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Ferreira GE, Patanwala AE, Turton H, Langford AV, Harris IA, Maher CG, McLachlan AJ, Glare P, Lin CWC. How is postoperative pain after hip and knee replacement managed? An analysis of two large hospitals in Australia. Perioper Med (Lond) 2024; 13:49. [PMID: 38822448 PMCID: PMC11143609 DOI: 10.1186/s13741-024-00403-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/20/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Multimodal analgesia regimens are recommended for the postoperative period after hip and knee replacement surgeries. However, there are no data on practice patterns for analgesic use in the immediate postoperative period after hip and knee replacements in Australia. OBJECTIVES To describe analgesic prescribing patterns in the inpatient postoperative phase for patients undergoing hip and knee replacement. METHODS Retrospective study of electronic medical record data from two major hospitals in Sydney, Australia. We identified analgesic medication prescriptions for all patients aged 18 years and older who underwent hip or knee replacement surgery in 2019. We extracted data on pain medications prescribed while in the ward up until discharge. These were grouped into distinct categories based on the Anatomical Therapeutic Chemical classification. We described the frequency (%) of pain medications used by category and computed the average oral morphine equivalent daily dose (OMEDD) during hospitalisation. RESULTS We identified 1282 surgeries in 1225 patients. Patients had a mean (SD) age of 69 (11.8) years; most (57.1%) were female. Over 99% of patients were prescribed opioid analgesics and paracetamol during their hospital stay. Most patients (61.4%) were managed with paracetamol and opioids only. The most common prescribed opioid was oxycodone (87.3% of patients). Only 19% of patients were prescribed nonsteroidal anti-inflammatories (NSAIDs). The median (IQR) average daily OMEDD was 50.2 mg (30.3-77.9). CONCLUSION We identified high use of opioids analgesics as the main strategies for pain control after hip and knee replacement in hospital. Other analgesics were much less frequently used, such as NSAIDs, and always in combination with opioids and paracetamol.
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Affiliation(s)
- Giovanni E Ferreira
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia.
- Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Camperdown, NSW, 2050, Australia.
| | - Asad E Patanwala
- Pharmacy Department, Royal Prince Alfred Hospital, Sydney, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Hannah Turton
- Pharmacy Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Aili V Langford
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
- Orthopaedic Department, South Western Sydney Local Health District, Liverpool Hospital, Sydney, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Paul Glare
- Northern Clinical School, Faculty of Medicine & Health, University of Sydney, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
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Liu S, Patanwala AE, Naylor JM, Stevens JA, Bugeja B, Begley D, Khor KE, Lau E, Adie S, Penm J. Tapentadol Versus Oxycodone for Opioid-Related Adverse Drug Events and Clinical Outcomes After Inpatient Surgery. THE JOURNAL OF PAIN 2024; 25:466-475. [PMID: 37741523 DOI: 10.1016/j.jpain.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/25/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
Oxycodone is a commonly prescribed opioid for postoperative pain. However, there has been a marked increase in the use of tapentadol over the previous decade due to a perceived superior safety profile of tapentadol compared to oxycodone. There is limited real-world evidence on the safety of tapentadol compared to oxycodone after surgery. The primary objective was to examine the impact of tapentadol compared to oxycodone use on the incidence of opioid-related adverse drug events after surgery. Data for adult surgical patients receiving tapentadol or oxycodone during hospitalization between January 1, 2018, and December 31, 2021, were collected from electronic medical records of 3 tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events. Patients receiving tapentadol or oxycodone were matched using nearest-neighbour propensity score matching. In the matched cohorts (n = 1,530 vs n = 2,775; mean [standard deviation] age 62.3 [17.0] years vs 61.9 [standard deviation 17.9] years; 43% vs 45% male for the tapentadol vs oxycodone groups, respectively), patients given tapentadol experienced a similar incidence of adverse events overall (14.4%, 220/1,530 vs 12.6%, 349/2,775; P = .100; 95% CI -.35% to 3.95%). Secondary outcomes included an increased risk of delirium (2.7%, 41/1,530 vs 1.3%, 37/2,775), arrhythmias (3.4%, 52/1,530 vs 2.2%, 62/2,775), and length of hospital stay (5 [range 1-201] vs 4 [range 1-226] days) compared with oxycodone use. Further real-world studies are warranted to determine the impact of tapentadol use on a broad range of patient outcomes. PERSPECTIVE: This study provides an early signal that tapentadol use may be associated with an increased risk of some adverse events and a longer length of stay. Further research is needed to examine the impact of tapentadol use on a broad range of patient outcomes in clinical practice settings.
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Affiliation(s)
- Shania Liu
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Prince of Wales Hospital, Sydney, Australia
| | - Asad E Patanwala
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, Australia; South Western Sydney School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jennifer A Stevens
- School of Clinical Medicine, University of New South Wales Medicine and Health, St Vincent's Clinical School, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia; School of Medicine, University of Notre Dame, Sydney, Australia
| | - Bernadette Bugeja
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
| | - David Begley
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia
| | - Kok E Khor
- Department of Pain Management, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Eric Lau
- Department of Pharmacy, St George Hospital, Sydney, Australia
| | - Sam Adie
- St George and Sutherland Clinical School, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Jonathan Penm
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia; Department of Pharmacy, Prince of Wales Hospital, Sydney, Australia
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Wang A, Murphy J, Shteynman L, Daksla N, Gupta A, Bergese S. Novel Opioids in the Setting of Acute Postoperative Pain: A Narrative Review. Pharmaceuticals (Basel) 2023; 17:29. [PMID: 38256863 PMCID: PMC10819619 DOI: 10.3390/ph17010029] [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: 10/25/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Although traditional opioids such as morphine and oxycodone are commonly used in the management of acute postoperative pain, novel opioids may play a role as alternatives that provide potent pain relief while minimizing adverse effects. In this review, we discuss the mechanisms of action, findings from preclinical studies and clinical trials, and potential advantages of several novel opioids. The more established include oliceridine (biased ligand activity to activate analgesia and downregulate opioid-related adverse events), tapentadol (mu-opioid agonist and norepinephrine reuptake inhibitor), and cebranopadol (mu-opioid agonist with nociceptin opioid peptide activity)-all of which have demonstrated success in the clinical setting when compared to traditional opioids. On the other hand, dinalbuphine sebacate (DNS; semi-synthetic mu partial antagonist and kappa agonist), dual enkephalinase inhibitors (STR-324, PL37, and PL265), and endomorphin-1 analog (CYT-1010) have shown good efficacy in preclinical studies with future plans for clinical trials. Rather than relying solely on mu-opioid receptor agonism to relieve pain and risk opioid-related adverse events (ORAEs), novel opioids make use of alternative mechanisms of action to treat pain while maintaining a safer side-effect profile, such as lower incidence of nausea, vomiting, sedation, and respiratory depression as well as reduced abuse potential.
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Affiliation(s)
- Ashley Wang
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
| | - Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (L.S.)
| | - Lana Shteynman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (L.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
| | - Abhishek Gupta
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.W.); (N.D.); (A.G.)
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA
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Mitra B, Roman C, Wu B, Luckhoff C, Goubrial D, Amos T, Bannon-Murphy H, Huynh R, Dooley M, Smit DV, Cameron PA. Restriction of oxycodone in the emergency department (ROXY-ED): A randomised controlled trial. Br J Pain 2023; 17:491-500. [PMID: 38107754 PMCID: PMC10722107 DOI: 10.1177/20494637231189031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Background The prescription of opioids in emergency care has been associated with harm, including overdose and dependence. The aim of this trial was to assess restriction of access to oxycodone (ROXY), in combination with education and guideline modifications, versus education and guideline modifications alone (standard care) to reduce oxycodone administration in the Emergency Department (ED). Methods An unblinded, active control, randomised controlled trial was conducted in an adult tertiary ED. Participants were patients aged 18-75 years who had analgesics administered in the ED. The primary intervention was ROXY, through removal of all oxycodone immediate release tablets from the ED imprest, with availability of a small supply after senior clinician approval. The intervention did not restrict prescription of discharge medications. The primary outcome measure was oxycodone administration rates. Secondary outcomes were administration rates of other analgesic medications, time to initial analgesics and oxycodone prescription on discharge. Results There were 2258 patients eligible for analysis. Oxycodone was administered to 80 (6.1%) patients in the ROXY group and 221 (23.3%) patients in the standard care group (relative risk (RR) 0.26; 95% CI: 0.21 to 0.33; p < .001). Tapentadol was prescribed more frequently in the ROXY group (RR 2.17; 95% CI: 1.71-2.74), while there were no differences in prescription of other analgesic medications. On discharge, significantly fewer patients were prescribed oxycodone (RR 0.51; 95% CI: 0.39-0.66) and no differences were observed in prescription rates of other analgesic medications. There was no difference in time to first analgesic (HR 0.94; 95% CI: 0.86-1.02). Conclusions Restricted access to oxycodone was superior to education and guideline modifications alone for reducing oxycodone use in the ED and reducing discharge prescriptions of oxycodone from the ED. The addition of simple restrictive interventions is recommended to enable rapid changes to clinician behaviour to reduce the potential harm associated with the prescribing of oxycodone in the ED.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Cristina Roman
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Bertha Wu
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Carl Luckhoff
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Diana Goubrial
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Timothy Amos
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Ronald Huynh
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael Dooley
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - De Villiers Smit
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter A. Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Barbosa J, Leal S, Pereira FC, Dinis-Oliveira RJ, Faria J. Tramadol and Tapentadol Induce Conditioned Place Preference with a Differential Impact on Rewarding Memory and Incubation of Craving. Pharmaceuticals (Basel) 2023; 16:ph16010086. [PMID: 36678582 PMCID: PMC9864601 DOI: 10.3390/ph16010086] [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: 11/21/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Tramadol and tapentadol, synthetic opioids commonly prescribed for moderate-to-severe pain, have a unique pharmacology that optimizes their analgesia and safety. However, they are not devoid of risks, presenting addictive, abuse, and dependence potential. While tramadol-reinforcing properties have been documented by various studies with human and animal models, including conditioned place preference (CPP) assays, no similar studies have been performed with tapentadol. In the present study, we performed CPP assays by intraperitoneally administering Wistar rats with a tramadol/tapentadol therapeutic dose. Animal permanence and the number of entries in the CPP compartments were recorded in the preconditioning phase and then 1 (T1), 7 (T7), and 14 (T14) days after conditioning. Both opioids induced a change in place preference (T1), suggesting that they have short-term reinforcing properties. However, only tramadol was associated with place preference retention (T7 and T14), with an increase in the number of entries in the opioid-paired compartment (T1 and T7), showing that it causes rewarding memory and incubation of craving. The results indicate that at therapeutic doses: (1) both drugs cause short-term rewarding effects and (2) as opposed to tramadol, tapentadol does not cause CPP retention, despite its higher central nervous system activity and stricter scheduling.
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Affiliation(s)
- Joana Barbosa
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences—CESPU (IUCS-CESPU), 4585-116 Gandra, PRD, Portugal
- UCIBIO-REQUIMTE—Applied Molecular Biosciences Unit-Network of Chemistry and Technology, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Correspondence: (J.B.); (J.F.)
| | - Sandra Leal
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences—CESPU (IUCS-CESPU), 4585-116 Gandra, PRD, Portugal
- CINTESIS@RISE—Center for Health Technology and Services Research of the Health Research Network, MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, 4200-450 Porto, Portugal
| | - Frederico C. Pereira
- Institute of Pharmacology and Experimental Therapeutics/iCBR—Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, 3000-354 Coimbra, Portugal
| | - Ricardo Jorge Dinis-Oliveira
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences—CESPU (IUCS-CESPU), 4585-116 Gandra, PRD, Portugal
- UCIBIO-REQUIMTE—Applied Molecular Biosciences Unit-Network of Chemistry and Technology, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, 4099-002 Porto, Portugal
- MTG Research and Development Lab, 4200-604 Porto, Portugal
| | - Juliana Faria
- TOXRUN—Toxicology Research Unit, University Institute of Health Sciences—CESPU (IUCS-CESPU), 4585-116 Gandra, PRD, Portugal
- UCIBIO-REQUIMTE—Applied Molecular Biosciences Unit-Network of Chemistry and Technology, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Correspondence: (J.B.); (J.F.)
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Guo X, Li R, Huang N, Zhang T, Li J, Gong L, Sun R. Efficacy and safety of Shouhui Tongbian Capsules in the treatment of constipation: A systematic review and meta-analysis. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 108:154541. [PMID: 36375236 DOI: 10.1016/j.phymed.2022.154541] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/20/2022] [Accepted: 11/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Constipation is a common gastrointestinal disorder, which has seriously affected the quality of people's daily life. Traditional Chinese Medicine (TCM) therapy takes syndrome differentiation and treatment as the theoretical guidance with certain advantages in treating constipation with the holistic approach. However, there are few studies on the treatment of constipation with Shouhui Tongbian Capsules (SHTB). PURPOSE This study was aimed to evaluate the clinical effect and safety of SHTB in the treatment of constipation and provide evidence-based references for clinical application. STUDY DESIGN A systematic review and meta-analysis of existing literature on SHTB for treating constipation. METHODS Chinese databases (China Network Knowledge Infrastructure, Wan Fang Database and Chinese Scientific Journal Database) and English databases (PubMed, EmBase and the Cochrane Library) were thoroughly investigated through screening randomized controlled trials on SHTB for constipation from the establishment of all databases to September 26, 2022. Data extraction and quality evaluation were performed on the literature that met the inclusion criteria and a meta-analysis was performed for selected data using Review Manager 5.4, ROB 2.0 and Stata 17.0. RESULTS A total of 14 RCTs (randomized controlled trial) including 1310 participants were included in the analysis. The results showed that the test group was superior to the control group in improving the total effective rate and curative effect, clinical symptom score, gastrointestinal peptide index and reducing adverse reactions and recurrence rate. The specific results were as follows: ① The total effective rate increased significantly (RR = 1.24, 95% CI [1.18, 1.30], Z = 8.25, p< 0.00001); ② The clinical symptom indexs, including the difficulty of defecation [SMD = -1.28, 95% CI (-1.44, -1.12), Z = 15.65, p< 0.00001], the frequency of spontaneous defecation [SMD = 1.28, 95% CI (1.01, 1.54), Z = 9.52, p< 0.00001], defecation interval [SMD = -1.47, 95% CI (-1.68, -1.26), Z = 13.79, p < 0.00001], incomplete defecation [SMD = -1.34, 95% CI (-1.57, -1.11), Z = 11.42, p < 0.00001], duration of defecation [SMD = -2.02, 95% CI (-2.39, -1.65), Z = 10.73, p < 0.00001], stool characteristics [SMD = -2.30, 95% CI (-2.60, -1.99), Z = 14.72, p< 0.00001] and TCM main syndrome scores [SMD = -1.25, 95% CI (-1.46, -1.05), Z = 11.79, p< 0.00001] increased observably; ③ The gastrointestinal peptide hormone indexs, including MTL Level [SMD = 0.43, 95% CI (0.24, 0.62), Z = 4.44, p < 0.00001] and SP Level [RR =0.57, 95% CI (0.37, 0.87), Z = 2.61, p = 0.009] were improved obviously; ④ The incidence of adverse reactions (RR = 0.57, 95% CI [0.37, 0.87], Z = 2.61, p = 0.009) and recurrence rate (RR = 0.31, 95% CI [0.18, 0.54], Z = 4.28, P <0.001) reduced significantly. Sensitivity analysis showed that there was no significant change in all outcome indicators, which suggested that the results of meta-analysis were relatively stable. Funnel plot and Egger test results showed that the literature included in the study might have publication bias. CONCLUSION SHTB can be used to treat functional constipation, especially elderly functional constipation, constipation caused by tumor chemotherapy and disease concomitant constipation. The optimal dosage of SHTB was 0.70 g (2 capsules) each time, 3 times a day, for 28 days. Combined with basic treatment, lactose oral solution, mosaic or castor oil could improve the total effective rate, clinical symptom indicators, gastrointestinal peptide hormone indicators and reduce adverse reaction rate of patients. However, due to the limitations of the included clinical trials, high-quality clinical trials with long follow ups are needed to evaluate the effectiveness and safety of SHTB in treating different types of constipation.
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Affiliation(s)
- Xin Guo
- Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China
| | - Rongrong Li
- The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China; Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Nana Huang
- The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China
| | - Tianyu Zhang
- The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China; Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Jianchao Li
- The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China; Shandong University of Traditional Chinese Medicine, Jinan 250355, China
| | - Liping Gong
- The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China.
| | - Rong Sun
- The Second Hospital of Shandong University, No. 247 Beiyuan Street, Jinan 250033, China; Advanced Medical Research Institute, Shandong University, Jinan 250012, China.
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Mirabella J, Ravi D, Chiew AL, Buckley NA, Chan BS. Prescribing trend of tapentadol in a Sydney local health district. Br J Clin Pharmacol 2022; 88:3929-3935. [PMID: 35763675 PMCID: PMC9544395 DOI: 10.1111/bcp.15448] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/29/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022] Open
Abstract
AIMS Tapentadol, an opioid with mu-opioid receptor agonism and noradrenaline reuptake inhibition, has been increasingly used in Australia since 2011. However, data on hospital prescribing trends and indications are scarce. This study aimed to investigate hospital prescribing trends of tapentadol, oxycodone and tramadol in a Sydney local health district (LHD) and the indications for tapentadol hospital prescriptions in an Australian tertiary hospital. METHODS We analysed 5-year patient dispensing for tapentadol, oxycodone and tramadol from four hospitals in a Sydney LHD with data expressed as oral morphine equivalents (OME). We also conducted a retrospective review of 140 and 54 patients prescribed tapentadol at a tertiary hospital's surgical and spinal units in 2020. RESULTS Over 5 years in the Sydney LHD, there was a 19.5% reduction in total dispensing of these opioids from 1 225 210 to 986 477.5 OME milligrams. Decreases were specifically for oxycodone (-37.8% immediate-release, -65.2% sustained-release) and tramadol (-74.6% immediate-release, -70.1% sustained-release). Contrastingly, hospital prescriptions of tapentadol immediate-release increased by 223.2% between 2018-19 and 2020-21 while sustained-release increased by 17.9% from 2016-17 to 2020-21. By 2020-21, tapentadol overtook oxycodone to become the most prescribed opioid in the Sydney LHD (51.4%). At the hospital's surgical units, 137 (97.9%) patients were prescribed tapentadol for acute post-operative pain with the majority (54.0%) prescribed both immediate-release and sustained-release tapentadol, while 71.1% were prescribed for neuropathic pain in the spinal units. CONCLUSION In a Sydney LHD, tapentadol prescriptions increased significantly to become the preferred opioid analgesic. At the hospital's surgical units, off-label prescriptions of tapentadol sustained-release for acute post-operative pain were observed.
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Affiliation(s)
| | - Deepa Ravi
- PharmacyPrince of Wales HospitalRandwickNSWAustralia
| | - Angela L. Chiew
- Faculty of MedicineUniversity of New South WalesRandwickNSWAustralia
- Department of Emergency Medicine, Clinical Toxicology UnitPrince of Wales HospitalRandwickNSWAustralia
| | | | - Betty S. Chan
- Faculty of MedicineUniversity of New South WalesRandwickNSWAustralia
- Department of Emergency Medicine, Clinical Toxicology UnitPrince of Wales HospitalRandwickNSWAustralia
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Somogyi AA, Musolino ST, Barratt DT. New pharmacological perspectives and therapeutic options for opioids: Differences matter. Anaesth Intensive Care 2022; 50:127-140. [PMID: 35112584 DOI: 10.1177/0310057x211063891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Opioids remain the major drug class for the treatment of acute, chronic and cancer pain, but have major harmful effects such as dependence and opioid-induced ventilatory impairment. Although no new typical opioids have come onto the market in the past almost 50 years, a plethora of new innovative formulations has been developed to meet the clinical need. This review is intended to shed light on new understanding of the molecular pharmacology of opioids, which has arisen largely due to the genomic revolution, and what new drugs may become available in the coming years. Atypical opioids have and are being developed which not only target the mu opioid receptor but other targets in the pain pathway. Biased mu agonists have been developed but remain 'unbiased' clinically. The contribution of drugs targeting non-mu opioid receptors either alone or as heterodimers shows potential promise but remains understudied. That gene splice variants of the mu opioid receptor produce multiple receptor isoforms in different brain regions, and may change with pain chronicity and phenotype, presents new challenges but also opportunities for precision pain medicine. Finally, that opioids also have pro-inflammatory effects not aligned with mu opioid receptor binding affinity implicates a fresh understanding of their role in chronic pain, whether cancer or non-cancer. Hopefully, a new understanding of opioid analgesic drug action may lead to new drug development and better precision medicine in acute and chronic pain relief with less patient harm.
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Affiliation(s)
- Andrew A Somogyi
- Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
| | - Stefan T Musolino
- Discipline of Pharmacology, University of Adelaide, Adelaide, Australia
| | - Daniel T Barratt
- Discipline of Physiology, University of Adelaide, Adelaide, Australia
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9
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Manandhar P, Connor M, Santiago M. Tapentadol shows lower intrinsic efficacy at µ receptor than morphine and oxycodone. Pharmacol Res Perspect 2022; 10:e00921. [PMID: 35084120 PMCID: PMC8929351 DOI: 10.1002/prp2.921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022] Open
Abstract
Tapentadol is a centrally acting analgesic with a dual mechanism of action. It acts as an agonist at the µ receptor and inhibitor of noradrenaline reuptake. Clinical trials suggest similar analgesic efficacy of tapentadol, oxycodone, and morphine in acute and chronic pain. Given the limited information about the molecular actions of tapentadol at the µ receptor, we investigated the intrinsic efficacy of tapentadol and compared it with other opioids. β-chlornaltrexamine (β-CNA, 100 nM, 20 min) was used to deplete spare receptors in AtT20 cells stably transfected with human µ receptor wild-type (WT). Opioid-mediated changes in membrane potential were measured in real-time using a membrane potential-sensitive fluorescent dye. Using Black and Leff's operational model, intrinsic efficacy relative to DAMGO was calculated for each opioid. Tapentadol (0.05 ± 0.01) activated the GIRK channel with lesser intrinsic efficacy than morphine (0.17 ± 0.02) and oxycodone (0.16 ± 0.02). We further assessed the signaling of tapentadol in the common µ receptor variants (N40D and A6V) which are associated with altered receptor signaling. We found no difference in the response of tapentadol between these receptor variants.
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Affiliation(s)
- Preeti Manandhar
- Macquarie Medical SchoolMacquarie UniversitySydneyNew South WalesAustralia
| | - Mark Connor
- Macquarie Medical SchoolMacquarie UniversitySydneyNew South WalesAustralia
| | - Marina Santiago
- Macquarie Medical SchoolMacquarie UniversitySydneyNew South WalesAustralia
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10
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Wang X, Penm J, Patanwala AE. Cost-effectiveness of tapentadol immediate release versus oxycodone immediate release for acute post-operative pain after major hip surgeries. Curr Med Res Opin 2022; 38:115-121. [PMID: 34641744 DOI: 10.1080/03007995.2021.1993161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of tapentadol immediate-release (IR) versus oxycodone IR for post-operative pain after a major hip surgery. METHODS This study has been conducted using an Australian societal perspective, focusing on adult patients after a major hip surgery. A cost-effectiveness analysis was conducted using a decision-analytic model. The model incorporated drug and other resource costs, the probability of opioid-related adverse events, and quality-adjusted life months (QALM) in each treatment arm. A willingness to pay (WTP) threshold of AU$2500 was used per QALM gained. A probabilistic sensitivity analysis was conducted to examine the uncertainty of the assumptions. The primary outcome was the incremental cost-effectiveness ratio (ICER) of tapentadol IR versus oxycodone IR, expressed as Australian dollars (AU$) per QALM gained. RESULTS Tapentadol IR dominated oxycodone IR, with a cost savings of AU$201 and an increase in QALM by 0.014. The ICER was -13,946 AU$/QALM (negative value attributed to numerator). In the probabilistic sensitivity analysis, 84.2% of the simulations were in favour of tapentadol IR at the WTP threshold. CONCLUSIONS Tapentadol IR may be more cost-effective than oxycodone IR for the treatment of acute postoperative pain after major hip surgeries.
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Affiliation(s)
- Xinyi Wang
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, Australia
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11
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Comelon M, Raeder J, Drægni T, Lieng M, Lenz H. Tapentadol versus oxycodone analgesia and side effects after laparoscopic hysterectomy: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:995-1002. [PMID: 33428347 DOI: 10.1097/eja.0000000000001425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tapentadol is an opioid, which acts as a μ-opioid receptor agonist and inhibits noradrenaline reuptake in the central nervous system. This dual mechanism of action results in synergistic analgesic effects and potentially less side effects. This has been shown in treatment of chronic pain but postoperative studies are sparse. OBJECTIVES The main aim was to compare the analgesic effect of tapentadol with oxycodone after laparoscopic hysterectomy. Opioid side effects were recorded as secondary outcomes. DESIGN Randomised, blinded trial. SETTING Single-centre, Oslo University Hospital, Norway, December 2017 to February 2019. PATIENTS Eighty-six opioid-naïve American Society of Anesthesiologists physical status 1 to 3 women undergoing laparoscopic hysterectomy for nonmalignant conditions. INTERVENTION The patients received either oral tapentadol (group T) or oxycodone (group O) as part of multimodal pain treatment. Extended-release study medicine was administered 1 h preoperatively and after 12 h. Immediate-release study medicine was used as rescue analgesia. MAIN OUTCOME MEASURES Pain scores, opioid consumption and opioid-induced side effects were evaluated during the first 24 h after surgery. RESULTS The groups scored similarly for pain at rest using a numerical rating scale (NRS) 1 h postoperatively (group T 4.4, 95% CI, 3.8 to 5.0, group O 4.6, 95% CI, 3.8 to 5.3). No statistically significant differences were found between the groups for NRS at rest or while coughing during the 24-h follow-up period (P = 0.857 and P = 0.973). Mean dose of oral rescue medicine was similar for the groups (P = 0.914). Group T had significantly lower odds for nausea at 2 and 3 h postoperatively (P = 0.040, P = 0.020) and less need for antiemetics than group O. No differences were found for respiratory depression, vomiting, dizziness, pruritus, headache or sedation. CONCLUSION We found tapentadol to be similar in analgesic efficacy to oxycodone during the first 24 h after hysterectomy, but with significantly less nausea. TRIAL REGISTRATION ClinicalTrials.gov, NCT03314792.
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Affiliation(s)
- Marlin Comelon
- From the Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital (MC, JR, HL), Faculty of Medicine, Institute of Clinical Medicine, University of Oslo (MC, JR, TD, ML, HL), Division of Emergencies and Critical Care, Department of Research and Development (TD) and Division of Gynaecology and Obstetrics, Oslo University Hospital, Oslo, Norway (ML)
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12
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Tapentadol Versus Tramadol: A Narrative and Comparative Review of Their Pharmacological, Efficacy and Safety Profiles in Adult Patients. Drugs 2021; 81:1257-1272. [PMID: 34196947 PMCID: PMC8318929 DOI: 10.1007/s40265-021-01515-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
We conducted a narrative review of the literature to compare the pharmacological, efficacy and safety profiles of tapentadol and tramadol, and to assess the clinical interest of tapentadol in adult patients. Tapentadol and tramadol share a mixed mechanism of action, including both mu-agonist and monoaminergic properties. Tapentadol is approximately two to three times more potent than tramadol and two to three times less potent than morphine. It has no identified analgesically active metabolite and is not significantly metabolised by cytochrome P450 enzymes, thus overcoming some limitations of tramadol, including the potential for pharmacokinetic drug-drug interactions and interindividual variability due to genetic polymorphisms of cytochrome P450 enzymes. The toxicity profiles of tramadol and tapentadol are similar; however tapentadol is likely to result in less exposure to serotoninergic adverse effects (nausea, vomiting, hypoglycaemia) but cause more opioid adverse effects (constipation, respiratory depression, abuse) than tramadol. The safety of tapentadol in real-world conditions remains poorly documented, particularly in at-risk patient subgroups and also in the ability to assess the risk associated with its residual serotonergic activity (serotonin syndrome, seizures). Because of an earlier market introduction, more real-world safety data are available for tramadol, including data from at-risk patient subgroups. The level of evidence on the efficacy of both tramadol and tapentadol for the treatment of chronic pain is globally low. The trials published to date show overall that tapentadol does not provide a clinically significant analgesic improvement compared to existing treatments, for which the safety profile is much better known. In conclusion, tapentadol is not a first-line opioid but represents an additional analgesic in the therapeutic choices, which some patients may benefit from after careful examination of their clinical situation, co-morbidities and co-medications.
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13
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Comparison of opioid prescribing upon hospital discharge in patients receiving tapentadol versus oxycodone following orthopaedic surgery. Int J Clin Pharm 2021; 43:1602-1608. [PMID: 34089144 DOI: 10.1007/s11096-021-01290-7] [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: 01/21/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
Background The changing of opioids during the transition of care from hospital to home may be associated with harm. Objective To compare patients receiving tapentadol IR versus oxycodone IR following orthopaedic surgery during hospitalisation with regard to the changing of opioids at hospital discharge. Setting A major metropolitan tertiary referral hospital in Australia. Methods This is a retrospective cohort study. Participants included adult orthopaedic surgery patients receiving postoperative tapentadol IR or oxycodone IR during hospitalisation between 1 January 2018 and 30 June 2019. Main outcome measure The proportion of patients for whom the opioid prescribed was changed at hospital discharge. Results The study cohort included 199 patients. Of these, 100 patients received oxycodone and 99 patients received tapentadol post-operatively during hospitalisation. The mean age was 66 years (SD, 12 years) and 111 (56%) were female. The most common surgeries were total knee arthroplasty (91, 46%), total hip arthroplasty (63, 32%) and shoulder surgery (26, 13%). Patients in the tapentadol group were more likely to be changed to a different opioid upon hospital discharge than the oxycodone group (57% versus 9%, difference 48% [95% CI 36-59%, p < 0.01). After adjusting for confounders, post-operative tapentadol use was more likely to be associated with opioid changing upon discharge (OR 16.5, 95% CI 6.7 to 40.8, p < 0.01). Conclusions The post-operative use of tapentadol IR during hospitalisation was associated with an increased likelihood of opioid changing at hospital discharge. This practice could have patient safety implications.
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14
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Ni J, Jiang J, Mao S, Sun RF. Pregabalin does not decrease acute pain or postoperative nausea and vomiting after hysterectomy: a meta-analysis. J Int Med Res 2021; 48:300060520954720. [PMID: 33334230 PMCID: PMC7750779 DOI: 10.1177/0300060520954720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Hysterectomy is associated with severe postoperative pain. The relative efficacy of pregabalin compared with other treatments for post-hysterectomy pain is unclear. METHODS We searched the PubMed, Cochrane Library, and Web of Science databases for studies that compared the use of pregabalin and placebo for reducing pain in patients undergoing hysterectomy. RESULTS This meta-analysis showed that pregabalin had limited pain-relieving effects at 2, 6, 24, and 48 hours after hysterectomy compared with placebo. Pregabalin significantly reduced postoperative nausea and vomiting. However, there was no significant difference in postoperative sedation or visual disturbances between patients treated with pregabalin and placebo. CONCLUSIONS Pregabalin is not clinically superior to placebo in terms of reducing pain intensity and morphine consumption in patients undergoing hysterectomy. However, the limitations of this meta-analysis mean that more high-quality randomized controlled trials are necessary to verify our pooled results.
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Affiliation(s)
- Jie Ni
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
| | - Juan Jiang
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
| | - Shiqin Mao
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
| | - Rui-Fang Sun
- Department of Gynecology, Jingjiang People's Hospital, Taizhou, Jiangsu Province, China
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15
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Lamy JB. A data science approach to drug safety: Semantic and visual mining of adverse drug events from clinical trials of pain treatments. Artif Intell Med 2021; 115:102074. [PMID: 34001324 DOI: 10.1016/j.artmed.2021.102074] [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] [Received: 06/22/2020] [Revised: 01/21/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Clinical trials are the basis of Evidence-Based Medicine. Trial results are reviewed by experts and consensus panels for producing meta-analyses and clinical practice guidelines. However, reviewing these results is a long and tedious task, hence the meta-analyses and guidelines are not updated each time a new trial is published. Moreover, the independence of experts may be difficult to appraise. On the contrary, in many other domains, including medical risk analysis, the advent of data science, big data and visual analytics allowed moving from expert-based to fact-based knowledge. Since 12 years, many trial results are publicly available online in trial registries. Nevertheless, data science methods have not yet been applied widely to trial data. In this paper, we present a platform for analyzing the safety events reported during clinical trials and published in trial registries. This platform is based on an ontological model including 582 trials on pain treatments, and uses semantic web technologies for querying this dataset at various levels of granularity. It also relies on a 26-dimensional flower glyph for the visualization of the Adverse Drug Events (ADE) rates in 13 categories and 2 levels of seriousness. We illustrate the interest of this platform through several use cases and we were able to find back conclusions that were initially found during meta-analyses. The platform was presented to four experts in drug safety, and is publicly available online, with the ontology of pain treatment ADE.
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Affiliation(s)
- Jean-Baptiste Lamy
- Université Sorbonne Paris Nord, LIMICS, Sorbonne Université, INSERM, UMR 1142, F-93000 Bobigny, France; Laboratoire de Recherche en Informatique, CNRS/Université Paris-Sud/Université Paris-Saclay, Orsay, France.
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16
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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17
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Tyler KR, Hullick C, Newton BA, Adams CB, Arendts G. Emergency department pain management in older patients. Emerg Med Australas 2020; 32:840-846. [PMID: 32594659 DOI: 10.1111/1742-6723.13562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katren R Tyler
- Department of Emergency Medicine, University of California, Davis, Davis, California, USA
| | - Carolyn Hullick
- Emergency Department, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Brittany A Newton
- Department of Pharmacy Services, UC Davis Health System, University of California, Davis, Davis, California, USA
| | - Christopher B Adams
- Department of Pharmacy Services, UC Davis Health System, University of California, Davis, Davis, California, USA
| | - Glenn Arendts
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
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