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Fu Y, Madsen SD, Shaheed CA, de Zoete A, Chiarotto A, Koes B. Moderators of treatment effect of non-steroidal anti-inflammatory drugs for patients with (sub) acute low back pain: Protocol for a systematic review with individual participant data meta-analysis. MethodsX 2024; 12:102713. [PMID: 38660043 PMCID: PMC11041908 DOI: 10.1016/j.mex.2024.102713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024] Open
Abstract
A Cochrane review found that non-steroidal anti-inflammatory drugs (NSAIDs) are slightly more effective than placebo on acute and subacute low back pain (LBP) outcomes (pain intensity, disability, and global improvement). Our objectives are: (1) to assess the overall treatment effect of NSAIDs in adults with acute and subacute LBP; (2) to identify the moderation of baseline patients' characteristics on treatment effect. We will conduct a systematic search of RCTs on effectiveness of NSAIDs compared with placebo in adults with non-chronic LBP in Medline ALL, Embase, Cochrane Central Register of Controlled Trials*. We will screen the records after January 2020, and include eligible RCTs before January 2020 screened by the Cochrane review mentioned above. Our primary outcomes are pain intensity, disability, and health-related quality of life, secondary outcomes are adverse events. Our IPD dataset will consist of the information on each eligible trial characteristics and included variables according to a predefined coding scheme. We will assess risk-of-bias of included RCTs with the Cochrane Risk Of Bias (RoB)-2 assessment tool. We will perform power calculations with closed-form solutions and prioritize a one-stage approach for IPD-MA. For reporting the results, we will adhere to the PRISMA-IPD statement.
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Affiliation(s)
- Yanyan Fu
- Department of General Practice, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Simon Dyrløv Madsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
- Chiropractic Knowledge Hub, Campusvej 55 5230, Odense, Denmark
| | - Christina Abdel Shaheed
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Bart Koes
- Department of General Practice, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
- Research Unit of General Practice, Department of Public Health & Center for Muscle and Joint Health, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
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Abdel Shaheed C, Hayes C, Maher CG, Ballantyne JC, Underwood M, McLachlan AJ, Martin JH, Narayan SW, Sidhom MA. Opioid analgesics for nociceptive cancer pain: A comprehensive review. CA Cancer J Clin 2024; 74:286-313. [PMID: 38108561 DOI: 10.3322/caac.21823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 12/19/2023] Open
Abstract
Pain is one of the most burdensome symptoms in people with cancer, and opioid analgesics are considered the mainstay of cancer pain management. For this review, the authors evaluated the efficacy and toxicities of opioid analgesics compared with placebo, other opioids, nonopioid analgesics, and nonpharmacologic treatments for background cancer pain (continuous and relatively constant pain present at rest), and breakthrough cancer pain (transient exacerbation of pain despite stable and adequately controlled background pain). They found a paucity of placebo-controlled trials for background cancer pain, although tapentadol or codeine may be more efficacious than placebo (moderate-certainty to low-certainty evidence). Nonsteroidal anti-inflammatory drugs including aspirin, piroxicam, diclofenac, ketorolac, and the antidepressant medicine imipramine, may be at least as efficacious as opioids for moderate-to-severe background cancer pain. For breakthrough cancer pain, oral transmucosal, buccal, sublingual, or intranasal fentanyl preparations were identified as more efficacious than placebo but were more commonly associated with toxicities, including constipation and nausea. Despite being recommended worldwide for the treatment of cancer pain, morphine was generally not superior to other opioids, nor did it have a more favorable toxicity profile. The interpretation of study results, however, was complicated by the heterogeneity in the study populations evaluated. Given the limited quality and quantity of research, there is a need to reappraise the clinical utility of opioids in people with cancer pain, particularly those who are not at the end of life, and to further explore the effects of opioids on immune system function and quality of life in these individuals.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher Hayes
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher G Maher
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Jane C Ballantyne
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer H Martin
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sujita W Narayan
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark A Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Jones CMP, Langford A, Maher CG, Abdel Shaheed C, Day R, Lin CWC. Opioids for Acute Musculoskeletal Pain: A Systematic Review with Meta-Analysis. Drugs 2024; 84:305-317. [PMID: 38451443 PMCID: PMC10982090 DOI: 10.1007/s40265-024-01999-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo. STUDY DESIGN Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h). DATA SOURCES Multiple databases were searched from their inception to February 22nd, 2023. DATA SYNTHESIS Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed. RESULTS We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%). DISCUSSION Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits. PROSPERO REGISTRATION CRD42021249346.
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Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
- , Level 10N KGV Building, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Aili Langford
- School of Pharmacy, The University of Sydney and the Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Richard Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney and St Vincent's Clinical Campus, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Jones CMP, Lin CWC, Blease C, Lawson J, Abdel Shaheed C, Maher CG. Reply to Ballou and Kube. Pain 2024; 165:488-489. [PMID: 38207197 DOI: 10.1097/j.pain.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University, Sweden
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
| | - Jen Lawson
- Patient Advocate, Kalamazoo, MI, United States
| | | | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
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Hamilton M, Christine Lin CW, Arora S, Harrison M, Tracy M, Nickel B, Shaheed CA, Gnjidic D, Mathieson S. Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment. Int J Clin Pharm 2024; 46:111-121. [PMID: 37882955 PMCID: PMC10831024 DOI: 10.1007/s11096-023-01649-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/07/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms. AIM This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting. METHOD This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome. RESULTS Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP. CONCLUSION GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).
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Affiliation(s)
- Melanie Hamilton
- Institute for Musculoskeletal Health, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), Missenden Road, PO Box M179, Camperdown, Sydney, NSW, 2050, Australia.
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), Missenden Road, PO Box M179, Camperdown, Sydney, NSW, 2050, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sheena Arora
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
- The Centre for Health Evaluation and Outcomes Sciences (CHEOS) at St. Paul's Hospital, Vancouver, Canada
| | - Marguerite Tracy
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Brooke Nickel
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), Missenden Road, PO Box M179, Camperdown, Sydney, NSW, 2050, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), Missenden Road, PO Box M179, Camperdown, Sydney, NSW, 2050, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Mathieson S, O'Keeffe M, Traeger AC, Ferreira GE, Abdel Shaheed C. Content and sentiment analysis of gabapentinoid-related tweets: An infodemiology study. Drug Alcohol Rev 2024; 43:45-55. [PMID: 36539307 DOI: 10.1111/dar.13590] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The increasing number of gabapentinoid (pregabalin and gabapentin) harms, including deaths observed across countries is concerning to health-care professionals and policy makers. However, it is unclear if the public shares these concerns. This study aimed to describe posts related to gabapentinoids, conduct a content analysis to identify common themes and describe adverse events or symptoms. METHODS Keywords of 'pregabalin' or 'Lyrica' or 'gabapentin' or 'Neurontin' were used to search for related tweets posted by people in the community between 8 March and 7 May 2021. Eligible tweets included a keyword in the post. We extracted de-identified data which included descriptive data of the total number of posts over time; and data on individual tweets including date, number of re-tweets and post content. Data were exported separately for pregabalin- and gabapentin-related tweets. A 20% random sample was used for the thematic analysis. RESULTS There were 2931 pregabalin-related tweets and 2736 gabapentin-related tweets. Thematic analysis revealed three themes (sharing positive experiences and benefits of taking gabapentinoids, people voicing their negative experiences, and people seeking opinions and sharing information). Positive experiences of gabapentinoids were related to sharing stories and giving advice. This was contrasted to negative experiences including ineffectiveness, withdrawals, side effects and frustration related to cost and insurance coverage. Brain fog was the most common adverse symptom reported. Gabapentinoid-related deaths were only mentioned in three tweets. DISCUSSION The increasing public health concern of gabapentinoid-related deaths was not translated to Twitter discussions.
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Affiliation(s)
- Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Abdel Shaheed C, Ivers R, Vizza L, McLachlan A, Kelly PJ, Blyth F, Stanaway F, Clare PJ, Thompson R, Lung T, Degenhardt L, Reid S, Martin B, Wright M, Osman R, French S, McCaffery K, Campbell G, Jenkins H, Mathieson S, Boogs M, McMaugh J, Bennett C, Maher C. Clinical Observation, Management and Function Of low back pain Relief Therapies (COMFORT): A cluster randomised controlled trial protocol. BMJ Open 2023; 13:e075286. [PMID: 37989377 PMCID: PMC10668201 DOI: 10.1136/bmjopen-2023-075286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/04/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Low back pain (LBP) is commonly treated with opioid analgesics despite evidence that these medicines provide minimal or no benefit for LBP and have an established profile of harms. International guidelines discourage or urge caution with the use of opioids for back pain; however, doctors and patients lack practical strategies to help them implement the guidelines. This trial will evaluate a multifaceted intervention to support general practitioners (GPs) and their patients with LBP implement the recommendations in the latest opioid prescribing guidelines. METHODS AND ANALYSIS This is a cluster randomised controlled trial that will evaluate the effect of educational outreach visits to GPs promoting opioid stewardship alongside non-pharmacological interventions including heat wrap and patient education about the possible harms and benefits of opioids, on GP prescribing of opioids medicines dispensed. At least 40 general practices will be randomised in a 1:1 ratio to either the intervention or control (no outreach visits; GP provides usual care). A total of 410 patient-participants (205 in each arm) who have been prescribed an opioid for LBP will be enrolled via participating general practices. Follow-up of patient-participants will occur over a 1-year period. The primary outcome will be the cumulative dose of opioid dispensed that was prescribed by study GPs over 1 year from the enrolment visit (in morphine milligram equivalent dose). Secondary outcomes include prescription of opioid medicines, benzodiazepines, gabapentinoids, non-steroidal anti-inflammatory drugs by study GPs or any GP, health services utilisation and patient-reported outcomes such as pain, quality of life and adverse events. Analysis will be by intention to treat, with a health economics analysis also planned. ETHICS AND DISSEMINATION The trial received ethics approval from The University of Sydney Human Research Ethics Committee (2022/511). The results will be disseminated via publications in journals, media and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12622001505796.
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Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rowena Ivers
- Graduate School of Medicine, University of Wollongong, Sydney, New South Wales, Australia
| | - Lisa Vizza
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Blyth
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Stanaway
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Philip James Clare
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Prevention Research Collaboration, University of Sydney, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Rachel Thompson
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Thomas Lung
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Sharon Reid
- Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences College of Pharmacy, Arkansas, Arkansas, USA
| | - Michael Wright
- Centre for Health Economics Research Evaluation, University of Technology Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rawa Osman
- Quality Use of Medicines (QUM) Connect, Sydney, New South Wales, Australia
| | - Simon French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gabrielle Campbell
- School of Psychology, University of Queensland, Queensland, Queensland, Australia
| | - Hazel Jenkins
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Stephanie Mathieson
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Monika Boogs
- Painaustralia Consumer Advisory Group, Canberra, ACT, Australia
| | - Jarrod McMaugh
- Pharmaceutical Society of Australia, Canberra, ACT, Australia
| | - Carol Bennett
- Alliance for Gambling Reform, National, Victoria, Australia
- College of Arts and Social Sciences, The Australian National University, Canberra, ACT, Australia
- Department of Health, Therapeutic Goods Administration National Medicines Scheduling Advisory Committee, Canberra, ACT, Australia
- Faculty of Health Science, University of Canberra, Canberra, ACT, Australia
| | - Christopher Maher
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
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Chen Q, Maher CG, Han CS, Abdel Shaheed C, Lin CWC, Rogan EM, Machado GC. Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis. Drugs 2023; 83:1523-1535. [PMID: 37768540 PMCID: PMC10624756 DOI: 10.1007/s40265-023-01941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge. METHODS Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge. CONCLUSIONS Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days. PROTOCOL REGISTRATION 10.31219/osf.io/w4z3u.
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Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia.
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Eileen M Rogan
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
- Emergency Department, Canterbury Hospital, Campsie, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
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Yang Z, Mathieson S, Kobayashi S, Abdel Shaheed C, Nogueira LAC, Simic M, Machado G, McLachlan AJ. Prevalence of Nonsteroidal Antiinflammatory Drugs Prescribed for Osteoarthritis: A Systematic Review and Meta-Analysis of Observational Studies. Arthritis Care Res (Hoboken) 2023; 75:2345-2358. [PMID: 37221152 DOI: 10.1002/acr.25157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/04/2023] [Accepted: 05/11/2023] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Our systematic review aimed to investigate the proportion of participants with osteoarthritis who were prescribed nonsteroidal antiinflammatory drugs (NSAIDs) by their health care provider. METHODS Electronic databases were searched for observational studies reporting NSAID prescribing to participants with diagnosed osteoarthritis of any region. Risk of bias was assessed using a tool designed for observational studies measuring prevalence. Random and fixed-effects meta-analysis was used. Meta-regression investigated study-level factors associated with prescribing. The overall evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria. RESULTS Fifty-one studies were included, published between 1989 and 2022, with 6,494,509 participants. The mean age of participants was 64.7 years (95% confidence interval [95% CI] 62.4, 67.0; n = 34 studies). Most studies were from Europe and Central Asia (n = 23 studies), and North America (n = 12 studies). Most studies were judged to be at low risk of bias (75%). Heterogeneity was eliminated when removing studies with a high risk of bias, to give a pooled estimate of NSAIDs prescribing to participants with osteoarthritis of 43.8% (95% CI 36.8, 51.1; moderate quality of evidence). Meta-regression determined that prescribing was associated with year (decreased prescribing over time; P = 0.05) and geographic region (P = 0.03; higher in Europe and Central Asia and in South Asia than in North America) but not with clinical setting. CONCLUSION Data from over 6.4 million participants with osteoarthritis between 1989 and 2022 indicate that NSAID prescribing has decreased over time and that prescribing differs between geographic locations.
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Affiliation(s)
| | | | - Sarah Kobayashi
- University of Sydney and Australian Catholic University, Sydney, New South Wales, Australia
| | | | | | - Milena Simic
- University of Sydney, Sydney, New South Wales, Australia
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Ferreira GE, Zadro J, Jones C, Ayre J, Lin C, Richards B, Needs C, Abdel Shaheed C, McLachlan A, Day RO, Maher C. General practitioners' decision-making process to prescribe pain medicines for low back pain: a qualitative study. BMJ Open 2023; 13:e074380. [PMID: 37899160 PMCID: PMC10619041 DOI: 10.1136/bmjopen-2023-074380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Pain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines. OBJECTIVES The aim of this study was to investigate what influences GPs' decision to prescribe pain medicines for LBP. DESIGN Qualitative study with in-depth interviews. SETTING Australian primary care. PARTICIPANTS We interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes. DATA ANALYSIS We summarised GP's choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP's decision-making. RESULTS GPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient's pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process. CONCLUSIONS We identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.
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Affiliation(s)
- Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Joshua Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Caitlin Jones
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Julie Ayre
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher Needs
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard O Day
- St Vincent's Clinical School, Department of Clinical Pharmacology & Toxicology, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Jones CMP, Lin CWC, Blease C, Lawson J, Abdel Shaheed C, Maher CG. Time to reflect on open-label placebos and their value for clinical practice. Pain 2023; 164:2139-2142. [PMID: 37713359 DOI: 10.1097/j.pain.0000000000003017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/24/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University Sweden
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
| | - Jen Lawson
- Patient Advocate, Kalamazoo, Michigan, United States
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- The University of Sydney, School of Public Health, Sydney, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Anderson PA, McLachlan AJ, Abdel Shaheed C, Gnjidic D, Ivers R, Mathieson S. Deprescribing interventions for gabapentinoids in adults: A scoping review. Br J Clin Pharmacol 2023; 89:2677-2690. [PMID: 37221314 DOI: 10.1111/bcp.15798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/08/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Abstract
The emerging issue of rising gabapentinoid misuse is being recognized alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23 February 2022 without restrictions. Eligible studies included randomized, non-randomized and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated the type of intervention, prescribing rates, cessations, patient outcomes and adverse events. Extracted outcome data were categorized as either short (≤3 months), intermediate (>3 but <12 months) or long (≥12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Interventions were of dose-reducing protocols, education and/or pharmacological-based approaches. In the randomized trials, gabapentinoid use could be ceased in at least one third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient-focused psychological interventions in the deprescribing process, nor provided any long-term follow-up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area.
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Affiliation(s)
- Prue A Anderson
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Pharmacy Department, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Andrew J McLachlan
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Christina Abdel Shaheed
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
- Sydney Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Danijela Gnjidic
- Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Rowena Ivers
- Faculty of Science, Medicine and Health, University of Wollongong, Sydney, Australia
| | - Stephanie Mathieson
- Sydney Musculoskeletal Health, Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
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Maher C, McLachlan A, Shaheed CA. A Second Look at the Risks of Serious Adverse Events with Orthopaedic Manual Therapy, Paracetamol, and NSAID Treatment of Neck Pain. J Orthop Sports Phys Ther 2023; 53:369–369. [PMID: 37213098 DOI: 10.2519/jospt.2023.0202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Letter to the Editor-in-Chief in response to JOSPT article "International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework" by Rushton A, Carlesso LC, Flynn T, et al. J Orthop Sports Phys Ther 2023;53(6):1-2. doi:10.2519/jospt.2023.0202.
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Affiliation(s)
- Chris Maher
- Sydney Musculoskeletal Health, The University of Sydney
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Abdel Shaheed C, Mathieson S, Wilson R, Furmage AM, Maher CG. Who should judge treatment effects as unimportant? J Physiother 2023:S1836-9553(23)00034-6. [PMID: 37263906 DOI: 10.1016/j.jphys.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/30/2022] [Accepted: 04/06/2023] [Indexed: 06/03/2023] Open
Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Institute for Musculoskeletal Health, Sydney, Australia.
| | - Stephanie Mathieson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Institute for Musculoskeletal Health, Sydney, Australia
| | - Ross Wilson
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ann-Mason Furmage
- Royal Prince Alfred Hospital Consumer Advisory Group, Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Institute for Musculoskeletal Health, Sydney, Australia
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Liu C, Ferreira GE, Abdel Shaheed C, Chen Q, Harris IA, Bailey CS, Peul WC, Koes B, Lin CWC. Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ 2023; 381:e070730. [PMID: 37076169 PMCID: PMC10498296 DOI: 10.1136/bmj-2022-070730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To investigate the effectiveness and safety of surgery compared with non-surgical treatment for sciatica. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organisation International Clinical Trials Registry Platform from database inception to June 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials comparing any surgical treatment with non-surgical treatment, epidural steroid injections, or placebo or sham surgery, in people with sciatica of any duration due to lumbar disc herniation (diagnosed by radiological imaging). DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data. Leg pain and disability were the primary outcomes. Adverse events, back pain, quality of life, and satisfaction with treatment were the secondary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). Data were pooled using a random effects model. Risk of bias was assessed with the Cochrane Collaboration's tool and certainty of evidence with the grading of recommendations assessment, development, and evaluation (GRADE) framework. Follow-up times were into immediate term (≤six weeks), short term (>six weeks and ≤three months), medium term (>three and <12 months), and long term (at 12 months). RESULTS 24 trials were included, half of these investigated the effectiveness of discectomy compared with non-surgical treatment or epidural steroid injections (1711 participants). Very low to low certainty evidence showed that discectomy, compared with non-surgical treatment, reduced leg pain: the effect size was moderate at immediate term (mean difference -12.1 (95% confidence interval -23.6 to -0.5)) and short term (-11.7 (-18.6 to -4.7)), and small at medium term (-6.5 (-11.0 to -2.1)). Negligible effects were noted at long term (-2.3 (-4.5 to -0.2)). For disability, small, negligible, or no effects were found. A similar effect on leg pain was found when comparing discectomy with epidural steroid injections. For disability, a moderate effect was found at short term, but no effect was observed at medium and long term. The risk of any adverse events was similar between discectomy and non-surgical treatment (risk ratio 1.34 (95% confidence interval 0.91 to 1.98)). CONCLUSION Very low to low certainty evidence suggests that discectomy was superior to non-surgical treatment or epidural steroid injections in reducing leg pain and disability in people with sciatica with a surgical indication, but the benefits declined over time. Discectomy might be an option for people with sciatica who feel that the rapid relief offered by discectomy outweighs the risks and costs associated with surgery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021269997.
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Affiliation(s)
- Chang Liu
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
| | - Giovanni E Ferreira
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Qiuzhe Chen
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christopher S Bailey
- Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Wilco C Peul
- Neurosurgical Center Holland, Leiden University Medical Center and Haaglanden MC and Haga Teaching Hospital, The Hague-Leiden, Netherlands
| | - Bart Koes
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
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Jones CM, Coombs D, Lin CWC, Traeger A, Li Q, Abdel Shaheed C, Sharma S, Maher CG, Machado GC. Implementation of a model of care for low back pain produces sustained reduction in opioid use in emergency departments. Emerg Med J 2023; 40:359-360. [PMID: 37012024 DOI: 10.1136/emermed-2022-212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Caitlin Mp Jones
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Danielle Coombs
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Adrian Traeger
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Gustavo C Machado
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
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Jones CMP, Abdel Shaheed C, Ferreira G, Mannix L, Harris IA, Buchbinder R, Maher CG. Author Response. J Patient Saf 2023; 19:e55. [PMID: 36538290 DOI: 10.1097/pts.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
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Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
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Abdel Shaheed C, Maher CG, Furmage A, Hoffmann T, McLachlan AJ. Strengthening the reporting of harms of all interventions in clinical trials. Med J Aust 2022; 217:502-504. [PMID: 36287028 PMCID: PMC9828512 DOI: 10.5694/mja2.51755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Tammy Hoffmann
- Institute for Evidence‐Based HealthcareBond UniversityGold CoastQLD
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Jones CMP, Shaheed CA, Ferreira G, Mannix L, Harris IA, Buchbinder R, Maher CG. Spinal Cord Stimulators: An Analysis of the Adverse Events Reported to the Australian Therapeutic Goods Administration. J Patient Saf 2022; 18:507-511. [PMID: 35067619 PMCID: PMC9329040 DOI: 10.1097/pts.0000000000000971] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal cord stimulators are used to treat intractable pain. Placebo-controlled trials of spinal cord stimulators typically involve short-term treatment and follow-up, so long-term safety and efficacy are unclear. AIM The aim of the study was to describe the adverse events relating to spinal cord stimulators reported to the Therapeutic Goods Administration of Australia between July 2012 and January 2019. METHODS Adverse events were coded by seriousness, severity, body system affected, type of event, action taken, and attribution of fault. Data on the number of stimulators implanted and removed were sourced from the Admitted Patient Care Minimum Data Set. RESULTS Five hundred twenty adverse events were reported for spinal cord stimulators. Most events were rated as severe (79%) or life-threatening (13%). Device malfunction was the most common event (56.5%). The most common action taken in response to an adverse event was surgical intervention with or without antibiotics (80%). The ratio of removals to implants was 4 per every 10 implanted. CONCLUSIONS Spinal cords stimulators have the potential for serious harm, and each year in Australia, many are removed. In view of the low certainty evidence of their long-term safety and effectiveness, our results raise questions about their role in providing long-term management of intractable pain.
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Affiliation(s)
| | | | - Giovanni Ferreira
- From the Institute for Musculoskeletal Health/The University of Sydney
| | | | - Ian A. Harris
- Orthopaedic Surgery, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney
| | | | - Chris G. Maher
- From the Institute for Musculoskeletal Health/The University of Sydney
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Hamilton M, Gnjidic D, Christine Lin CW, Jansen J, Weir KR, Shaheed CA, Blyth F, Mathieson S. Opioid deprescribing: Qualitative perspectives from those with chronic non-cancer pain. Res Social Adm Pharm 2022; 18:4083-4091. [DOI: 10.1016/j.sapharm.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/06/2022] [Accepted: 07/24/2022] [Indexed: 11/24/2022]
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22
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Abdel Shaheed C, Maher CG, Furmage AM, Hoffmann T, McLachlan AJ. Better measuring and reporting of adverse events are needed in back pain trials of non-drug interventions. BMJ 2022; 377:o1055. [PMID: 35483713 DOI: 10.1136/bmj.o1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Ann-Mason Furmage
- Disability Action Plan Steering Committee, Sydney Local Health District, Sydney, Australia
- Consumer Advisory Council, Clinical Council and the Disability Action Plan Working Group, Sydney Dental Hospital, Sydney, Australia
| | - Tammy Hoffmann
- Institute for Evidence Based Healthcare, Bond University, Queensland, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Coombs DM, Maher CG, Collett M, Mathieson S, Abdel Shaheed C, Lin CWC, Machado GC. Continued opioid use following an emergency department presentation for low back pain. Emerg Med Australas 2022; 34:694-697. [PMID: 35441464 DOI: 10.1111/1742-6723.13979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the proportion of patients with low back pain who receive an opioid analgesic prescription on hospital discharge, the proportion using opioid analgesics 4 weeks after discharge, and to identify predictors of continued opioid analgesic use at 4 weeks after an ED presentation in opioid-naïve patients. METHODS An observational cohort study nested within a randomised controlled trial in four EDs in New South Wales, Australia. Participants were adults who presented to the ED with non-specific low back pain or low back pain with lower limb neurological signs and symptoms. Electronic medical records supplemented the patient-reported pain and use of opioid analgesics at 4-week follow up. RESULTS Of the 104 patients included, 33 (31.7%, 95% confidence interval [CI] 22.9-41.6) received an opioid analgesic prescription at hospital discharge and 38 (36.5%, 95% CI 27.3-46.6) reported taking an opioid analgesic for pain 4 weeks after the ED presentation. Among opioid-naïve patients (n = 85), older age (odds ratio [OR] 1.04, 95% CI 1.00-1.08, P = 0.031) was the only predictor for continued opioid analgesic use at 4 weeks post-ED presentation. CONCLUSION About one-third of patients who present to the ED with low back pain receive an opioid analgesic prescription on discharge and are taking an opioid analgesic 4 weeks later. These findings justify future research to identify strategies to reduce the risk of long-term opioid use in patients who present to the ED with low back pain.
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Affiliation(s)
- Danielle M Coombs
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Physiotherapy Department, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Melinda Collett
- Physiotherapy Department, Dubbo Health Service, Western New South Wales Local Health District, Sydney, New South Wales, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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24
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Abdel Shaheed C, Awal W, Zhang G, Gilbert SE, Gallacher D, McLachlan A, Day RO, Ferreira GE, Jones CMP, Ahedi H, Tamrakar M, Blyth FM, Stanaway F, Maher CG. Efficacy, safety, and dose‐dependence of the analgesic effects of opioid therapy for people with osteoarthritis: systematic review and meta‐analysis. Med J Aust 2022; 216:305-311. [DOI: 10.5694/mja2.51392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/01/2021] [Accepted: 08/17/2021] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Stephen E Gilbert
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | | | - Andrew McLachlan
- The University of Sydney Sydney NSW
- Centre for Education and Research on Ageing University of Sydney Sydney NSW
| | - Richard O Day
- St Vincent's Hospital Sydney NSW
- St Vincent's Clinical School UNSW Sydney NSW
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Caitlin MP Jones
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Harbeer Ahedi
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Mamata Tamrakar
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
| | - Fiona M Blyth
- Centre for Education and Research on Ageing University of Sydney Sydney NSW
| | | | - Christopher G Maher
- The University of Sydney Sydney NSW
- Institute for Musculoskeletal Health University of Sydney and Sydney Local Health District Sydney NSW
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Abdel Shaheed C, Beardsley J, Day RO, McLachlan AJ. Immunomodulatory effects of pharmaceutical opioids and antipyretic analgesics: Mechanisms and relevance to infection. Br J Clin Pharmacol 2022; 88:3114-3131. [PMID: 35229890 DOI: 10.1111/bcp.15281] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 12/12/2022] Open
Abstract
Understanding how pharmaceutical opioids and antipyretic analgesics interact with the immune system potentially has major clinical implications for management of patients with infectious diseases and surgical and critical care patients. An electronic search was carried out on MEDLINE, EMBASE, PsycINFO, CENTRAL and the Cochrane library to identify reports describing the immunomodulatory effects of opioid analgesics and antipyretic analgesics, and their effects in infectious diseases. In adaptive immunity, nonsteroidal anti-inflammatory drugs have divergent effects: augmenting cell-mediated immunity but inhibiting humoral immunity. Nonsteroidal anti-inflammatory drugs have demonstrated a beneficial role in Mycobacterium tuberculosis infection and histoplasmosis in animals, and may be plausible adjuvants to antimicrobial agents in these diseases. There is a need to evaluate these findings rigorously in human clinical trials. There is preliminary evidence demonstrating antiviral effects of indomethacin in SARS CoV-2 in vitro; however, uncertainty regarding its clinical benefit in humans needs to be resolved in large clinical trials. Certain opioid analgesics are associated with immunosuppressive effects, with a developing understanding that fentanyl, morphine, methadone and buprenorphine suppress innate immunity, whilst having diverse effects on adaptive immunity. Morphine suppresses key cells of the innate immunity and is associated with greater risk of infection in the postsurgical setting. Efforts are needed to achieve adequate analgesia whilst avoiding suppression of the innate immunity in the immediate postoperative period caused by certain opioids, particularly in cancer surgery.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Justin Beardsley
- Westmead Institute for Medical Research, Sydney, Australia.,Sydney Institute for Infectious Diseases, University of Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, Australia
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Maher CG, Jones CMP, Shaheed CA, Lin CWC. Letter to the Editor: An Updated Overview of Low Back Pain Management. Asian Spine J 2022; 16:150-151. [PMID: 35196782 PMCID: PMC8874006 DOI: 10.31616/asj.2022.0004.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/03/2022] [Indexed: 01/06/2023] Open
Affiliation(s)
- Christopher G. Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia,Corresponding author: Christopher G. Maher Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Level 10N KGV Building, Missenden Road, Camperdown NSW 2050, Australia Tel: +61-2-8627-6263, Fax: +61-2-8627-6262, E-mail:
| | - Caitlin M. P. Jones
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Fiona Blyth
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ann-Mason Furmage
- Disability Action Plan Steering Group, Sydney Local Health District, Sydney, Australia
- Consumer Advisory Council, the Clinical Council and the Disability Action Plan Working Group, Sydney Dental Hospital, Sydney, Australia
| | - Fiona Stanaway
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Jones CM, Shaheed CA, Ferreira GE, Kharel P, Christine Lin CW, Maher CG. Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: a systematic review. J Physiother 2021; 67:263-270. [PMID: 34518145 DOI: 10.1016/j.jphys.2021.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/14/2021] [Accepted: 08/31/2021] [Indexed: 12/28/2022] Open
Abstract
QUESTIONS What is the effect of advice/education compared with placebo or no advice/education on pain and disability in people with non-specific spinal pain? To what extent do characteristics of the patients, trial or intervention modify the estimate of the treatment effects? DESIGN A systematic review with meta-analyses of randomised controlled trials. PARTICIPANTS Adults with non-specific back and/or neck pain with or without radiating leg/arm pain of any duration were included. Trials recruiting pregnant women or surgical patients in the immediate postoperative phase were ineligible. INTERVENTION Advice or education. OUTCOME MEASURES The primary outcomes were self-reported pain and disability, and the secondary outcome was adverse events. The following potential effect modifiers were examined: risk of bias, duration of pain, location of pain, intensity of intervention and mode of intervention. RESULTS Twenty-seven trials involving 7,006 participants were included. Eighteen of the included trials were assessed as being at low risk of bias (≥ 6 on the PEDro scale). There was low-quality evidence that advice had a small effect on pain (MD -8.2, 95% CI -12.5 to -3.9, n = 2,241) and moderate-quality evidence that advice had a small effect on disability (MD -4.5, 95% CI -7.9 to -1.0, n = 2,579) compared with no advice or placebo advice in the short-term. None of the items that were assessed modified the treatment effects. CONCLUSION Advice provides short-term improvements in pain and disability in non-specific spinal pain, but the effects are small and may be insufficient as the sole treatment for patients with spinal pain. REGISTRATION PROSPERO CRD42020162008.
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Affiliation(s)
- Caitlin Mp Jones
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Priti Kharel
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Liu C, Abdel Shaheed C, Braten LC, Hancock MJ, Underwood M, Jarvik JG, Elliott J, Maher CG, Buchbinder R, Lin CWC. Antibiotic treatment for low back pain or radicular pain, or both. Hippokratia 2021. [DOI: 10.1002/14651858.cd014221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chang Liu
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Lars Christian Braten
- Research and Communication Unit for Musculoskeletal Health (FORMI); Oslo University Hospital; Oslo Norway
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Mark J Hancock
- Faculty of Medicine, Health and Human Sciences; Macquarie University; Sydney Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit; University of Warwick; Coventry UK
| | - Jeffrey G Jarvik
- Radiology and Neurological Surgery, Clinical Learning, Evidence And Research (CLEAR) Center; University of Washington School of Medicine; Seattle USA
| | - Julian Elliott
- Cochrane Australia; School of Public Health & Preventive Medicine; Melbourne Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
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Maher CG, Traeger AC, Abdel Shaheed C, O'Keeffe M. Placebos in clinical care: a suggestion beyond the evidence. Med J Aust 2021; 215:252. [PMID: 34537963 PMCID: PMC9293195 DOI: 10.5694/mja2.51230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Christopher G Maher
- University of SydneySydneyNSW
- Institute for Musculoskeletal HealthUniversity of SydneySydneyNSW
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Danta M, Tan RZH, Lockart I, Abdel Shaheed C. Editorial: aspirin and NSAID for chemoprevention of hepatocellular carcinoma - ready for their use? Authors' reply. Aliment Pharmacol Ther 2021; 54:852-853. [PMID: 34425011 DOI: 10.1111/apt.16568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Mark Danta
- St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, St Vincent's Clinical School, UNSW, Sydney, NSW, Australia.,Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Regina Zi Hwei Tan
- Faculty of Medicine and Health, St Vincent's Clinical School, UNSW, Sydney, NSW, Australia
| | - Ian Lockart
- St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, St Vincent's Clinical School, UNSW, Sydney, NSW, Australia.,Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, NSW, Australia
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Tan RZH, Lockart I, Abdel Shaheed C, Danta M. Systematic review with meta-analysis: The effects of non-steroidal anti-inflammatory drugs and anti-platelet therapy on the incidence and recurrence of hepatocellular carcinoma. Aliment Pharmacol Ther 2021; 54:356-367. [PMID: 34247393 DOI: 10.1111/apt.16515] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/18/2021] [Accepted: 06/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chemoprevention with NSAIDs, including aspirin, and anti-platelet therapy (APT), has been suggested to reduce the incidence and recurrence of hepatocellular carcinoma (HCC). AIM To determine by meta-analysis whether NSAIDs and APT use affected HCC incidence, HCC recurrence and liver-related mortality in at-risk populations with chronic liver disease. METHOD Electronic databases including Pubmed, Scopus, Medline, Embase and Cochrane Library were searched (from inception to 31 May 2021) for eligible studies evaluating the impacts of NSAID or APT use on HCC incidence, recurrence and mortality. Data on HCC incidence, recurrence, liver-related mortality or bleeding complications had to be available. Studies were included if they evaluated adults with hepatitis B virus (HBV), hepatitis C virus (HCV), alcohol-related liver disease (ALD) or nonalcoholic steatohepatitis that were administered at least one NSAID or APT for a defined period of time and were followed for at least 6 months. The primary outcome was HCC incidence. Secondary outcomes included: HCC recurrence, liver-related mortality and bleeding complications. Data were pooled using a random effects model with hazard ratios (HRs) or odds ratio (OR), and 95% confidence intervals (CIs) presented. RESULTS Of 3773 articles screened, 19 studies were included, with a total of 147 283 participants. Aspirin use reduced the risk of HCC incidence (HR: 0.51, 95% CI: 0.36-0.72); and improved liver-related mortality (OR: 0.32, 95% CI: 0.15-0.70), with a small increased risk of gastrointestinal bleeding events (OR: 1.32, 95% CI: 1.08-1.94). With respect to HCC recurrence following treatment, analysis of all aspirin and NSAID treatment (including; aspirin only; non-aspirin NSAIDs only; and combination NSAIDs groups) was associated with a decreased risk of HCC recurrence (HR: 0.80, 95% CI: 0.75-0.86). By stratified analysis, only the non-aspirin NSAID group showed significant risk reduction (HR: 0.73, 95% CI: 0.63-0.84). CONCLUSION The study supports the use of aspirin in at-risk individuals to reduce the incidence of HCC and liver-related mortality. HCC recurrence following treatment was lower with NSAID treatment.
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Affiliation(s)
- Regina Zi Hwei Tan
- St Vincent's Clinical School, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - Ian Lockart
- St Vincent's Clinical School, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
- St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, NSW, Australia
| | | | - Mark Danta
- St Vincent's Clinical School, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
- St Vincent's Centre for Applied Medical Research, St Vincent's Hospital, Sydney, NSW, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Sydney, NSW, Australia
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Abdel Shaheed C, Ferreira GE, Dmitritchenko A, McLachlan AJ, Day RO, Saragiotto B, Lin C, Langendyk V, Stanaway F, Latimer J, Kamper S, McLachlan H, Ahedi H, Maher CG. The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews. Med J Aust 2021; 214:324-331. [PMID: 33786837 DOI: 10.5694/mja2.50992] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions. STUDY DESIGN Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo-controlled trials. Conduct of systematic reviews was assessed with AMSTAR-2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. DATA SOURCES MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 - 30 April 2020. DATA SYNTHESIS We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0-10-point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, -0.3 points; 95% CI, -0.6 to -0.1 points) and after craniotomy (MD, -0.8 points; 95% CI, -1.4 to -0.2 points); there is moderate quality evidence for its efficacy in tension-type headache (pain-free at 2 hours: RR, 1.3; 95% CI, 1.1-1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5-3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, -0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9-7.4). CONCLUSIONS For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required. PROSPERO REGISTRATION CRD42015029282 (prospective).
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Affiliation(s)
| | | | | | - Andrew J McLachlan
- Centre for Education and Research on Ageing, University of Sydney, Sydney, NSW
| | - Richard O Day
- St Vincent's Hospital, Sydney, NSW.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW
| | | | - Christine Lin
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | | | | | - Jane Latimer
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Steven Kamper
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Hanan McLachlan
- Institute for Musculoskeletal Health, University of Sydney, Sydney
| | - Harbeer Ahedi
- Institute for Musculoskeletal Health, University of Sydney, Sydney
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Liu C, Shaheed CA, Maher CG, McLachlan AJ, Latimer J, Lin CWC. Response to comment by Bhatia. Eur J Pain 2020; 24:1209-1210. [PMID: 32307800 DOI: 10.1002/ejp.1577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Chang Liu
- Sydney School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Christina Abdel Shaheed
- Sydney School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Chris G Maher
- Sydney School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia
| | - Jane Latimer
- Sydney School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Chung-Wei Christine Lin
- Sydney School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
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35
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Jones C, Abdel Shaheed C, Maher C. Letter to the Editor of the Clinical Journal of Pain. Clin J Pain 2020; 36:567-568. [DOI: 10.1097/ajp.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Liu C, Abdel Shaheed C, McLachlan AJ, Latimer J, Li Q, Buchbinder R, Day RO, Maher CG, Richards B, Oliveira JS, Lin CWC. OASIS-a randomised, placebo-controlled trial of oral glucocorticoids for leg pain in patients with acute sciatica: trial protocol. BMJ Open 2020; 10:e040559. [PMID: 32580990 PMCID: PMC7312281 DOI: 10.1136/bmjopen-2020-040559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Sciatica is a lower spine condition characterised by radiating leg pain below the knee. It may be accompanied by motor and sensory loss in the distribution of a spinal nerve. There are few effective treatments for sciatica. Orally administered glucocorticoids have shown some promise, however, any beneficial effects need to be confirmed and weighed against drug safety and cost-effectiveness, in a high-quality, definitive trial. METHODS AND ANALYSIS The Oral Steroids In Sciatica (OASIS) trial is a randomised, placebo-controlled, double-blind trial that will evaluate a tapering regimen of oral prednisolone in 200 participants with acute sciatica. Participants will be recruited on presentation to general practice, specialist outpatient clinics or hospital emergency departments and randomised to receive orally administered prednisolone 50 mg per day, up to 3 days then tapering to cessation over 10 days, or placebo, for a maximum of 13 days, in addition to guideline advice. Participants will be followed for 1 year. The primary endpoint will be leg pain intensity at 2 weeks. Secondary outcomes will include back pain intensity, disability, time to recovery, quality of life and treatment success rate. Adverse events will be assessed and a cost-effectiveness analysis will be conducted. ETHICS AND DISSEMINATION Ethical approval has been granted from the Human Research Ethics Committee, The University of Sydney. Trial results will be disseminated by publications and conference presentations and via the media. TRIAL REGISTRATION NUMBER ACTRN12619001716156.
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Affiliation(s)
- Chang Liu
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane Latimer
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent Hospital, Sydney, New South Wales, Australia
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Rheumatology Department, Institute of Rheumatology and Orthopaedics, Sydney, New South Wales, Australia
| | - Juliana S Oliveira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Downie AS, Hancock M, Abdel Shaheed C, McLachlan AJ, Kocaballi AB, Williams CM, Michaleff ZA, Maher CG. An Electronic Clinical Decision Support System for the Management of Low Back Pain in Community Pharmacy: Development and Mixed Methods Feasibility Study. JMIR Med Inform 2020; 8:e17203. [PMID: 32390593 PMCID: PMC7248808 DOI: 10.2196/17203] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
Background People with low back pain (LBP) in the community often do not receive evidence-based advice and management. Community pharmacists can play an important role in supporting people with LBP as pharmacists are easily accessible to provide first-line care. However, previous research suggests that pharmacists may not consistently deliver advice that is concordant with guideline recommendations and may demonstrate difficulty determining which patients require prompt medical review. A clinical decision support system (CDSS) may enhance first-line care of LBP, but none exists to support the community pharmacist–client consultation. Objective This study aimed to develop a CDSS to guide first-line care of LBP in the community pharmacy setting and to evaluate the pharmacist-reported usability and acceptance of the prototype system. Methods A cross-platform Web app for the Apple iPad was developed in conjunction with academic and clinical experts using an iterative user-centered design process during interface design, clinical reasoning, program development, and evaluation. The CDSS was evaluated via one-to-one user-testing with 5 community pharmacists (5 case vignettes each). Data were collected via video recording, screen capture, survey instrument (system usability scale), and direct observation. Results Pharmacists’ agreement with CDSS-generated self-care recommendations was 90% (18/20), with medicines recommendations was 100% (25/25), and with referral advice was 88% (22/25; total 70 recommendations). Pharmacists expressed uncertainty when screening for serious pathology in 40% (10/25) of cases. Pharmacists requested more direction from the CDSS in relation to automated prompts for user input and page navigation. Overall system usability was rated as excellent (mean score 92/100, SD 6.5; 90th percentile compared with similar systems), with acceptance rated as good to excellent. Conclusions A novel CDSS (high-fidelity prototype) to enhance pharmacist care of LBP was developed, underpinned by clinical practice guidelines and informed by a multidisciplinary team of experts. User-testing revealed a high level of usability and acceptance of the prototype system, with suggestions to improve interface prompts and information delivery. The small study sample limits the generalizability of the findings but offers important insights to inform the next stage of system development.
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Affiliation(s)
- Aron Simon Downie
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Faculty of Science and Engineering, Macquarie University, Macquarie Park, Australia
| | - Mark Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Ahmet Baki Kocaballi
- Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, Australia.,Faculty of Engineering and Information Technology, University of Technology Sydney, Sydney, Australia
| | - Christopher M Williams
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, Australia
| | - Zoe A Michaleff
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
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Abdel Shaheed C, Maher CG, Buchbinder R, Ng B, Enke O, Guzowski R, McLachlan AJ, Day RO, Richards B, Latimer J, Lin CWC. Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis. Eur J Pain 2020; 24:518-535. [PMID: 31715647 DOI: 10.1002/ejp.1505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/03/2019] [Accepted: 11/05/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting. OBJECTIVE To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica. DATABASES AND DATA TREATMENT MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo-controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow-up period was the immediate-term (<2 weeks from administration). We also considered adverse events. RESULTS Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD -13.4 [-23.3, -3.5] but not for pain MD -2.5 [-16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD -24.5 [-38.8, -10.2] and -14.0 [-27.4, -0.6], respectively. There were no immediate-term benefits with IV administration. CONCLUSION The effects of glucocorticoids on immediate-term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.
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Affiliation(s)
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Beverly Ng
- Department of Rheumatology, St George Hospital Kogarah, Sydney, NSW, Australia
| | - Oliver Enke
- Department of Orthopaedics, Nepean Hospital, Kingswood, NSW, Australia
| | - Robert Guzowski
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.,Centre for Research Excellence in Medicines and Ageing, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Ric O Day
- St Vincent's Hospital Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,Department of Pharmacology, University of New South Wales, Sydney, NSW, Australia
| | - Bethan Richards
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jane Latimer
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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Affiliation(s)
- Bruno T Saragiotto
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
- Institute for Musculoskeletal Health, University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, University of Sydney, New South Wales, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, University of Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, University of Sydney, New South Wales, Australia
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Abdel Shaheed C, Carland JE, Graham GG, Stocker SL, Smith G, Hicks M, Williams KM, Furlong T, Macdonald P, Greenfield JR, Smith FC, Chowdhury G, Day RO. Is the use of metformin in patients undergoing dialysis hazardous for life? A systematic review of the safety of metformin in patients undergoing dialysis. Br J Clin Pharmacol 2019; 85:2772-2783. [PMID: 31471973 DOI: 10.1111/bcp.14107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/04/2019] [Accepted: 08/18/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS Metformin may have clinical benefits in dialysis patients; however, its safety in this population is unknown. This systematic review evaluated the safety of metformin in dialysis patients. METHODS MEDLINE, Embase, CENTRAL, PsycINFO and the Cochrane Library were searched for randomised controlled trials and observational studies evaluating metformin use in dialysis patients. Three authors reviewed the studies and extracted data. The primary outcomes were mortality, occurrence of lactic acidosis and myocardial infarction (MI) in patients taking metformin during dialysis treatment for ≥12 months (long term). Risk of bias was assessed using Risk Of Bias In Nonrandomised Studies of Interventions (ROBINS-1). Overall quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Fifteen observational studies were eligible; 7 were prospective observational studies and 8 were case reports/case series. No randomised controlled trials were identified. The 7 prospective observational studies (n = 194) reported on cautious metformin use in patients undergoing maintenance dialysis. Only 3 provided long-term follow-up data. In 2 long-term studies of metformin therapy (≤1000 mg/d) in patients undergoing peritoneal dialysis (PD), 1 reported 6 deaths (6/83; 7%) due to major cardiovascular events (3 MI) and the other reported no deaths (0/35). One long-term study of metformin therapy (250 mg to 500 mg thrice weekly) in patients undergoing haemodialysis reported 4 deaths (4/61; 7%) due to major cardiovascular events (2 MI). These findings provide very low-quality evidence as they come from small observational studies. CONCLUSION The evidence regarding the safety of metformin in people undergoing dialysis is inconclusive. Appropriately designed randomised controlled trials are needed to resolve this uncertainty.
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Affiliation(s)
- Christina Abdel Shaheed
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Greg Smith
- Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Mark Hicks
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Timothy Furlong
- Department of Nephrology, St Vincent's Hospital, Sydney, Australia
| | - Peter Macdonald
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Jerry R Greenfield
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,Diabetes and Metabolism Division, Garvan Institute of Metabolic Research, Sydney, Australia.,Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Gina Chowdhury
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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Affiliation(s)
- Christina Abdel Shaheed
- Institute for Musculoskeletal Health, University of Sydney, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Andrew J McLachlan
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, University of Sydney, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Ferreira GE, Machado GC, Abdel Shaheed C, Lin CWC, Needs C, Edwards J, Facer R, Rogan E, Richards B, Maher CG. Management of low back pain in Australian emergency departments. BMJ Qual Saf 2019; 28:826-834. [DOI: 10.1136/bmjqs-2019-009383] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/26/2019] [Accepted: 05/16/2019] [Indexed: 01/08/2023]
Abstract
BackgroundTo describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by ambulance, received imaging, opioids and were admitted to hospital; and to explore factors associated with these four outcomes.MethodsIn this retrospective study, we analysed electronic medical records for all adults presenting with LBP at three Australian EDs from January 2016 to June 2018. Outcomes included discharge diagnoses and key aspects of care (ambulance transport, lumbar spine imaging, provision of opioids, admission). We explored factors associated with these care outcomes using multilevel mixed-effects logistic regression models and reported data as ORs.ResultsThere were 14 024 presentations with a ‘visit reason’ for low back pain, of which 6393 (45.6%) had a diagnosis of a lumbar spine condition. Of these, 31.4% arrived by ambulance, 23.6% received lumbar imaging, 69.6% received opioids and 17.6% were admitted to hospital. Older patients (OR 1.79, 95% CI 1.56 to 2.04) were more likely to be imaged. Opioids were less used during working hours (OR 0.81, 95% CI 0.67 to 0.98) and in patients with non-serious LBP compared with patients with serious spinal pathology (OR 1.65, 95% CI 1.07 to 2.55). Hospital admission was more likely to occur during working hours (OR 1.74, 95% CI 1.48 to 2.05) and for those who arrived by ambulance (OR 2.98, 95% CI 2.53 to 3.51).ConclusionMany ED presentations of LBP were not due to a lumbar spine condition. Of those that were, we noted relatively high rates of lumbar imaging, opioid use and hospital admission.
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Binny J, Joshua Wong NL, Garga S, Lin CWC, Maher CG, McLachlan AJ, Traeger AC, Machado GC, Shaheed CA. Transcutaneous electric nerve stimulation (TENS) for acute low back pain: systematic review. Scand J Pain 2019; 19:225-233. [PMID: 30849052 DOI: 10.1515/sjpain-2018-0124] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/22/2019] [Indexed: 01/08/2023]
Abstract
Background and aims There has been no comprehensive evaluation of the efficacy of transcutaneous electric nerve stimulation (TENS) for acute low back pain (LBP). The aim of this systematic review was to investigate the efficacy and safety of TENS for acute LBP. Methods We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL and PsycINFO (inception to May 2018) for randomised placebo controlled trials. The primary outcome measure was pain relief in the immediate term (within 2-weeks of administration) assessed using the 100 mm visual analogue scale. A mean difference of at least 10 points on the 100-point pain scale was considered clinically significant. Methodological quality of the eligible studies was assessed using the PEDro scale and overall quality assessment rating was assessed using GRADE. Results Three placebo controlled studies (n = 192) were included. One low quality trial (n = 63) provides low quality evidence that ~30 min treatment with TENS in an emergency-care setting provides clinically worthwhile pain relief for moderate to severe acute LBP in the immediate term compared with sham TENS [Mean Difference (MD) - 28.0 (95% CI - 32.7, -23.3)]. Two other studies which administered a course of TENS over 4-5 weeks, in more usual settings provide inconclusive evidence; MD -2.75 (95% CI -11.63, 6.13). There was limited data on adverse events or long term follow-up. Conclusions The current evidence is insufficient to support or dismiss the use of TENS for acute LBP. Implications There is insufficient evidence to guide the use of TENS for acute LBP. There is low quality evidence of moderate improvements in pain with a short course of TENS (~30 min) during emergency transport of patients to the hospital. Future research should evaluate whether TENS has an opioid sparing role in the management of acute LBP.
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Affiliation(s)
- Justine Binny
- School of Medicine, Western Sydney University, Sydney, Australia
| | | | - Shirali Garga
- School of Medicine, Western Sydney University, Sydney, Australia
| | - Chung-Wei Christine Lin
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Chris G Maher
- Faculty of Medicine and Health, Sydney School of Public 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
| | - Adrian C Traeger
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Gustavo C Machado
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Christina Abdel Shaheed
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
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Graves J, Shaheed CA, McDonald J. A Lesson in Mental Health Stigma. Acad Psychiatry 2019; 43:250-251. [PMID: 30421291 DOI: 10.1007/s40596-018-1002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/05/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Jane Graves
- School of Medicine, Western Sydney University, Penrith, Australia
| | | | - Jenny McDonald
- School of Medicine, Western Sydney University, Penrith, Australia.
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Milder TY, Stocker SL, Abdel Shaheed C, McGrath-Cadell L, Samocha-Bonet D, Greenfield JR, Day RO. Combination Therapy with an SGLT2 Inhibitor as Initial Treatment for Type 2 Diabetes: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:jcm8010045. [PMID: 30621212 PMCID: PMC6352265 DOI: 10.3390/jcm8010045] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 12/29/2018] [Accepted: 12/29/2018] [Indexed: 02/06/2023] Open
Abstract
Background: Guidelines differ with regard to indications for initial combination pharmacotherapy for type 2 diabetes. Aims: To compare the efficacy and safety of (i) sodium-glucose cotransporter 2 (SGLT2) inhibitor combination therapy in treatment-naïve type 2 diabetes adults; (ii) initial high and low dose SGLT2 inhibitor combination therapy. Methods: PubMed, Embase and Cochrane Library were searched for randomised controlled trials (RCTs) of initial SGLT2 combination therapy. Mean difference (MD) for changes from baseline (HbA1c, weight, blood pressure) after 24–26 weeks of treatment and relative risks (RR, safety) were calculated using a random-effects model. Risk of bias and quality of evidence was assessed. Results: In 4 RCTs (n = 3749) there was moderate quality evidence that SGLT2 inhibitor/metformin combination therapy resulted in a greater reduction in HbA1c (MD (95% CI); −0.55% (−0.67, −0.43)) and weight (−2.00 kg (−2.34, −1.66)) compared with metformin monotherapy, and a greater reduction in HbA1c (−0.59% (−0.72, −0.46)) and weight (−0.57 kg (−0.89, −0.25)) compared with SGLT2 inhibitor monotherapy. The high dose SGLT2 inhibitor/metformin combination resulted in a similar HbA1c but greater weight reduction; −0.47 kg (−0.88, −0.06) than the low dose combination therapy. The RR of genital infection with combination therapy was 2.22 (95% CI 1.33, 3.72) and 0.69 (95% CI 0.50, 0.96) compared with metformin and SGLT2 inhibitor monotherapy, respectively. The RR of diarrhoea was 2.23 (95% CI 1.46, 3.40) with combination therapy compared with SGLT2 inhibitor monotherapy. Conclusions: Initial SGLT2 inhibitor/metformin combination therapy has glycaemic and weight benefits compared with either agent alone and appears relatively safe. High dose SGLT2 inhibitor/metformin combination therapy appears to have modest weight, but no glycaemic benefits compared with the low dose combination therapy.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
- St. Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia.
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
- St. Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
| | - Christina Abdel Shaheed
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.
| | - Lucy McGrath-Cadell
- St. Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
- Department of Cardiology, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
| | - Dorit Samocha-Bonet
- St. Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia.
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
- St. Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, NSW 2010, Australia.
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW 2010, Australia.
- St. Vincent's Clinical School, University of NSW, Sydney, NSW 2010, Australia.
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Aghajani M, Graham S, McCafferty C, Shaheed CA, Roberts T, DeSouza P, Yang T, Niles N. Clinicopathologic and Prognostic Significance of Programmed Cell Death Ligand 1 Expression in Patients with Non-Medullary Thyroid Cancer: A Systematic Review and Meta-Analysis. Thyroid 2018; 28:349-361. [PMID: 29455638 DOI: 10.1089/thy.2017.0441] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Evidence has shown that programmed cell death ligand 1 (PD-L1) overexpression is associated with poor prognosis and resistance to immune therapies in several human cancers. However, data on the prognostic significance of PD-L1 expression in thyroid cancer are limited and remain controversial. This systematic review and meta-analysis aimed to evaluate comprehensively the clinicopathologic significance and prognostic value of PD-L1 expression in non-medullary thyroid cancers. METHODS Electronic databases, including Medline/PubMed, EMBASE, and the Cochrane Library, were searched up until July 5, 2017. In total, seven comparisons (from six articles) comprising 1421 patients were included in the pooled analysis. RESULTS There was moderate quality evidence from four studies (n = 721) that shows positive PD-L1 expression was significantly associated with poor survival among thyroid cancer patients (pooled hazard ratio = 3.73 [confidence interval (CI) 2.75-5.06]). Increased PD-L1 expression was also found to be significantly associated with disease recurrence (odds ratio = 1.95 [CI 1.15-3.32]) and concurrent thyroiditis (odds ratio = 1.65 [CI 1.09-2.51]). CONCLUSIONS The results confirm the prognostic significance of PD-L1 expression in thyroid cancer patients. PD-L1 expression has the potential to be implemented as a prognostic biomarker used to guide clinicians in identifying patients with more aggressive cancers, and for the selection of individuals that would derive durable clinical benefit from anti-PD-1/PD-L1 immunotherapy. Prospective clinical trials will be useful to support these findings.
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Affiliation(s)
- Marra Aghajani
- 1 Department of Medical Oncology, Ingham Institute for Applied Medical Research , Liverpool, Australia
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
| | - Susannah Graham
- 1 Department of Medical Oncology, Ingham Institute for Applied Medical Research , Liverpool, Australia
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
- 3 Department of Head and Neck Surgery, Liverpool Hospital , Liverpool, Australia
| | - Charles McCafferty
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
| | | | - Tara Roberts
- 1 Department of Medical Oncology, Ingham Institute for Applied Medical Research , Liverpool, Australia
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
- 5 South West Sydney Clinical School , UNSW Sydney, Sydney, Australia
| | - Paul DeSouza
- 1 Department of Medical Oncology, Ingham Institute for Applied Medical Research , Liverpool, Australia
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
- 5 South West Sydney Clinical School , UNSW Sydney, Sydney, Australia
| | - Tao Yang
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
- 6 Saint Vincent's Clinical School , UNSW Sydney, Sydney, Australia
- 7 SydPath, Saint Vincent's Hospital , Sydney, Australia
| | - Navin Niles
- 1 Department of Medical Oncology, Ingham Institute for Applied Medical Research , Liverpool, Australia
- 2 School of Medicine, Western Sydney University , Campbelltown, Australia
- 3 Department of Head and Neck Surgery, Liverpool Hospital , Liverpool, Australia
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Yamato TP, Maher CG, Saragiotto BT, Shaheed CA, Moseley AM, Lin CWC, Koes B, McLachlan AJ. Comparison of effect sizes between enriched and nonenriched trials of analgesics for chronic musculoskeletal pain: a systematic review. Br J Clin Pharmacol 2017. [PMID: 28636752 DOI: 10.1111/bcp.13350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIMS To investigate the use of an enriched study design on the estimates of treatment effect in analgesic trials for chronic musculoskeletal pain. METHODS Database searches were conducted from 2004 to 2014. We included randomized placebo-controlled trials evaluating pain medications for chronic musculoskeletal pain. Methodological quality was assessed using the PEDro scale. The estimates of treatment effect on pain and adverse events were compared between enriched and nonenriched designs. Metaregression was used to assess the association between the effect size estimate and the study design controlling for analgesic dose and methodological quality. RESULTS We included 108 trials, of which 99 were included in the meta-analysis (n = 44 171). There were no overall differences in effect sizes between enriched and nonenriched designs for pain intensity. There was a significant difference for a reduction in any adverse events favouring enriched designs for opioids, but not for other analgesics or the outcome serious adverse events. There was an association between effect size and methodological quality, with failure to blind the outcome assessor and failure to use intention-to-treat analysis being associated with larger effect sizes. CONCLUSIONS There is no evidence that the use of an enriched study design changes the treatment effect size estimate for pain. There is some evidence that clinical trials that employ enriched designs report a reduced risk of adverse events in trials for chronic musculoskeletal pain, but it is unclear whether enriched designs influence estimates of serious adverse events. Features of trial design and study quality were associated with treatment effect estimates.
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Affiliation(s)
- Tie P Yamato
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | - Chris G Maher
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | - Bruno T Saragiotto
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | | | - Anne M Moseley
- School of Public Health, Sydney Medical School, The University of Sydney, Australia
| | | | - Bart Koes
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Andrew J McLachlan
- Faculty of Pharmacy and Centre for Education and Research on Ageing, The University of Sydney and Concord Hospital, Sydney, Australia
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Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Pharmacists' views on implementing a disease state management program for low back pain. Aust J Prim Health 2016; 22:211-217. [PMID: 25719762 DOI: 10.1071/py14116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 12/09/2014] [Indexed: 11/23/2022]
Abstract
Pharmacists have the potential to take a lead role in the primary care management of people with acute low back pain. The aim of this study was to investigate pharmacists' views on implementing a care program for people with acute low back pain in the community pharmacy. Recruitment of pharmacists for this study took place between July 2012 and March 2013. A convenience sample of 30 pharmacists who collaborated in recruiting participants for a low back pain clinical trial in Sydney (n=15 pharmacist recruiters and n=15 non-recruiters) completed an open-ended questionnaire. There was no marked variation in responses between the two groups. Participating pharmacists were receptive to the idea of implementing a care program for people with low back pain, highlighting the need for adequate reimbursement and adequate training of staff to ensure it is successful. Pharmacists identified that the follow up of people receiving such a service is dependent on several factors such as effective reminder systems and the proximity of patients to the pharmacy.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Pharmacy, University of Sydney, Pharmacy Building A15, Faculty of Pharmacy, University of Sydney, NSW 2006, Australia
| | - Christopher G Maher
- Graduate School of Health, The George Institute for Global Health, Sydney, Level 13, 321 Kent Street, Sydney, NSW 2000, Australia
| | - Kylie A Williams
- University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, Pharmacy Building A15, Faculty of Pharmacy, University of Sydney, NSW 2006, Australia
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Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med 2016; 176:958-68. [PMID: 27213267 DOI: 10.1001/jamainternmed.2016.1251] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Opioid analgesics are commonly used for low back pain, however, to our knowledge there has been no systematic evaluation of the effect of opioid dose and use of enrichment study design on estimates of treatment effect. OBJECTIVE To evaluate efficacy and tolerability of opioids in the management of back pain; and investigate the effect of opioid dose and use of an enrichment study design on treatment effect. DATA SOURCES Medline, EMBASE, CENTRAL, CINAHL, and PsycINFO (inception to September 2015) with citation tracking from eligible randomized clinical trials (RCTs). STUDY SELECTION Placebo-controlled RCTs in any language. DATA EXTRACTION AND SYNTHESIS Two authors independently extracted data and assessed risk of bias. Data were pooled using a random effects model with strength of evidence assessed using the grading of recommendations assessment, development, and evaluation (GRADE). MAIN OUTCOMES AND MEASURES The primary outcome measure was pain. Pain and disability outcomes were converted to a common 0 to 100 scale, with effects greater than 20 points considered clinically important. RESULTS Of 20 included RCTs of opioid analgesics (with a total of 7925 participants), 13 trials (3419 participants) evaluated short-term effects on chronic low back pain, and no placebo-controlled trials enrolled patients with acute low back pain. In half of these 13 trials, at least 50% of participants withdrew owing to adverse events or lack of efficacy. There was moderate-quality evidence that opioid analgesics reduce pain in the short term; mean difference (MD), -10.1 (95% CI, -12.8 to -7.4). Meta-regression revealed a 12.0 point greater pain relief for every 1 log unit increase in morphine equivalent dose (P = .046). Clinically important pain relief was not observed within the dose range evaluated (40.0-240.0-mg morphine equivalents per day). There was no significant effect of enrichment study design. CONCLUSIONS AND RELEVANCE For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking. The efficacy of opioid analgesics in acute low back pain is unknown.
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Affiliation(s)
- Christina Abdel Shaheed
- The George Institute for Global Health, Sydney, Australia2School of Medicine, Western Sydney University, Penrith, Australia
| | - Chris G Maher
- Musculoskeletal Division, The George Institute for Global Health, Sydney, Australia4Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kylie A Williams
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Richard Day
- Department of Clinical Pharmacology, St Vincent's Hospital and St Vincent's Clinical School, University of New South Wales, Sydney, Australia7School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Andrew J McLachlan
- The George Institute for Global Health, Sydney, Australia8Centre for Education and Research on Ageing, Sydney, Australia
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Abstract
BACKGROUND Analgesic medication is the most frequently prescribed treatment for low back pain (LBP), of which paracetamol (acetaminophen) is recommended as the first choice medication. However, there is uncertainty about the efficacy of paracetamol for LBP. OBJECTIVES To investigate the efficacy and safety of paracetamol for non-specific LBP. SEARCH METHODS We conducted searches on the Cochrane Central Register of Controlled Trials (CENTRAL, which includes the Back and Neck Review Group trials register), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, LILACS, and IPA from their inception to 7 August 2015. We also searched the reference lists of eligible papers and trial registry websites (WHO ICTRP and ClinicalTrials.gov). SELECTION CRITERIA We only considered randomised trials comparing the efficacy of paracetamol with placebo for non-specific LBP. The primary outcomes were pain and disability. We also investigated quality of life, function, adverse effects, global impression of recovery, sleep quality, patient adherence, and use of rescue medication as secondary outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently performed the data extraction and assessed risk of bias in the included studies. We also evaluated the quality of evidence using the GRADE approach. We converted scales for pain intensity to a common 0 to 100 scale. We quantified treatment effects using mean difference for continuous outcomes and risk ratios for dichotomous outcomes. We used effect sizes and 95% confidence intervals as a measure of treatment effect for the primary outcomes. When the treatment effects were smaller than 9 points on a 0 to 100 scale, we considered the effect as small and not clinically important. MAIN RESULTS Our searches retrieved 4449 records, of which three trials were included in the review (n = 1825 participants), and two trials were included in the meta-analysis. For acute LBP, there is high-quality evidence for no difference between paracetamol (4 g per day) and placebo at 1 week (immediate term), 2 weeks, 4 weeks, and 12 weeks (short term) for the primary outcomes. There is high-quality evidence that paracetamol has no effect on quality of life, function, global impression of recovery, and sleep quality for all included time periods. There were also no significant differences between paracetamol and placebo for adverse events, patient adherence, or use of rescue medication. For chronic LBP, there is very low-quality evidence (based on a trial that has been retracted) for no effect of paracetamol (1 g single intravenous dose) on immediate pain reduction. Finally, no trials were identified evaluating patients with subacute LBP. AUTHORS' CONCLUSIONS We found that paracetamol does not produce better outcomes than placebo for people with acute LBP, and it is uncertain if it has any effect on chronic LBP.
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Affiliation(s)
- Bruno T Saragiotto
- Universidade Cidade de São PauloMasters and Doctoral Programs in Physical TherapySao PauloBrazil
| | - Gustavo C Machado
- Sydney Medical School, The University of SydneySydney School of Public HealthPO Box M179, Missenden RdSydneyNSWAustralia2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyInstitute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
| | - Marina B Pinheiro
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health SciencesRoom S227, S BlockSydneyAustraliaNSW 2141
| | | | - Christopher G Maher
- University of SydneySydney School of Public HealthLevel 10 North, King George V Building, Missenden Road, CamperdownSydneyNSWAustralia2050
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