Tapentadol vs oxycodone/naloxone in the management of pain after total hip arthroplasty in the fast track setting: an observational study

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Effect of high-quality nursing on orthopedic trauma based on a fast-track surgery model

OBJECTIVE

To explore the effect of fast-track surgery (FTS) based high quality nursing on orthopedic trauma.

METHODS

In this retrospective study, 94 patients who received orthopedic trauma surgery in our hospital from December 2018 to November 2020 were included. The patients were assigned to a research group (n=47) or a control group (n=47) according to which nursing method they received. The control group received routine nursing, while the research group also received FTS-based high-quality nursing. Perioperative situation, quality of life score (SF-36) before and after operation, incidence of complications, pain score (VAS) at different time periods after operation, and nursing satisfaction were compared between the two groups.

RESULTS

There was no significant difference in operation time or blood loss between groups (P>0.05). The time to getting out of bed for the first time, time to drainage tube removal, and length of hospital stay in the research group were shorter than those in the control group (P<0.001). Repeated measurement analysis of variance revealed that the VAS score of the research group was lower than that of the control group at 1 h, 3 h, 6 h, 24 h and 48 h after operation (P<0.05). Intra-group comparison manifested that the VAS scores of both groups decreased at 1 h, 3 h, 6 h, 24 h and 48 h after operation (P<0.05). Comparison at different time points revealed that the difference was statistically significant (P<0.05). The incidence of complications in the research group (4.26%) was lower than that in the control group (17.02%; P<0.05). The satisfaction rate of nursing in the research group (93.62%) was higher than that in the control group (78.72%; P<0.05). After intervention, the level of superoxide dismutase (SOD) and glutathione (GSH) in both groups decreased with a lesser decrease in the research group. The contents of reactive oxygen species (ROS) and malondialdehyde (MDA) in groups after intervention were higher than those before intervention with a milder increase in the research group.

CONCLUSION

FTS mode can shorten the recovery time, reduce the degree of pain and the reduce the time of analgesia. It also promotes the recovery and shortens the hospital stay of patients, and improves their quality of life, with high satisfaction. This may be related to an expeditedd surgical process and reduced oxidative stress response of patients undergoing surgery under the rapid recovery surgical model.

Tapentadol shows lower intrinsic efficacy at µ receptor than morphine and oxycodone

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.

Tapentadol and Oxycodone/Naloxone Prescribing Patterns in Primary Health Care in Catalonia, Spain: A Cross-Sectional Study

Objective

To characterize the use of tapentadol and the combination oxycodone/naloxone in primary health care. Data on their use and possible misuse will allow the identification of risk factors and to design protocols to reduce and prevent avoidable harm to patients being treated for pain.

Design

A descriptive, cross-sectional and multicenter study was performed.

Setting

Fifty-three primary health care teams, which provides healthcare for 1,300,000 inhabitants.

Patients

A total of 1840 patients had active prescriptions of tapentadol and 985 of oxycodone/naloxone.

Methods

Demographic (age, sex) and clinical (glomerular filtration rate; active liver disease; dosing and duration of treatment), prescribed daily dose (according to age, sex, length of treatment), concomitant analgesic treatment and diagnosis. Patient information was obtained from medical records.

Results

Most of the patients were women (>74.0% in both cases), and the average age was 69.3 years (women: 70.1±13.2; men: 66.7±13.9 years) in the case of tapentadol and 70.6 years (women: 64.0±13.6; men: 72.6±14.3 years) in the case of oxycodone/naloxone. Only 12.2% of patients taking tapentadol and 12.1% taking oxycodone/naloxone had a normal renal function. In both cases, 4.1% of patients had active liver disease. The average length of treatment was 246.4 days in oxycodone/naloxone and 199.0 days in tapentadol. It was recorded that 85.1% of patients in the case of tapentadol and 89.0% in the oxycodone/naloxone had at least another drug prescribed for pain. About 42.2% of patients treated with tapentadol and 34.4% of patients treated with oxycodone/naloxone had associated neuralgia as a diagnosis.

Conclusion

The pattern of use and profile of patients with tapentadol and oxycodone/naloxone had more similarities than differences, and suggested that prescribing practice, and monitoring should be assessed regularly to ensure patient safety and effective management of pain.

Effect of Observation of Shou Hui Tong Bian Capsule (Polygonum Multiflorum and Aloe-Based Herbal Capsule for Cathartic Effect) in Rapid Rehabilitation of Joint Surgery

OBJECTIVE

To observe the effect of Shou Hui Tong Bian capsule (polygonum multiflorum and aloe-based herbal capsule for cathartic effect) in rapid rehabilitation of joint surgery.

METHODS

A total of 98 patients undergoing perioperative joint surgery in our hospital from July 2019 to March 2020 were included in the study. According to the situation of arthroscopy and joint replacement therapy, the patients were randomly divided into a control group and an observation group, with 49 cases in each group. The control group was treated with conventional therapy. On the basis of the control group, the patients in the observation group were orally administrated with Shou Hui Tong Bian capsule, 2 capsules/time, 3 times/day. Both groups received continuous treatment for 14 days. The clinical effects, awakening time, postoperative exhaust time, and the number of patients with different degrees of abdominal distension in the four groups before and after treatment were observed and compared.

RESULTS

After treatment, the total effective rate of arthroscopy in the control group was 66.7%, which was significantly lower than 83.3% in the observation group (P < 0.05). The total effective rate of joint replacement in the control group was 64.0%, which was significantly lower than 84.0% in the observation group (P < 0.05). After arthroscopic treatment and joint replacement treatment, the recovery time and postoperative exhaust time of borborygmus in the observation group were significantly lower than those in the control group (both P < 0.05). After the treatment, the number of patients with different degrees of abdominal distension in the arthroscopic and joint replacement treatment group and the control group was significantly improved (P < 0.05), and the observation group was significantly better than the control group (P < 0.05).

CONCLUSION

The curative effect of Shou Hui Tong Bian capsule on patients undergoing arthroscopic joint surgery and joint replacement during perioperative period is obviously superior to that of conventional treatment. It can effectively improve the total effective rate, shorten the first exhaust time, and increase the number of patients without abdominal distension after treatment. It was safe and effective, and worthy of clinical promotion.

Postoperative pain: a review of emerging therapeutic options

INTRODUCTION

Postoperative pain is often managed by opioid medications, even though they carry a risk of adverse effects such as vomiting, constipation, sedation, respiratory depression and physical dependence. Furthermore, opioid use in the healthcare setting has likely contributed to the epidemic. However, the mismanagement of postoperative pain can result in delayed recovery time, impaired physical function, increased risk of morbidity and mortality, chronic pain, and higher healthcare costs.

AREAS COVERED

This review explores emerging therapeutic options and strategies in the management of acute postoperative pain and focuses on opioid-sparing, multimodal analgesia. This includes regional anesthetic techniques, non opioid pharmacotherapy, novel opioids and non-pharmacologic therapy. We have also discussed examples of novel analgesics and formulations which have potential benefits in reducing postoperative pain and opioid use after surgery.

EXPERT OPINION

The development of novel regional anesthesia techniques allows for opioid minimization in increasing number of surgical procedures. This synergizes with the availability of novel non-opioid analgesic adjucts. In addition, several novel opioid drugs have been developed which may be pathway selective and associated with less adverse effect than conventional opioids.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Safety of tapentadol compared with other opioids in chronic pain treatment: network meta-analysis of randomized controlled and withdrawal trials

OBJECTIVE

To assess the relative safety of oral tapentadol PR and other opioid analgesics for moderate or severe chronic pain in adults, we conducted a systematic review and network meta-analysis (NMA).

METHODS

A systematic review was conducted to identify randomized controlled trials (RCTs) and randomized withdrawal trials of tapentadol with other WHO stage II and III opioid analgesics in patients with moderate or severe chronic pain. Searches were conducted in MEDLINE, EMBASE, PubMed, Cochrane databases and trial registries. Feasibility assessment evaluated the trials' suitability for NMA. Outcomes assessed were overall AEs, overall serious adverse events, constipation, nausea, dizziness, somnolence, headache, and discontinuation due to AEs. Randomized withdrawal trials were analyzed separately to other RCTs.

RESULTS

Searches conducted in April 2019 identified 16,604 records. Following screening and feasibility assessment, 29 RCTs and 19 randomized withdrawal trials were identified and included in the NMA. Consistent with existing research, evidence from RCTs suggested that tapentadol is associated with relatively lower odds of adverse events occurring than most active comparators. The withdrawal trial data were less clear, with higher uncertainty around the results, and results that appear to contradict the RCT evidence. There are a number of trial design factors that may be affecting these results.

CONCLUSIONS

RCT evidence suggests that tapentadol can be a useful treatment option for patients suffering from chronic pain and in need of an opioid analgesic. Opioids should be prescribed by a qualified physician only after other analgesics have been considered, taking side effects and misuse risk into account.

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

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

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

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