Affiliation(s)
- Hamood H G Zaid
- Department of Sports Medicine, the First Affiliated Hospital of Xiamen University, No. 55, Zhenhai Street, Siming District, Fujian Province, 361026 Xiamen City, China
| | - Xu Hua
- Department of Orthopedics, Xinglin Branch of the First Affiliated Hospital of Xiamen University, No. 11, Xinglin Hongdai Road, Jimei District, Fujian Province, 361026 Xiamen City, China
| | - Yafu Huang
- Department of Orthopedics, Xinglin Branch of the First Affiliated Hospital of Xiamen University, No. 11, Xinglin Hongdai Road, Jimei District, Fujian Province, 361026 Xiamen City, China
| | - Bingyi Chen
- Department of Orthopedics, Xinglin Branch of the First Affiliated Hospital of Xiamen University, No. 11, Xinglin Hongdai Road, Jimei District, Fujian Province, 361026 Xiamen City, China
| | - Zhuang Jichuan
- Department of Orthopedics, Xinglin Branch of the First Affiliated Hospital of Xiamen University, No. 11, Xinglin Hongdai Road, Jimei District, Fujian Province, 361026 Xiamen City, China
| | - Guo Yang
- Department of Sports Medicine, the First Affiliated Hospital of Xiamen University, No. 55, Zhenhai Street, Siming District, Fujian Province, 361026 Xiamen City, China.
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Govil N, Arora P, Parag K, Tripathi M, Garg PK, Goyal T. Postoperative acute pain management with duloxetine as compared to placebo: A systematic review with meta-analysis of randomized clinical trials. Pain Pract 2023; 23:818-837. [PMID: 37246352 DOI: 10.1111/papr.13253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Duloxetine has been used as an adjunct in multimodal analgesia for acute postoperative pain in clinical studies. This meta-analysis aims to conclude whether oral duloxetine, when given perioperatively, is any better than a placebo in managing postoperative pain. Effects of duloxetine on postoperative pain scores, time to first rescue analgesia, postoperative rescue analgesia consumption, side effects attributable to duloxetine, and patient satisfaction profile were assessed. METHOD MEDLINE, Web of Science, EMBASE, Scholar Google, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched with keywords including "Duloxetine" AND "postoperative pain", "Duloxetine" AND "acute pain" and with "Duloxetine" till October 2022. This meta-analysis included randomized clinical trials in which perioperative duloxetine 60 mg per oral was administered not more than 7 days before surgery and for at least 24 after surgery but not more than 14 days after surgery. All RCTs in which the comparator is placebo and outcomes related to analgesic efficacy like pain scores, opioid consumption, and side effects of duloxetine until 48 h postoperatively were included. Data were extracted from the studies and a risk of bias summary was formed using the Cochrane Collaboration tool. Effect sizes were given as standardized mean differences for continuous outcomes and risk ratios (RR) by the Mantel-Haenszel test for the categorical outcome. Confirmation of publication bias was done by Egger's regression test (p < 0.05). If publication bias or heterogeneity was detected, the trim-and-fill method was used to calculate the adjusted effect size. Sensitivity analysis was done by leaving one out method after excluding the study with a high risk of bias. Subgroup analysis was done based on the type of surgery and gender. The study was prospectively registered in the PROSPERO under the registration number CRD42019139559. FINDINGS 29 studies with 2043 patients met the inclusion criteria and were reviewed for this meta-analysis. Postoperative pain scores at 24 h [Std. Mean Difference (95% CI); -0.69 (-1.07, -0.32)] and at 48 h [-1.13 (-1.68, -0.58)] are significantly less with duloxetine (p-value < 0.05). Time to first rescue analgesia was significantly more in patients where duloxetine was administered [1.27 (1.10, 1.45); p-value > 0.05]. Opioid consumption up to 24 h [-1.82 (-2.46, -1.18)] and 48 h [-2.48 (-3.46, -1.50)] was significantly less (p-value < 0.05) in patients who received duloxetine. Complications and recovery profiles were similar in patients receiving either duloxetine or a placebo. INTERPRETATION Based on GRADE findings, we conclude that there is low to moderate evidence to advocate the use of duloxetine for managing postoperative pain. Further trials are needed to replicate or refute these results based on robust methodology.
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Affiliation(s)
- Nishith Govil
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - Pankaj Arora
- Department of Neurosurgery, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - Kumar Parag
- Department of Anaesthesiology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | | | - Pankaj Kumar Garg
- Department of Surgical Oncology, Shri Guru Ram Rai Institute of Medical & Health Sciences, Dehradun, India
| | - Tarun Goyal
- Department of Orthopaedics, AIIMS Bathinda, Bathinda, India
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Beaudoin FL, Gaither R, DeLomba WC, McLean SA. Tolerability and efficacy of duloxetine for the prevention of persistent musculoskeletal pain after trauma and injury: a pilot three-group randomized controlled trial. Pain 2023; 164:855-863. [PMID: 36375173 PMCID: PMC10014491 DOI: 10.1097/j.pain.0000000000002782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/30/2022] [Indexed: 11/15/2022]
Abstract
ABSTRACT This study investigated the tolerability and preliminary efficacy of duloxetine as an alternative nonopioid therapeutic option for the prevention of persistent musculoskeletal pain (MSP) among adults presenting to the emergency department with acute MSP after trauma or injury. In this randomized, double-blind, placebo-controlled study, eligible participants (n = 78) were randomized to 2 weeks of a daily dose of one of the following: placebo (n = 27), 30 mg duloxetine (n = 24), or 60 mg duloxetine (n = 27). Tolerability, the primary outcome, was measured by dropout rate and adverse effects. Secondary outcomes assessed drug efficacy as measured by (1) the proportion of participants with moderate to severe pain (numerical rating scale ≥ 4) at 6 weeks (pain persistence); and (2) average pain by group over the six-week study period. We also explored treatment effects by type of trauma (motor vehicle collision [MVC] vs non-MVC). In both intervention groups, duloxetine was well tolerated and there were no serious adverse events. There was a statistically significant difference in pain over time for the 60 mg vs placebo group ( P = 0.03) but not for the 30 mg vs placebo group ( P = 0.51). In both types of analyses, the size of the effect of duloxetine was larger in MVC vs non-MVC injury. Consistent with the role of stress systems in the development of chronic pain after traumatic stress, our data indicate duloxetine may be a treatment option for reducing the transition from acute to persistent MSP. Larger randomized controlled trials are needed to confirm these promising results.
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Affiliation(s)
- Francesca L. Beaudoin
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
- Department of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI, United States
| | - Rachel Gaither
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
| | - Weston C. DeLomba
- Department of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI, United States
| | - Samuel A. McLean
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States
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Martinez GJ, Lautenschlager KA, Aden JK, Maani CV, Lopez EM, McCallin JP. Effects of Multimodal Analgesia on Recovery From Percutaneous Spinal Cord Stimulator Implantation. Neuromodulation 2023; 26:252-259. [PMID: 31851404 DOI: 10.1111/ner.13088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/25/2019] [Accepted: 11/20/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We aimed to determine the relationship between number and type of analgesic modalities utilized and postoperative pain after percutaneous spinal cord stimulator implantation. Secondary measures include opioid requirements, discharge times, and effects of specific modalities. MATERIALS AND METHODS This single-center retrospective cohort at Brooke Army Medical Center from April 2008 through July 2017 reviewed 70 patients undergoing stimulator implantation by a pain specialist. Data included: home opioid regimen; preoperative/postoperative medications and pain; intraoperative medications; and discharge times. Analysis utilized a Wilcoxon nonparametric mode, and chi-square testing for specific modalities. We compared outcomes based on the number of modalities administered and whether patients received specific medications. RESULTS Patients averaged receiving 3.8 modalities (standard deviation 1.4). Patients receiving ≥5 modalities had increased pain from preoperative to postoperative scores by two points, while those who received ≤4 had no increase (p < 0.01). Patients receiving ketamine had a median three point increase in pain scores from their baseline vs no change for others (p < 0.05). Patients receiving four modalities had shorter phase one recovery times vs ≤ 2 (median 66 vs 91.5 min; p = 0.01). Patients receiving ≥4 modalities had shorter times vs ≤3 (median 74 vs 88.5 min; p < 0.01). Patients receiving NSAIDs had shorter times than others (median 78 vs 87 min; p < 0.05). CONCLUSIONS Ketamine administration and use of ≥5 analgesic modalities were associated with more postoperative pain for unclear reasons. Patients receiving NSAIDs or ≥4 analgesic modalities had shorter recovery times. These data may lead to further work that could optimize ambulatory practices for stimulator implantation. More work is warranted on this subject.
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Affiliation(s)
- Greggory J Martinez
- Department of Anesthesia and Perioperative Services, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Karl A Lautenschlager
- Department of Anesthesia and Perioperative Services, Brooke Army Medical Center, Fort Sam Houston, TX, USA; Department of Pain Management, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - James K Aden
- Research Division, Graduate Medical Education, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Christopher V Maani
- Department of Anesthesia and Perioperative Services, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Edward M Lopez
- Department of Pain Management, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - John P McCallin
- Department of Pain Management, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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Hiroki T, Fujita N, Suto T, Suzuki H, Tsukamoto N, Ohta J, Saito S, Obata H. Randomized active-controlled study of a single preoperative administration of duloxetine to treat postoperative pain and numbness after posterior lumbar interbody fusion surgery. Medicine (Baltimore) 2022; 101:e32306. [PMID: 36550823 PMCID: PMC9771311 DOI: 10.1097/md.0000000000032306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This prospective, randomized, double-blinded, active controlled trial assessed whether a single preoperative administration of 40 mg of duloxetine could decrease postoperative pain and numbness after posterior lumbar interbody fusion surgery (PLIF). METHODS Patients with an American Society of Anesthesiologists physical status I or II undergoing PLIF were included. At 2 hours before inducing anesthesia, patients were administered 40 mg duloxetine or 4 mg diazepam (control drug). Postoperative pain and other symptoms were evaluated on the basis of a visual analog scale, amount of fentanyl used, fentanyl dose request times, rate of use of adjunctive analgesics (diclofenac sodium or pentazocine), and lower limb numbness score (0-3) during the first 2 postoperative days. RESULTS Forty-six patients were randomly assigned to the duloxetine and diazepam groups (n = 23 each); 6 were lost to follow-up, and analysis was performed on data from 22 patients in the duloxetine group and 18 in the diazepam group. No significant differences were detected in the patient background, postoperative visual analog scale score at rest in the lumbar region and lower limbs, fentanyl use, rate of analgesic adjuvant use, or incidence of side effects. The numbness score in the lower limbs, however, was significantly lower in the duloxetine group. CONCLUSION A single preoperative 40-mg dose of duloxetine did not improve postoperative pain after PLIF, but did improve lower limb numbness. Duloxetine may suppress neuropathic pain-like symptoms after PLIF surgery.
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Affiliation(s)
- Tadanao Hiroki
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Nao Fujita
- Department of Anesthesiology, Keiyu Orthopedic Hospital, Tatebayashi, Japan
| | - Takashi Suto
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideo Suzuki
- Department of Anesthesiology, Keiyu Orthopedic Hospital, Tatebayashi, Japan
| | - Noboru Tsukamoto
- Department of Anesthesiology, Keiyu Orthopedic Hospital, Tatebayashi, Japan
| | - Jo Ohta
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideaki Obata
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
- * Correspondence: Hideaki Obata, Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan (e-mail: )
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Gerber MT, Lyra HF, Erdmann TR, Bomfati F, Gaspareto PB, de Oliveira Filho GR. Efficacy of postoperative analgesia with duloxetine in posthemorrhoidectomy pain: a prospective, randomized, double-blind and placebo-controlled trial. BMC Anesthesiol 2022; 22:372. [PMID: 36457090 PMCID: PMC9714059 DOI: 10.1186/s12871-022-01908-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND To evaluate the effect of duloxetine when added to a multimodal analgesia regimen on posthemorrhoidectomy pain, opioid consumption, and side effects. METHODS Prospective, randomized, double-blind placebo-controlled trial. This study included 62 patients who underwent hemorrhoidectomy. The patients were randomly assigned to receive oral duloxetine 60 mg or placebo 2 h before and 24 h after surgery. The primary outcomes were pain intensity - measured on an 11-point visual analog pain scale - and cumulative morphine consumption at 12, 24, and 48 postoperative hours. RESULTS Fifty-two patients completed the study (25 in the duloxetine group and 27 in the placebo group). Pain scores did not differ between duloxetine and placebo: 4.5; 3.0 - 7.0 vs. 5.0; 3.5 - 7.0, p = 0.68 at 12 h, 3.0; 2.0 - 5.0 vs. 3.0; 2.0 - 5.0, p = 0.56 at 24 h, and 2.5; 1.75 - 3.75 vs. 1.5; 0.5 - 3, p = 0.08 at 48 h. Further, cumulative morphine consumption did not differ between the duloxetine and placebo groups: 4; 1.25 - 10.75 mg vs. 7; 1.0 - 12.0 mg, p = 0.68 at 12 h, 9.5; 2.0 - 17.5 mg vs. 8.0; 4.0 - 18.0 mg; p = 0.80 at 24 h, and 11.0; 2.0 - 27.0 mg vs. 10; 4.0 - 24.0 mg, p = 0.78 at 48 h. Side effects did not differ between the groups. CONCLUSIONS Compared with placebo, duloxetine did not decrease pain intensity or morphine consumption during the first 48 h postoperatively. TRIAL REGISTRATION The study was retrospectively registered on the Brazilian Clinical Trials Registry (identifier: RBR-9pdgms, registration date: 08/10/2020).
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Affiliation(s)
- Marlus Tavares Gerber
- grid.411237.20000 0001 2188 7235University Hospital, Federal University of Santa Catarina, Maria Flora Pausewang St. S/N Campus Universitário – Trindade, Florianopolis, Santa Catarina 88036-800 Brazil
| | - Humberto Fenner Lyra
- grid.411237.20000 0001 2188 7235University Hospital, Federal University of Santa Catarina, Maria Flora Pausewang St. S/N Campus Universitário – Trindade, Florianopolis, Santa Catarina 88036-800 Brazil ,grid.411237.20000 0001 2188 7235Department of Surgery, Federal University of Santa Catarina, Florianopolis, Santa Catarina Brazil
| | - Thomas Rolf Erdmann
- grid.411237.20000 0001 2188 7235University Hospital, Federal University of Santa Catarina, Maria Flora Pausewang St. S/N Campus Universitário – Trindade, Florianopolis, Santa Catarina 88036-800 Brazil
| | - Fernanda Bomfati
- grid.459527.80000 0004 0615 7359Erasto Gaertner Hospital, Curitiba, Parana Brazil
| | - Patrick Barcelos Gaspareto
- grid.411237.20000 0001 2188 7235University Hospital, Federal University of Santa Catarina, Maria Flora Pausewang St. S/N Campus Universitário – Trindade, Florianopolis, Santa Catarina 88036-800 Brazil
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Erdmann TR, Gerber MT, Gaspareto PB, de Oliveira Filho GR. The effects of a short-term perioperative duloxetine treatment on post-colectomy pain: A randomized, controlled clinical trial. J Clin Anesth 2022; 82:110948. [PMID: 35963028 DOI: 10.1016/j.jclinane.2022.110948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To test the hypothesis that duloxetine reduces postoperative morphine consumption and pain intensity in patients undergoing major colonic surgeries. DESIGN Single-center, prospective, double-blinded, randomized, controlled trial. SETTING Tertiary university hospital, from December 2019 to September 2021. PATIENTS Sixty 18-85 years old, ASA I - III patients undergoing elective open major colonic surgeries were randomly allocated into duloxetine (duloxetine) or placebo (placebo) groups (n = 30 per group). INTERVENTIONS Duloxetine 60 mg or placebo was administered orally 2 h before and 24 h after surgery. MEASUREMENTS PCA morphine consumption, surgical pain at rest, and movement measured on 10-cm visual analog scales (VAS), Ramsay sedation scores, and the incidence of adverse effects potentially associated with duloxetine were assessed at patients' admission to the post-anesthesia care unit (PACU), 6, 24, and 48 h postoperatively (PO). MAIN RESULTS After adjusting for age, BMI, ASA physical status, education level, and incision type, no differences were found between groups in PCA morphine consumption 24 PO h (duloxetine = 5.44 ± 2.06 mg; placebo = 10.33 ± 2.06 mg, p = 0.62) or 48 h PO (duloxetine = 9.18 ± 2.06 mg, placebo = 12.93 ± 2.06, p = 1). Pain at rest also did not differ between groups at 24 h PO (duloxetine = 1.76 ± 0.67 cm; placebo = 1 ± 0.67 cm, p = 1) or at 48 h PO (duloxetine = 0.84 ± 0.67 cm; placebo = 0.49 ± 0.67 cm, p = 1). Similarly, groups did not differ regarding pain on movement at 24 h PO (duloxetine = 2.09 ± 0.68 cm; placebo = 1.80 ± 0.68, p = 1) or at 48 h PO (duloxetine = 1.16 ± 0.68 cm; placebo = 0.88 ± 0.68 cm, p = 1). Sedation scores and adverse effects also did not differ between groups. CONCLUSION Under this study's conditions, short-term duloxetine did not reduce total opioid consumption or pain intensity during the initial 48 h following major colon surgery.
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Affiliation(s)
- Thomas Rolf Erdmann
- Polydoro Ernani de São Thiago University Hospital, Federal University of Santa Catarina.
| | - Marlus Tavares Gerber
- Polydoro Ernani de São Thiago University Hospital, Federal University of Santa Catarina
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12
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Nath S, Saha A, Srivastava A. Evaluating the Effect of Duloxetine Premedication on Postoperative Analgesic Requirement in Patients Undergoing Laparoscopic Cholecystectomies: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study. Clin J Pain 2022; 38:528-535. [PMID: 35696698 DOI: 10.1097/ajp.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim was to evaluate the effect of oral administration of preoperative duloxetine on postoperative pain and total analgesic requirement in the postoperative period as the primary objective. The secondary objective was to evaluate the perioperative hemodynamic parameters, sedation scores, demographic data, and incidence of side effects (if any) in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS This was a prospective, randomized, double-blind, placebo-controlled study conducted in a tertiary level medical college on 60 patients of either sex posted for laparoscopic cholecystectomies with American Society of Anesthesiologists (ASA) I and II. The patients were divided into 2 groups (n=30), the patients were given duloxetine 60 mg capsules and placebo capsules (Becosules) 2 hours before surgery. RESULTS The total requirement for both first and second rescue analgesics was higher in placebo as compared with duloxetine and was found to be significant ( P <0.05). The difference in mean visual analog scale score was significantly ( P <0.001) higher in placebo as compared with duloxetine at all-time intervals postoperatively 0 minute (7.6±0.7 vs. 4.6±0.8); 15 minutes (5.9±0.8 vs. 4.2±1.0); 30 minutes (4.4±0.5 vs. 3.6±0.9); 4 hours (6.6±0.06 vs. 5.3±1.3); 8 hours (5.2±1.2 vs. 3.9±1.0); and 12 hours (5.1±1.3 vs. 2.3±0.7). The mean arterial blood pressure and heart rate were significantly higher in placebo compared with duloxetine in most of the time intervals in the perioperative period. There was no significant difference in the sedation score between the groups except the 30 minutes and 8 hours postoperative. DISCUSSION Preoperative oral duloxetine during laparoscopic cholecystectomy could reduce postoperative pain, postoperative analgesic requirements, and better optimization of hemodynamics without causing major side effects.
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Affiliation(s)
- Shivika Nath
- Department of Anesthesiology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
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13
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Haider N, Shukla A, Chaurasia MK, Verma R, Hemlata, Singh GP. Effect of Preoperative Duloxetine Hydrochloride on Reducing Postoperative Morphine Requirement after Open Radical Cholecystectomy in Cancer Patients: A Randomized Controlled Study. Anesth Essays Res 2022; 16:316-320. [PMID: 36620122 PMCID: PMC9813995 DOI: 10.4103/aer.aer_75_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022] Open
Abstract
Background Recently, opoids are linked with cancer recurrence. Duloxetine hydrochloride (DH), an anxiolytic may reduce total opoid requirement after cancer surgery. Aims We assessed the efficacy of a single dose of DH in reducing the total morphine requirement after open radical cholecystectomy. We also calculated the Visual Analog Scale (VAS) score, patient satisfaction score (PSS), and time taken to the use of the first rescue analgesic. Setting and Designes This is a prospective, randomized, double blind, controlled study conducted in the patients aged 20-70 years (American Society of Anaesthesiologists classes I-III) undergoing open radical cholecystectomy under general anesthesia for carcinoma gall bladder. Materials and Methods The patients were divided into two groups of 32 patients each by computer-generated randomization. Group A received oral DH (60 mg); Group B received identical placebo capsules 2 h before surgery with a sip of water. Postoperatively, intravenous morphine was given using a patient-controlled analgesia pump. After 24 h, total morphine consumption, the VAS score, time to the first rescue analgesia, and PSS were recorded. Statistical Analysis Statistical Package for the Social Sciences software (SPSS version 22.0, IBM Corp., Chicago, IL, USA 2013). P value < 0.05 or 0.001 was considered statistically significant. Results The total morphine consumption and VAS score were significantly lower in Group A. No significant effects was observed on PSS. Conclusion A single 60 mg dose of DH administered 2 h before open radical cholecystectomy reduced total morphine consumption and improved VAS score postoperatively with no effect on PSS.
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Affiliation(s)
- Nida Haider
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Aparna Shukla
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Manoj Kumar Chaurasia
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Reetu Verma
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Hemlata
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Gyan Prakash Singh
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
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Prabhakar NK, Chadwick AL, Nwaneshiudu C, Aggarwal A, Salmasi V, Lii TR, Hah JM. Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review. Int J Gen Med 2022; 15:4535-4549. [PMID: 35528286 PMCID: PMC9075013 DOI: 10.2147/ijgm.s292698] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.
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Affiliation(s)
- Nitin K Prabhakar
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Chinwe Nwaneshiudu
- Department of Anesthesiology, Perioperative and Pain Management, Mount Sinai Hospital, Icahn School of Medicine, New York, NY, USA
| | - Anuj Aggarwal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Vafi Salmasi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Theresa R Lii
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer M Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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15
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Srinivasan ES, Than KD. Commentary: The Phenotypes of Anxiety and Depression: Analysis of Combined Comorbidity and Treatment in Patients Undergoing Spinal Fusion. Neurosurgery 2022; 91:e3-e4. [PMID: 35383684 DOI: 10.1227/neu.0000000000001978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ethan S Srinivasan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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16
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Evaluation of Analgesic Efficacy and Opioid Sparing Effect of Duloxetine After Arthroscopic Rotator Cuff Repair. Clin J Pain 2022; 38:328-333. [DOI: 10.1097/ajp.0000000000001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
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The Efficacy of Preoperative Duloxetine in Patients Undergoing Major Abdominal Cancer Surgery: A Randomized Controlled Trial. Clin J Pain 2021; 37:908-913. [PMID: 34757343 DOI: 10.1097/ajp.0000000000000983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We aimed to evaluate the analgesic efficacy as well as the postoperative quality of recovery of preoperative oral duloxetine a serotonin and norepinephrine reuptake inhibitor for patients undergoing major abdominal cancer surgery. MATERIALS AND METHODS Sixty-two patients, undergoing major abdominal cancer surgery were divided into 2 equal groups, received oral duloxetine 60 mg (2 h preoperative) or placebo. Postoperative 48 hours morphine consumption, visual analog scale pain score, and quality of recovery were measured. RESULTS The cumulative 48 hours morphine consumption was significantly reduced in the duloxetine group compared with the placebo group (mean±SD) (5.2±3.2 vs. 12.9±3.4 mg), mean difference (95% confidence interval) 7.6 mg (5.9-9.3) P<0.001. The time to first morphine request was delayed significantly in the duloxetine group, median (interquartile range), 25 (19 to 38) versus 8 (4 to 9) hours, P<0.001. The duloxetine group had lower pain scores than the placebo group at 8, 12, 16, and 24 hours postoperatively, however, nonsignificant changes were observed at 0, 2, 4, 36, and 48 hours postoperatively. Participants in the duloxetine group had a better postoperative quality of recovery than the placebo group. The median (interquartile range) of the global quality of recovery-40 scoring system for the duloxetine group was 185 (180 to 191) compared with 170 (163 to 175) in the placebo group (P<0.001). DISCUSSION A single preoperative dose of oral duloxetine, 60 mg for patients subjected to major abdominal cancer surgery reduced postoperative pain, decreased opioid consumption, and improved the quality of recovery.
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Wang L, Tobe J, Au E, Tran C, Jomy J, Oparin Y, Couban RJ, Paul J. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors as adjuncts for postoperative pain management: systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2021; 128:118-134. [PMID: 34756632 DOI: 10.1016/j.bja.2021.08.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND We conducted a systematic review and meta-analysis to assess effects of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) as adjuncts for postoperative pain management. METHODS We searched seven databases and two trial registers from inception to February 2021 for RCTs that compared SSRIs or SNRIs with placebo or an active control for postoperative pain management. RESULTS We included 24 RCTs with 2197 surgical patients (21 trials for SNRIs and three trials for SSRIs). Moderate-quality evidence found that, compared with placebo, SSRIs/SNRIs (majority SNRIs) significantly reduced postoperative pain within 6 h {weighted mean difference (WMD) -0.73 cm on a 10 cm VAS (95% confidence interval [CI]: -1.04 to -0.42)}, 12 h (-0.68 cm [-1.28 to -0.07]), 24 h (-0.68 cm [-1.16 to -0.20]), 48 h (-0.73 cm [-1.22 to -0.23]), 10 days to 1 month (-0.71 cm [-1.11 to -0.31]), 3 months (-0.64 cm [-1.05 to -0.22]), and 6 months (-0.95 cm [-1.64 to -0.25]), and opioid consumption within 24 h (WMD -12 mg [95% CI: -16 to -8]) and 48 h (-10 mg [-15 to -5]), and improved patient satisfaction (WMD 0.49 point on a 1-4 Likert scale [95% CI: 0.09 to 0.89]) without significant increase in adverse events. Selective serotonin reuptake inhibitors tended to be less effective despite non-significant subgroup effects. CONCLUSIONS Serotonin-norepinephrine reuptake inhibitors as an adjunct to standard perioperative care probably provide small reduction in both acute and chronic postoperative pain and opioid consumption, and small improvement in patient satisfaction without increases in adverse events. The effects of SSRIs are inconclusive because of very limited evidence.
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Affiliation(s)
- Li Wang
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Joshua Tobe
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Emily Au
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Cody Tran
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Jomy
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yvgeniy Oparin
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Rachel J Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
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Fanelli D, Weller G, Liu H. New Serotonin-Norepinephrine Reuptake Inhibitors and Their Anesthetic and Analgesic Considerations. Neurol Int 2021; 13:497-509. [PMID: 34698218 PMCID: PMC8544373 DOI: 10.3390/neurolint13040049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 01/12/2023] Open
Abstract
Serotonin-norepinephrine reuptake inhibitors (SNRIs) inhibit the presynaptic neuronal uptake of serotonin and norepinephrine and prolong the effects of the monoamines in the synaptic cleft within the central nervous system, leading to increased postsynaptic receptor activation and neuronal activities. Serotonin-norepinephrine reuptake inhibitors can have multiple clinical indications, including as the first-line agents for the management of depression and anxiety, and as analgesics in the treatment of chronic pain. The effects of reuptake inhibition of norepinephrine and serotonin are often dose-dependent and agent-dependent. There are five FDA-approved serotonin-norepinephrine reuptake inhibitors (desvenlafaxine, duloxetine, levomilnacipran, milnacipran and sibutramine) currently being marketed in the United States. As the COVID-19 pandemic significantly increased the incidence and prevalence of anxiety and depression across the country, there are significantly increased prescriptions of these medications perioperatively. Thus, anesthesiologists are more likely than ever to have patients administered with these agents and scheduled for elective or emergency surgical procedures. A thorough understanding of these commonly prescribed serotonin-norepinephrine reuptake inhibitors and their interactions with commonly utilized anesthetic agents is paramount. There are two potentially increased risks related to the continuation of SNRIs through the perioperative period: intraoperative bleeding and serotonin syndrome. SNRIs have some off-label uses, more new indications, and ever-increasing new applications in perioperative practice. This article aims to review the commonly prescribed serotonin-norepinephrine reuptake inhibitors and the current clinical evidence regarding their considerations in perioperative anesthesia and analgesia.
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Schnabel A, Weibel S, Reichl SU, Meißner M, Kranke P, Zahn PK, Pogatzki-Zahn EM, Meyer-Frießem CH. Efficacy and adverse events of selective serotonin noradrenaline reuptake inhibitors in the management of postoperative pain: A systematic review and meta-analysis. J Clin Anesth 2021; 75:110451. [PMID: 34311244 DOI: 10.1016/j.jclinane.2021.110451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Selective-serotonin-noradrenaline-reuptake inhibitors (SSNRI) might be an interesting option for postoperative pain treatment. Objective was to investigate postoperative pain outcomes of perioperative SSNRI compared to placebo or other additives in adults undergoing surgery. DESIGN Systematic review of randomised controlled trials (RCT) with meta-analysis and GRADE assessment. SETTING Acute and chronic postoperative pain treatment. PATIENTS Adult patients undergoing surgery. INTERVENTIONS Perioperative administration of SSNRI. MEASUREMENTS Primary outcomes were postoperative acute pain at rest/during movement (measured on a scale from 0 to 10), number of patients with chronic postsurgical pain (CPSP) and with SSNRI-related adverse events. MAIN RESULTS Fourteen RCTs (908 patients) were included. We have high-quality evidence that duloxetine has no effect on pain at rest at 2 h (MD: -0.02; 95% confidence interval (CI) -0.51 to 0.47), but probably reduces it at 48 h (MD: -1.16; 95%CI -1.78 to -0.54). There is low- and moderate-quality evidence that duloxetine has no effects on pain during movement at 2 h (MD: -0.42; 95%CI -1.53 to 0.69) and 48 h (MD: -0.91; 95% CI -2.08 to 0.26), respectively. We have very low-quality evidence that duloxetine might reduce pain at rest (MD: -0.45; 95%CI -0.74 to -0.15) and movement (MD: -1.19; 95%CI -2.32 to -0.06) after 24 h. We have low-quality evidence that duloxetine may reduce the risk of CPSP at 6 months (RR:0.35; 95%CI 0.14 to 0.90). There is moderate-quality evidence that duloxetine increases the risk of dizziness (RR:1.72; 95%CI 1.26 to 2.34). CONCLUSION At the expense of a higher risk for dizziness, SSNRI may be effective in reducing postoperative pain between 24 and 48 h after surgery. However, the results of the meta-analyses are mostly imprecise and duloxetine might only be used in individual cases. Protocol registration: CRD42018094699.
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Affiliation(s)
- Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, Wuerzburg, Germany
| | - Sylvia U Reichl
- Department of Anaesthesiology, Perioperative and Intensive Care Medicine, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, Salzburg, Austria
| | - Michael Meißner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Wuerzburg, Oberduerrbacherstr. 6, Wuerzburg, Germany
| | - Peter K Zahn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, BG-Universitätsklinikum Bergmannsheil gGmbH, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, BG-Universitätsklinikum Bergmannsheil gGmbH, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany
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Mostafa MF, Ali Ibraheim O, Ibrahim AK, Ibrahim RAE, Herdan R. Impact of duloxetine on succinylcholine-induced postoperative myalgia after direct microlaryngoscopic surgeries: Randomized controlled double-blind study. Pain Pract 2021; 22:57-65. [PMID: 34145727 DOI: 10.1111/papr.13050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Succinylcholine is a preferred muscle relaxant for rapid sequence intubation. Postoperative myalgia (POM) is one of its commonest adverse effects with unknown pathogenesis. Various modalities were examined to reduce POM. We hypothesized that duloxetine may reduce the incidence and severity of fasciculation or succinylcholine-induced POM in outpatient surgeries. METHODS This randomized double-blinded trial involved controlled 70 adult participants scheduled for elective direct microlaryngoscopic surgeries. Before induction of general anesthesia by 2 h, 35 patients received duloxetine 30 mg orally (group D) and 35 patients received similar oral starch placebo capsules (group C). Fasciculations, POM, sedation score, time to first rescue analgesia, total analgesic consumption 24 h after surgery, patients' satisfaction, and adverse effects were recorded. RESULTS Incidence of fasciculation was 77.1% and 94.3% in groups D and C (p value = 0.04), whereas its severity was not significant between groups (p value = 0.09). Incidence and severity of POM were significantly lower in group D (p values = 0.004 and 0.021). Positive correlation was recorded between fasciculations and POM scores (r = 0.732 and p < 0.001). Time required for first analgesia was prolonged in group D (p value < 0.001) with less total analgesic consumption (p value = 0.039). The potassium and creatine kinase levels showed significant differences between both groups after 30 min and 24 h, respectively (p value < 0.05). Sedation scores and patients' satisfaction were better in duloxetine group (p value < 0.05) with no severe complications. CONCLUSIONS Preoperative oral duloxetine 30 mg administration decreased incidence and severity of succinylcholine-related muscle POM and fasciculations. It was also effective in reducing postoperative rescue analgesic requirement with better patients' satisfaction and no serious adverse effects.
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Affiliation(s)
- Mohamed F Mostafa
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Osama Ali Ibraheim
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed K Ibrahim
- Department of Public Health, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Reham A E Ibrahim
- Unit of Phoniatric, Otorhinolaryngology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ragaa Herdan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
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de Corde-Skurska A, Krzascik P, Lesniak A, Sacharczuk M, Nagraba L, Bujalska-Zadrozny M. Disulfiram Abrogates Morphine Tolerance-A Possible Role of µ-Opioid Receptor-Related G-Protein Activation in the Striatum. Int J Mol Sci 2021; 22:4057. [PMID: 33919998 PMCID: PMC8071001 DOI: 10.3390/ijms22084057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
One of the key strategies for effective pain management involves delaying analgesic tolerance. Early clinical reports indicate an extraordinary effectiveness of off-label disulfiram-an agent designed for alcohol use disorder-in potentiating opioid analgesia and abrogation of tolerance. Our study aimed to determine whether sustained µ-opioid signaling upon disulfiram exposure contributes to these phenomena. Wistar rats were exposed to acute and chronic disulfiram and morphine cotreatment. Nociceptive thresholds were assessed with the mechanical Randal-Selitto and thermal tail-flick tests. µ-opioid receptor activation in brain structures important for pain processing was carried out with the [35S]GTPγS assay. The results suggest that disulfiram (12.5-50 mg/kg i.g.) augmented morphine antinociception and diminished morphine (25 mg/kg, i.g.) tolerance in a supraspinal, opioid-dependent manner. Disulfiram (25 mg/kg, i.g.) induced a transient enhancement of µ-opioid receptor activation in the periaqueductal gray matter (PAG), rostral ventromedial medulla (RVM), hypothalamus, prefrontal cortex and the dorsal striatum at day 1 of morphine treatment. Disulfiram rescued µ-opioid receptor signaling in the nucleus accumbens and caudate-putamen 14 days following morphine and disulfiram cotreatment. The results of this study suggest that striatal µ-opioid receptors may contribute to the abolition of morphine tolerance following concomitant treatment with disulfiram.
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Affiliation(s)
- Anna de Corde-Skurska
- Department of Pharmacodynamics, Centre for Preclinical Research and Technology, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (A.d.C.-S.); (A.L.)
| | - Pawel Krzascik
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland;
| | - Anna Lesniak
- Department of Pharmacodynamics, Centre for Preclinical Research and Technology, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (A.d.C.-S.); (A.L.)
| | - Mariusz Sacharczuk
- Department of Experimental Genomics, Institute of Genetics and Animal Biotechnology in Jastrzebiec, Polish Academy of Sciences, Postepu 36A Str., 05-552 Magdalenka, Poland;
| | - Lukasz Nagraba
- Department of Orthopaedics and Rehabilitation, Medical University of Warsaw, Bursztynowa 2 Str., 04-749 Warsaw, Poland;
| | - Magdalena Bujalska-Zadrozny
- Department of Pharmacodynamics, Centre for Preclinical Research and Technology, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (A.d.C.-S.); (A.L.)
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Ntalouka MP, Brotis AG, Bareka MV, Stertsou ES, Fountas KN, Arnaoutoglou EM. Multimodal Analgesia in Spine Surgery: An Umbrella Review. World Neurosurg 2021; 149:129-139. [PMID: 33610874 DOI: 10.1016/j.wneu.2021.02.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE In recent years, there has been a growing interest regarding the implementation of multimodal analgesia as an important component of the ideal perioperative patient management. The aim of the current umbrella review was to establish the role of multimodal analgesia in patients undergoing spine surgery during the immediate postoperative period. METHODS A systematic review of the pertinent literature was performed. The evaluation was based on a multitude of primary endpoints including the postoperative requirements for patient-controlled analgesia, pain intensity, back-related disability, overall functionality, patient satisfaction, complications, length of hospitalization, and costs. RESULTS The results were summarized using a meta-analysis in the presence of quantitative data or in a narrative review, otherwise. There was a large body of high-quality evidence supporting that the implementation of multimodal analgesia improves patient outcome in terms of the intensity of postoperative pain, the requirements for postoperative opioid analgesia, and the opioid-associated side effects. Similarly, limited high-quality evidence supported that multimodal analgesia improved patients' functionality and satisfaction while decreasing the length of hospitalization and overall costs of surgery. However, the results were inconclusive as far as the disability was concerned. CONCLUSIONS Multimodal analgesia seems to have an essential role for the optimal management of patients undergoing spine surgery. Future research is required to optimize the multimodal analgesia protocols in this group of patients.
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Affiliation(s)
- Maria P Ntalouka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece.
| | - Alexandros G Brotis
- Department of Neurosurgery, General University Hospital of Larissa, Larissa, Greece
| | - Metaxia V Bareka
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
| | - Eleonora S Stertsou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
| | - Kostantinos N Fountas
- Department of Neurosurgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Eleni M Arnaoutoglou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, Larissa, Greece
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Duloxetine for the reduction of opioid use in elective orthopedic surgery: a systematic review and meta-analysis. Int J Clin Pharm 2021; 43:394-403. [PMID: 33459948 DOI: 10.1007/s11096-020-01216-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 12/08/2020] [Indexed: 12/19/2022]
Abstract
Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of the review This systematic review and meta-analysis is to determine if duloxetine 60 mg given perioperatively, is safe and effective at reducing postoperative opioid consumption and reported pain following elective orthopedic surgery. Method CINAHL, Medline, Cochrane Central Registry for Clinical Trials, Google Scholar, and Clinicaltrials.gov were searched using a predetermined search strategy from inception to January 15, 2019. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias tool. Opioid consumption data were converted to oral morphine milligram equivalents (MME) and exported to RevMan where meta-analysis was conducted using a DerSimonian and Laird random effects model. Results Six randomized-controlled trials were included in the literature review of postoperative pain and adverse effects. Five studies were utilized for the meta-analysis of postoperative opioid consumption; totaling 314 patients. Postoperative pain analysis showed variable statistical significance with overall lower pain scores with duloxetine. Adverse effects included an increase in insomnia with duloxetine but lower rates of nausea and vomiting. Meta-analysis revealed statistically significant [mean difference (95% CI)] lower total opioid use with duloxetine postoperatively at 24 h [- 31.9 MME (- 54.22 to - 9.6), p = 0.005], 48 h [- 30.90 MME (- 59.66 to - 2.15), p = 0.04] and overall [- 31.68 MME (- 46.62 to - 16.74), p < 0.0001]. Conclusion These results suggest that adding perioperative administration duloxetine 60 mg to a multimodal analgesia regimen within the orthopedic surgery setting significantly lowers total postoperative opioid consumption and reduces pain without significant adverse effects.
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Hetta DF, Elgalaly NA, Hetta HF, Fattah Mohammad MA. Preoperative Duloxetine to improve acute pain and quality of recovery in patients undergoing modified radical mastectomy: A dose-ranging randomized controlled trial. J Clin Anesth 2020; 67:110007. [DOI: 10.1016/j.jclinane.2020.110007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
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Tsuji O, Kosugi S, Suzuki S, Nori S, Nagoshi N, Okada E, Fujita N, Yagi M, Nakamura M, Matsumoto M, Watanabe K. Effectiveness of Duloxetine for Postsurgical Chronic Neuropathic Disorders after Spine and Spinal Cord Surgery. Asian Spine J 2020; 15:650-658. [PMID: 33189110 PMCID: PMC8561146 DOI: 10.31616/asj.2020.0191] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/20/2020] [Indexed: 12/26/2022] Open
Abstract
Study Design This is a retrospective observational study with an outpatient setting. Purpose This study aimed to describe the effects of duloxetine (DLX) administration for postsurgical chronic neuropathic disorders (both pain and numbness) following spinal surgery in patients without depression. Overview of Literature Although several reports indicated the potential of DLX to effectively treat postoperative symptoms as a perioperative intervention, there have been no reports of its positive effect on postsurgical chronic neuropathic disorders. Methods A total of 24 patients with postsurgical chronic pain and/or numbness Numeric Rating Scale (NRS) scores of ≥4 were enrolled. All patients underwent spine or spinal cord surgery at Keio University Hospital and received daily administration of DLX for more than 3 months. The mean postoperative period before the first administration of DLX was 35.5±57.0 months. DLX was administered for more than 3 months at a dose of 20, 40, or 60 mg/day, and the degree of pain and numbness was evaluated using the NRS before administration and 3 months after administration. Effectiveness was defined as more than a 2-point decrease in the NRS score following administration. Results In terms of the type of symptoms, 15 patients experienced only numbness, eight experienced both pain and numbness, and one experienced only pain. Of the 24 patients, 19 achieved effective relief with DLX. DLX was effective for all patients with postsurgical chronic pain (n=9), and it reduced postsurgical chronic numbness in 18 of 23 patients. No significant difference was observed in background spinal disorders. DLX was not effective for five patients who complained only of postsurgical chronic numbness. Conclusions This study reports the effectiveness of DLX for postsurgical chronic neuropathic disorders. Although DLX reduced postsurgical chronic pain (efficacy rate=100%) and numbness (78.3%) in certain patients, further investigation is needed to determine its optimal use.
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Affiliation(s)
- Osahiio Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shizuko Kosugi
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, Fujita Health University, Aichi, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Bastanhagh E, Zamiri F, Samimi Sadeh S, Adabi K, Pourfakhr P. Effect of Preoperative Duloxetine on Opioid Consumption in Women Undergoing Abdominal Hysterectomy: A Randomized, Double-Blinded, Placebo-Controlled Trial. Anesth Pain Med 2020; 10:e103729. [PMID: 34150561 PMCID: PMC8207876 DOI: 10.5812/aapm.103729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 01/13/2023] Open
Abstract
Background Pain is one of the most challenging issues following surgery, and it is crucial to provide adequate and appropriate pain control measures. Objectives This study assessed the efficacy of preoperative duloxetine in controlling postoperative pain in women following an abdominal hysterectomy in Yas Hospital affiliated to Tehran University of Medical Sciences between December 2019 and April 2020. Methods The study involved 80 women who were candidates for elective abdominal hysterectomy. The participants were randomly assigned to one of two groups. Group 1 received a 60 mg duloxetine capsule two hours before surgery. Group 2 received placebo following the same schedule. The amount of administrated opioids and the time from surgery to the administration of opioids were recorded, along with the frequency of nausea and vomiting experienced. Results Two patients from each group withdrew before the study ended. In total, 38 women in each group were assessed. There were no significant differences in age, duration of surgery, and the amount of administrated opioids between the two groups. However, the number of patients who had nausea and vomiting differed significantly between the two groups (65% vs. 34%; P = 0.006). Conclusions Our findings showed that duloxetine was not effective in controlling pain after abdominal hysterectomy. In addition, patients who received duloxetine had a significantly higher rate of nausea/vomiting.
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Affiliation(s)
- Ehsan Bastanhagh
- Department of Anesthesiology, Pain, and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahime Zamiri
- Department of Anesthesiology, Pain, and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
| | - Saghar Samimi Sadeh
- Department of Anesthesiology, Pain, and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Department of Anesthesiology, Pain, and Critical Care, Tehran University of Medical Sciences, Tehran, Iran. Fax: +98-2188948217,
| | - Khadijeh Adabi
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Pejman Pourfakhr
- Department of Anesthesiology, Pain, and Critical Care, Tehran University of Medical Sciences, Tehran, Iran
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de Oliveira Filho GR, Kammer RS, dos Santos HDC. Duloxetine for the treatment acute postoperative pain in adult patients: A systematic review with meta-analysis. J Clin Anesth 2020; 63:109785. [DOI: 10.1016/j.jclinane.2020.109785] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/01/2020] [Accepted: 03/07/2020] [Indexed: 10/24/2022]
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Lupu D, Hancu G. Achiral and chiral analysis of duloxetine by chromatographic and electrophoretic methods, a review on the separation methodologies. Biomed Chromatogr 2020; 35:e4883. [PMID: 32396990 DOI: 10.1002/bmc.4883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 11/06/2022]
Abstract
Duloxetine (DLX) is a widely used antidepressant drug belonging to the class of selective serotonin and norepinephrine reuptake inhibitors (SNRIs); its efficacy has been demonstrated in the treatment of not only major depressive disorders but also diabetic neuropathic pain, generalized anxiety disorder, fibromyalgia or stress urinary incontinence. It is a chiral substance and is used in therapy in the form of the enantiopure S-DLX, which is twice as active as R-DLX. Several methods have been published for the achiral and chiral determination of DLX in pharmaceuticals, biological materials and environmental samples, the majority using liquid chromatography and capillary electrophoresis coupled with different detection techniques (UV detection, fluorescence, mass spectrometry). The aim of the current review is to provide a systematic survey of the analytical techniques used for the determination of DLX from different matrices.
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Affiliation(s)
- Daniela Lupu
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy Science and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Gabriel Hancu
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy Science and Technology of Târgu Mureş, Târgu Mureş, Romania
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Takmaz O, Bastu E, Ozbasli E, Gundogan S, Karabuk E, Kocyigit M, Dede S, Naki M, Kose F, Gungor M. Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy: A Randomized Placebo-Controlled Trial. J Minim Invasive Gynecol 2020; 27:665-672. [DOI: 10.1016/j.jmig.2019.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 01/22/2023]
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Murphy GS, Avram MJ, Greenberg SB, Shear TD, Deshur MA, Dickerson D, Bilimoria S, Benson J, Maher CE, Trenk GJ, Teister KJ, Szokol JW. Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery. Anesthesiology 2020; 132:330-342. [PMID: 31939849 DOI: 10.1097/aln.0000000000003025] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Methadone is a long-acting opioid that has been reported to reduce postoperative pain scores and analgesic requirements and may attenuate development of chronic postsurgical pain. The aim of this secondary analysis of two previous trials was to follow up with patients who had received a single intraoperative dose of either methadone or traditional opioids for complex spine or cardiac surgical procedures. METHODS Preplanned analyses of long-term outcomes were conducted for spinal surgery patients randomized to receive 0.2 mg/kg methadone at the start of surgery or 2 mg hydromorphone at surgical closure, and for cardiac surgery patients randomized to receive 0.3 mg/kg methadone or 12 μg/kg fentanyl intraoperatively. A pain questionnaire assessing the weekly frequency (the primary outcome) and intensity of pain was mailed to subjects 1, 3, 6, and 12 months after surgery. Ordinal data were compared with the Mann-Whitney U test, and nominal data were compared using the chi-square test or Fisher exact probability test. The criterion for rejection of the null hypothesis was P < 0.01. RESULTS Three months after surgery, patients randomized to receive methadone for spine procedures reported the weekly frequency of chronic pain was less (median score 0 on a 0 to 4 scale [less than once a week] vs. 3 [daily] in the hydromorphone group, P = 0.004). Patients randomized to receive methadone for cardiac surgery reported the frequency of postsurgical pain was less at 1 month (median score 0) than it was in patients randomized to receive fentanyl (median score 2 [twice per week], P = 0.004). CONCLUSIONS Analgesic benefits of a single dose of intraoperative methadone were observed during the first 3 months after spinal surgery (but not at 6 and 12 months), and during the first month after cardiac surgery, when the intensity and frequency of pain were the greatest.
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Affiliation(s)
- Glenn S Murphy
- From the Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, Illinois (G.S.M., S.B.G., T.D.S., M.A.D., D.D., S.B., J.B., C.E.M., G.J.T., K.J.T., J.W.S.) the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (M.J.A.)
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Zorrilla-Vaca A, Stone A, Caballero-Lozada AF, Paredes S, Grant MC. Perioperative duloxetine for acute postoperative analgesia: a meta-analysis of randomized trials. Reg Anesth Pain Med 2019; 44:rapm-2019-100687. [PMID: 31375539 DOI: 10.1136/rapm-2019-100687] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/02/2019] [Accepted: 07/10/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Multimodal analgesia is a fundamental part of modern surgery and enhanced recovery pathways. Duloxetine, a serotonin and norepinephrine reuptake inhibitor, has been validated for the treatment of chronic neuropathic pain. The evidence for duloxetine as an adjunct for the treatment of acute postoperative pain remains controversial. We conducted a meta-analysis to determine the efficacy of duloxetine in the acute perioperative setting. METHODS A literature search was conducted in the major databases (PubMed, EMBASE and Google Scholar) for randomized controlled trials (RCTs) evaluating duloxetine compared with placebo control for acute postoperative pain. The primary outcome was postoperative pain assessed at 2, 4, 6, 24 and 48 hours time frames. Secondary outcomes included postoperative opioid administration, as well as side effects, such as postoperative nausea/vomiting (PONV), pruritus, dizziness and headache. RESULTS 574 patients (n=9 RCTs) were included in the analysis, divided between duloxetine (n=285 patients) and placebo (n=289 patients). Duloxetine use was associated with a significant reduction in pain scores as early as 4 (mean difference (MD) -0.9, 95% CI -1.33 to -0.47) and as late as 48 (MD -0.94, 95% CI -1.56 to -0.33) hours postoperatively compared with placebo. In addition, duloxetine was associated with a significant reduction in opioid administration at 24 (standardized MD (SMD) -2.24, 95% CI -4.28 to -0.19) and 48 (SMD -2.21, 95% CI -4.13 to -0.28) hours as well as a significant reduction in PONV (risk ratio 0.69, 95% CI 0.49 to 0.95, p=0.03) compared with placebo. There was no difference between groups in other side effects. CONCLUSION Duloxetine, a non-opioid neuromodulator, may provide efficacy for the treatment of acute perioperative pain. Additional prospective studies are required to establish optimal perioperative dosing regimens, role in the setting of a comprehensive multimodal analgesic plan and impact on chronic postsurgical pain. PROSPERO REGISTRATION NUMBER CRD42019121416.
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Affiliation(s)
| | - Alexander Stone
- Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Michael Conrad Grant
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Abstract
Critically ill patients commonly experience pain, and the provision of analgesia is an essential component of intensive care unit (ICU) care. Opioids are the mainstay of pain management in the ICU but are limited by their adverse effects, risk of addiction and abuse, and recent drug shortages of injectable formulations. A multimodal analgesia approach, utilizing nonopioid analgesics as adjuncts to opioid therapy, is recommended since they may modulate the pain response and reduce opioid requirements by acting on multiple pain mediators. Nonopioid analgesics discussed in detail in this article are acetaminophen, α-2 receptor agonists, gabapentinoids, ketamine, lidocaine, and nonsteroidal anti-inflammatory drugs. This literature review describes the clinical pharmacology, supportive ICU and relevant non-ICU data, and practical considerations associated with the administration of nonopioid analgesics in critically ill adult patients.
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Affiliation(s)
| | - Kathryn E Smith
- 1 Department of Pharmacy, Maine Medical Center, Portland, ME, USA
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Muscatello MRA, Zoccali RA, Pandolfo G, Mangano P, Lorusso S, Cedro C, Battaglia F, Spina E, Bruno A. Duloxetine in Psychiatric Disorders: Expansions Beyond Major Depression and Generalized Anxiety Disorder. Front Psychiatry 2019; 10:772. [PMID: 31749717 PMCID: PMC6844294 DOI: 10.3389/fpsyt.2019.00772] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background: Duloxetine hydrochloride (DUL) is an antidepressant included in the pharmacological class of serotonin-norepinephrine reuptake inhibitors approved for the treatment of major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain. The aim of this review was to elucidate current evidences on the use of DUL in the treatment of a variety of psychiatric disorders. Methods: This systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed database was searched from January 1, 2003, to September 30, 2018, using 11 key terms related to psychiatric disorders ("persistent depressive disorder," "dysthymic disorder," "bipolar disorder," "seasonal affective disorder," "obsessive-compulsive disorder," "social phobia," "panic disorder," "posttraumatic stress disorder," "schizophrenia," "eating disorders," "sexual disorders," "personality disorders") and one key term related to duloxetine ("duloxetine hydrochloride"). Article titles and abstracts were scanned to determine relevance to the topic. For additional studies, the authors also examined the reference lists of several of the included papers. Results: Duloxetine may be an effective treatment for mood spectrum disorders, panic disorder, several symptom clusters of borderline personality, and as add-on drug in schizophrenia. Modest or conflicting results have been found for the efficacy of duloxetine in obsessive-compulsive disorder, posttraumatic stress disorder, eating, and sexual disorders. Conclusion: Major limitations of the reviewed studies were short trial duration, small sample sizes, and the lack of control groups. Defining the potential role of DUL in the treatment of psychiatric disorders other than major depressive disorder and generalized anxiety disorder needs further randomized, placebo-controlled studies.
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Affiliation(s)
| | - Rocco A Zoccali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Gianluca Pandolfo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Paolo Mangano
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Simona Lorusso
- Department of Clinical Neurosciences, Villa San Benedetto Menni, Italy
| | - Clemente Cedro
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
| | - Fortunato Battaglia
- Department of Medical Sciences, Neurology and Psychiatry, Hackensack Meridian School of Medicine, Seton Hall University, United States
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Antonio Bruno
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy
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Comparison of Preoperative Administration of Pregabalin and Duloxetine on Cognitive Functions and Pain Management After Spinal Surgery. Clin J Pain 2018; 34:1114-1120. [DOI: 10.1097/ajp.0000000000000640] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Jain NB, Schneider BJ, Murrell WB, Hettrich CM, Archer KR. What's New in Orthopaedic Rehabilitation. J Bone Joint Surg Am 2018; 100:1993-1999. [PMID: 30480605 DOI: 10.2106/jbjs.18.00828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Nitin B Jain
- Departments of Physical Medicine and Rehabilitation (N.B.J., B.J.S., and K.R.A.) and Orthopaedics (N.B.J. and K.R.A.) and Division of Epidemiology (N.B.J.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Byron J Schneider
- Departments of Physical Medicine and Rehabilitation (N.B.J., B.J.S., and K.R.A.) and Orthopaedics (N.B.J. and K.R.A.) and Division of Epidemiology (N.B.J.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - William B Murrell
- Emirates Hospitals Group, Integra Medical and Surgical Center, Dubai, United Arab Emirates.,Department of Orthopaedics, Rehabilitation, and Podiatry, Ft. Belvoir Community Hospital, Ft. Belvoir, Virginia
| | | | - Kristin R Archer
- Departments of Physical Medicine and Rehabilitation (N.B.J., B.J.S., and K.R.A.) and Orthopaedics (N.B.J. and K.R.A.) and Division of Epidemiology (N.B.J.), Vanderbilt University Medical Center, Nashville, Tennessee
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Koepke EJ, Manning EL, Miller TE, Ganesh A, Williams DGA, Manning MW. The rising tide of opioid use and abuse: the role of the anesthesiologist. Perioper Med (Lond) 2018; 7:16. [PMID: 29988696 PMCID: PMC6029394 DOI: 10.1186/s13741-018-0097-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/18/2018] [Indexed: 12/13/2022] Open
Abstract
Opioid use has risen dramatically in the past three decades. In the USA, opioid overdose has become a leading cause of unintentional death, surpassing motor vehicle accidents. A patient's first exposure to opioids may be during the perioperative period, a time where anesthesiologists have a significant role in pain management. Almost all patients in the USA receive opioids during a surgical encounter. Opioids have many undesirable side effects, including potential for misuse, or opioid use disorder. Anesthesiologists and surgeons employ several methods to decrease unnecessary opioid use, opioid-related adverse events, and side effects in the perioperative period. Multimodal analgesia, enhanced recovery pathways, and regional anesthesia are key tools as we work towards optimal opioid stewardship and the ideal of effective analgesia without undesirable sequelae.
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Affiliation(s)
- Elena J. Koepke
- Division of General, Vascular and Transplant Anesthesiology, Department of Anesthesiology, Duke University, Box 3094, 2301 Erwin Road, Durham, NC 27710 USA
| | - Erin L. Manning
- Division of Regional Anesthesiology, Department of Anesthesiology, Duke University, Durham, USA
| | - Timothy E. Miller
- Division of General, Vascular and Transplant Anesthesiology, Department of Anesthesiology, Duke University, Box 3094, 2301 Erwin Road, Durham, NC 27710 USA
| | - Arun Ganesh
- Division of Pain, Department of Anesthesiology, Duke University, Durham, USA
| | - David G. A. Williams
- Division of General, Vascular and Transplant Anesthesiology, Department of Anesthesiology, Duke University, Box 3094, 2301 Erwin Road, Durham, NC 27710 USA
| | - Michael W. Manning
- Division of General, Vascular and Transplant Anesthesiology, Department of Anesthesiology, Duke University, Box 3094, 2301 Erwin Road, Durham, NC 27710 USA
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Attia JZ, Mansour HS. Perioperative Duloxetine and Etoricoxibto improve postoperative pain after lumbar Laminectomy: a randomized, double-blind, controlled study. BMC Anesthesiol 2017; 17:162. [PMID: 29197345 PMCID: PMC5712123 DOI: 10.1186/s12871-017-0450-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/20/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Duloxetine, Etoricoxib and opioid are of the commonly administered drugs in Lumbar laminectomy. The aim of this study is to assess the effect of perioperative use of Duloxetine in combination with Etoricoxib on postoperative pain and opioid requirements. METHODS One hundred twenty patients with ASA physical status were enrolled with age between 18 and 70 years. Patients were divided randomly into four groups of 30 patients: group P received placebo, group E received etoricoxib 120 mg, group D received duloxetine 60 mg and group D/E received duloxetine 60 mg capsules and etoricoxib 120 mg; 1 h before surgery and 24 h after. RESULTS Neither Duloxetine nor etoricoxib individually had effect on pain with movement, while their combination revealed a significant reduction in pain scores over the entire postoperative period at rest and on movement. Etoricoxib showed a significant decrease in pain at all times at rest when compared with group P, while it showed significant pain decrease only at 0, 2 and 4 h when compared with group D. On the other hand duloxetine alone showed significant decrease in pain at rest at 24 h and 48 h when compared with group P. ConcerningMorphine requirement after 24 h.; it wassignificantly lower in the D/E group in comparison with groups P, E and D. It should be noted also that there was a significant decrease morphine requirement in both groups E and D. CONCLUSION The perioperative administration of the combination of etoricoxib and duloxetine improved analgesia and reduced opioid consumption without significant side effects. TRIAL REGISTRATION ISRCTN48329522 . 17 June 2017.
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Affiliation(s)
- Josef Zekry Attia
- Departments of Anesthesiology and I.C.U Al-Minia University, Faculty of Medicine, Minia University, Minia, 61111, Egypt.
| | - Haidy Salah Mansour
- Departments of Anesthesiology and I.C.U Al-Minia University, Faculty of Medicine, Minia University, Minia, 61111, Egypt
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Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management. Anesth Analg 2017; 125:1749-1760. [DOI: 10.1213/ane.0000000000002497] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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