Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis / Luis Enrique Chaparro Gómez  

Público ISBD Título : Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis Tipo de documento : documento electrónico Autores : Luis Enrique Chaparro Gómez, Fecha de publicación : 2016 Títulos uniformes : Regional Anesthesia and Pain Medicine Idioma : Inglés (eng) Resumen : Background: This systematic review examines the evidence for preprocedural neuraxial ultrasound as an adjunct to lumbar spinal and epidural anesthesia in adults. Methods: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to June 30, 2014, for randomized controlled trials (RCTs) and cohort studies that reported data answering one or more of the following 3 questions: (1) Does ultrasound accurately identify a given lumbar intervertebral space? (2) Does ultrasound accurately predict the needle insertion depth required to reach the epidural or intrathecal space? (3) Does ultrasound improve the efficacy and safety of spinal or lumbar epidural anesthesia? Results: Thirty-one clinical trials and 1 meta-analysis were included in this review. Data from 8 studies indicate that neuraxial ultrasound can identify a given lumbar intervertebral space more accurately than by landmark palpation alone. Thirteen studies reported an excellent correlation between ultrasound-measured depth and needle insertion depth to the epidural or intrathecal space. The mean difference between the 2 measurements was within 3 mm in most studies. Thirteen RCTs, 5 cohort studies, and 1 metaanalysis reported data on efficacy and safety outcomes. Results consistently showed that ultrasound resulted in increased success and ease of performance. Ultrasound seemed to reduce the risk of traumatic procedures but there was otherwise insufficient evidence to conclude if it significantly improves safety. Conclusions: There is significant evidence supporting the role of neuraxial ultrasound in improving the precision and efficacy of neuraxial anesthetic techniques. What's New: We know that neuraxial ultrasound is a useful complement to clinical examination when performing lumbar central neuraxial blocks. It provides anatomical information including the depthof the epidural space, the identity of a given intervertebral level, and the location of the midline and interspinous/interlaminar spaces. This information can be used to successfully guide subsequent needle insertion. Since 2010, new data from RCTs and 1 meta-analysis suggest that neuraxial ultrasound increases the success and reduces the technical difficulty of lumbar central neuraxial blocks. Findings from the meta-analysis suggest that neuraxial ultrasound reduces the risk of traumatic procedures, and thus may possibly contribute to the safety of lumbarcentral neuraxial blocks. Mención de responsabilidad : Anahi Perlas, Luis E Chaparro, Ki Jinn Chin Referencia : Reg Anesth Pain Med. 2016 Mar-Apr;41(2):251-60. DOI (Digital Object Identifier) : 10.1097/AAP.0000000000000184 PMID : 25493689 En línea : https://rapm.bmj.com/content/41/2/251 Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=4000 Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis [documento electrónico] / Luis Enrique Chaparro Gómez,  . - 2016. Obra : Regional Anesthesia and Pain Medicine Idioma : Inglés (eng) Resumen : Background: This systematic review examines the evidence for preprocedural neuraxial ultrasound as an adjunct to lumbar spinal and epidural anesthesia in adults. Methods: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to June 30, 2014, for randomized controlled trials (RCTs) and cohort studies that reported data answering one or more of the following 3 questions: (1) Does ultrasound accurately identify a given lumbar intervertebral space? (2) Does ultrasound accurately predict the needle insertion depth required to reach the epidural or intrathecal space? (3) Does ultrasound improve the efficacy and safety of spinal or lumbar epidural anesthesia? Results: Thirty-one clinical trials and 1 meta-analysis were included in this review. Data from 8 studies indicate that neuraxial ultrasound can identify a given lumbar intervertebral space more accurately than by landmark palpation alone. Thirteen studies reported an excellent correlation between ultrasound-measured depth and needle insertion depth to the epidural or intrathecal space. The mean difference between the 2 measurements was within 3 mm in most studies. Thirteen RCTs, 5 cohort studies, and 1 metaanalysis reported data on efficacy and safety outcomes. Results consistently showed that ultrasound resulted in increased success and ease of performance. Ultrasound seemed to reduce the risk of traumatic procedures but there was otherwise insufficient evidence to conclude if it significantly improves safety. Conclusions: There is significant evidence supporting the role of neuraxial ultrasound in improving the precision and efficacy of neuraxial anesthetic techniques. What's New: We know that neuraxial ultrasound is a useful complement to clinical examination when performing lumbar central neuraxial blocks. It provides anatomical information including the depthof the epidural space, the identity of a given intervertebral level, and the location of the midline and interspinous/interlaminar spaces. This information can be used to successfully guide subsequent needle insertion. Since 2010, new data from RCTs and 1 meta-analysis suggest that neuraxial ultrasound increases the success and reduces the technical difficulty of lumbar central neuraxial blocks. Findings from the meta-analysis suggest that neuraxial ultrasound reduces the risk of traumatic procedures, and thus may possibly contribute to the safety of lumbarcentral neuraxial blocks. Mención de responsabilidad : Anahi Perlas, Luis E Chaparro, Ki Jinn Chin Referencia : Reg Anesth Pain Med. 2016 Mar-Apr;41(2):251-60. DOI (Digital Object Identifier) : 10.1097/AAP.0000000000000184 PMID : 25493689 En línea : https://rapm.bmj.com/content/41/2/251 Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=4000

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Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review / Luis Enrique Chaparro Gómez  

Público ISBD Título : Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review Tipo de documento : documento electrónico Autores : Luis Enrique Chaparro Gómez, Fecha de publicación : 2014 Títulos uniformes : Spine Idioma : Inglés (eng) Palabras clave : Analgesics  opioid/adverse effects  opioid/therapeutic use  buprenorphine/therapeutic use  Cochrane Review  hydromorphone/therapeutic use  low back pain/drug therapy  metaanalysis  morphine/therapeutic use  oxycodone/therapeutic use  oxymorphone/therapeutic use  sciatica/drug therapy  systematic review  tramadol/therapeutic use Resumen : Study Design: Systematic review and meta-analysis. Objective:To assess the efficacy of opioids in adults with chronic low back pain (CLBP). Summary of Background Data. Opioids for CLBP has increased dramatically. However, the benefits and risks remain unclear. Methods: We updated a 2007 Cochrane Review through October 2012 of randomized controlled trials from multiple databases. Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments; comparisons with different opioids were excluded. Outcomes included pain and function using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (CIs), and absolute risk difference with 95% CI for adverse effects. Study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria. Results: Fifteen trials (5540 participants), including twelve new, met the criteria. Tramadol was better than placebo for pain (SMD, −0.55; 95% CI, −0.66 to −0.44) and function (SMD, −0.18; 95% CI, −0.29 to −0.07). Compared with placebo, transdermal buprenorphine decreased pain (SMD, −2.47; 95% CI, −2.69 to −2.25), but not function (SMD, −0.14; 95% CI, −0.53 to 0.25). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), were better than placebo for pain (SMD, −0.43; 95% CI, −0.52 to −0.33) and function (SMD, −0.26; 95% CI, −0.37 to −0.15). One trial demonstrated little difference with tramadol compared with celecoxib for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for pain or function. Reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported. Conclusion. There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long- term opioid therapy for treatment of CLBP remains unproven. Level of Evidence: 1 Mención de responsabilidad : Luis Enrique Chaparro, Andrea D Furlan, Amol Deshpande, Angela Mailis-Gagnon, Steven Atlas, Dennis C Turk Referencia : Spine (Phila Pa 1976). 2014 Apr 1;39(7):556-63. DOI (Digital Object Identifier) : 10.1097/BRS.0000000000000249 PMID : 24480962 En línea : https://insights.ovid.com/crossref?an=00007632-201404010-00010 Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3786 Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review [documento electrónico] / Luis Enrique Chaparro Gómez,  . - 2014. Obra : Spine Idioma : Inglés (eng) Palabras clave : Analgesics  opioid/adverse effects  opioid/therapeutic use  buprenorphine/therapeutic use  Cochrane Review  hydromorphone/therapeutic use  low back pain/drug therapy  metaanalysis  morphine/therapeutic use  oxycodone/therapeutic use  oxymorphone/therapeutic use  sciatica/drug therapy  systematic review  tramadol/therapeutic use Resumen : Study Design: Systematic review and meta-analysis. Objective:To assess the efficacy of opioids in adults with chronic low back pain (CLBP). Summary of Background Data. Opioids for CLBP has increased dramatically. However, the benefits and risks remain unclear. Methods: We updated a 2007 Cochrane Review through October 2012 of randomized controlled trials from multiple databases. Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments; comparisons with different opioids were excluded. Outcomes included pain and function using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (CIs), and absolute risk difference with 95% CI for adverse effects. Study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria. Results: Fifteen trials (5540 participants), including twelve new, met the criteria. Tramadol was better than placebo for pain (SMD, −0.55; 95% CI, −0.66 to −0.44) and function (SMD, −0.18; 95% CI, −0.29 to −0.07). Compared with placebo, transdermal buprenorphine decreased pain (SMD, −2.47; 95% CI, −2.69 to −2.25), but not function (SMD, −0.14; 95% CI, −0.53 to 0.25). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), were better than placebo for pain (SMD, −0.43; 95% CI, −0.52 to −0.33) and function (SMD, −0.26; 95% CI, −0.37 to −0.15). One trial demonstrated little difference with tramadol compared with celecoxib for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for pain or function. Reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported. Conclusion. There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long- term opioid therapy for treatment of CLBP remains unproven. Level of Evidence: 1 Mención de responsabilidad : Luis Enrique Chaparro, Andrea D Furlan, Amol Deshpande, Angela Mailis-Gagnon, Steven Atlas, Dennis C Turk Referencia : Spine (Phila Pa 1976). 2014 Apr 1;39(7):556-63. DOI (Digital Object Identifier) : 10.1097/BRS.0000000000000249 PMID : 24480962 En línea : https://insights.ovid.com/crossref?an=00007632-201404010-00010 Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3786

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Opioids compared to placebo or other treatments for chronic low-back pain / Luis Enrique Chaparro Gómez  

Público ISBD Título : Opioids compared to placebo or other treatments for chronic low-back pain Tipo de documento : documento electrónico Autores : Luis Enrique Chaparro Gómez, Fecha de publicación : 2013 Títulos uniformes : Cochrane Database of Systematic Reviews Idioma : Inglés (eng) Resumen : Background: The use of opioids in the long‐term management of chronic low‐back pain (CLBP) has increased dramatically. Despite this trend, the benefits and risks of these medications remain unclear. This review is an update of a Cochrane review first published in 2007. Objectives: To determine the efficacy of opioids in adults with CLBP. Search methods: We electronically searched the Cochrane Back Review Group's Specialized Register, CENTRAL, CINAHL and PsycINFO, MEDLINE, and EMBASE from January 2006 to October 2012. We checked the reference lists of these trials and other relevant systematic reviews for potential trials for inclusion. Selection criteria: We included randomized controlled trials (RCTs) that assessed the use of opioids (as monotherapy or in combination with other therapies) in adults with CLBP that were at least four weeks in duration. We included trials that compared non‐injectable opioids to placebo or other treatments. We excluded trials that compared different opioids only. Data collection and analysis: Two authors independently assessed the risk of bias and extracted data onto a pre‐designed form. We pooled results using Review Manager (RevMan) 5.2. We reported on pain and function outcomes using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (95% CI). We used absolute risk difference (RD) with 95% CI to report adverse effects. Main results: We included 15 trials (5540 participants). Tramadol was examined in five trials (1378 participants); it was found to be better than placebo for pain (SMD ‐0.55, 95% CI ‐0.66 to ‐0.44; low quality evidence) and function (SMD ‐0.18, 95% CI ‐0.29 to ‐0.07; moderate quality evidence). Transdermal buprenorphine (two trials, 653 participants) may make little difference for pain (SMD ‐2.47, 95%CI ‐2.69 to ‐2.25; very low quality evidence), but no difference compared to placebo for function (SMD ‐0.14, 95%CI ‐0.53 to 0.25; very low quality evidence). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), examined in six trials (1887 participants), were better than placebo for pain (SMD ‐0.43, 95%CI ‐0.52 to ‐0.33; moderate quality evidence) and function (SMD ‐0.26, 95% CI ‐0.37 to ‐0.15; moderate quality evidence). One trial (1583 participants) demonstrated that tramadol may make little difference compared to celecoxib (RR 0.82, 95% CI 0.76 to 0.90; very low quality evidence) for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for either pain (SMD 0.21, 95% CI ‐0.03 to 0.45; very low quality evidence), or function (SMD ‐0.11, 95% ‐0.63 to 0.42; very low quality evidence). The included trials in this review had high drop‐out rates, were of short duration, and had limited interpretability of functional improvement. They did not report any serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid‐induced hyperalgesia, hypogonadism). In general, the effect sizes were medium for pain and small for function. Authors' conclusions: There is some evidence (very low to moderate quality) for short‐term efficacy (for both pain and function) of opioids to treat CLBP compared to placebo. The very few trials that compared opioids to non‐steroidal anti‐inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long‐term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo‐RCTs supporting the effectiveness and safety of long‐term opioid therapy for treatment of CLBP. Mención de responsabilidad : Luis Enrique Chaparro, Andrea D Furlan, Amol Deshpande, Angela Mailis-Gagnon, Steven Atlas, Dennis C Turk Referencia : Cochrane Database Syst Rev. 2013 Aug 27;(8):CD004959. DOI (Digital Object Identifier) : 10.1002/14651858.CD004959.pub4 PMID : 23983011 En línea : https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004959.pub4/full Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3723 Opioids compared to placebo or other treatments for chronic low-back pain [documento electrónico] / Luis Enrique Chaparro Gómez,  . - 2013. Obra : Cochrane Database of Systematic Reviews Idioma : Inglés (eng) Resumen : Background: The use of opioids in the long‐term management of chronic low‐back pain (CLBP) has increased dramatically. Despite this trend, the benefits and risks of these medications remain unclear. This review is an update of a Cochrane review first published in 2007. Objectives: To determine the efficacy of opioids in adults with CLBP. Search methods: We electronically searched the Cochrane Back Review Group's Specialized Register, CENTRAL, CINAHL and PsycINFO, MEDLINE, and EMBASE from January 2006 to October 2012. We checked the reference lists of these trials and other relevant systematic reviews for potential trials for inclusion. Selection criteria: We included randomized controlled trials (RCTs) that assessed the use of opioids (as monotherapy or in combination with other therapies) in adults with CLBP that were at least four weeks in duration. We included trials that compared non‐injectable opioids to placebo or other treatments. We excluded trials that compared different opioids only. Data collection and analysis: Two authors independently assessed the risk of bias and extracted data onto a pre‐designed form. We pooled results using Review Manager (RevMan) 5.2. We reported on pain and function outcomes using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (95% CI). We used absolute risk difference (RD) with 95% CI to report adverse effects. Main results: We included 15 trials (5540 participants). Tramadol was examined in five trials (1378 participants); it was found to be better than placebo for pain (SMD ‐0.55, 95% CI ‐0.66 to ‐0.44; low quality evidence) and function (SMD ‐0.18, 95% CI ‐0.29 to ‐0.07; moderate quality evidence). Transdermal buprenorphine (two trials, 653 participants) may make little difference for pain (SMD ‐2.47, 95%CI ‐2.69 to ‐2.25; very low quality evidence), but no difference compared to placebo for function (SMD ‐0.14, 95%CI ‐0.53 to 0.25; very low quality evidence). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), examined in six trials (1887 participants), were better than placebo for pain (SMD ‐0.43, 95%CI ‐0.52 to ‐0.33; moderate quality evidence) and function (SMD ‐0.26, 95% CI ‐0.37 to ‐0.15; moderate quality evidence). One trial (1583 participants) demonstrated that tramadol may make little difference compared to celecoxib (RR 0.82, 95% CI 0.76 to 0.90; very low quality evidence) for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for either pain (SMD 0.21, 95% CI ‐0.03 to 0.45; very low quality evidence), or function (SMD ‐0.11, 95% ‐0.63 to 0.42; very low quality evidence). The included trials in this review had high drop‐out rates, were of short duration, and had limited interpretability of functional improvement. They did not report any serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid‐induced hyperalgesia, hypogonadism). In general, the effect sizes were medium for pain and small for function. Authors' conclusions: There is some evidence (very low to moderate quality) for short‐term efficacy (for both pain and function) of opioids to treat CLBP compared to placebo. The very few trials that compared opioids to non‐steroidal anti‐inflammatory drugs (NSAIDs) or antidepressants did not show any differences regarding pain and function. The initiation of a trial of opioids for long‐term management should be done with extreme caution, especially after a comprehensive assessment of potential risks. There are no placebo‐RCTs supporting the effectiveness and safety of long‐term opioid therapy for treatment of CLBP. Mención de responsabilidad : Luis Enrique Chaparro, Andrea D Furlan, Amol Deshpande, Angela Mailis-Gagnon, Steven Atlas, Dennis C Turk Referencia : Cochrane Database Syst Rev. 2013 Aug 27;(8):CD004959. DOI (Digital Object Identifier) : 10.1002/14651858.CD004959.pub4 PMID : 23983011 En línea : https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004959.pub4/full Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3723

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Pharmacotherapy for the prevention of chronic pain after surgery in adults / Luis Enrique Chaparro Gómez  

Público ISBD Título : Pharmacotherapy for the prevention of chronic pain after surgery in adults Tipo de documento : documento electrónico Autores : Luis Enrique Chaparro Gómez, Fecha de publicación : 2013 Títulos uniformes : Cochrane Database of Systematic Reviews Idioma : Francés (fre) Resumen : Background: Chronic pain can often occur after surgery, substantially impairing patients’ health and quality of life. It is caused by complex mechanisms that are not yet well understood. The predictable nature of most surgical procedures has allowed for the conduct of randomized controlled trials of pharmacological interventions aimed at preventing chronic postsurgical pain. Objectives: The primary objective was to evaluate the efficacy of systemic drugs for the prevention of chronic pain after surgery by examining the proportion of patients reporting pain three months or more after surgery. The secondary objective was to evaluate the safety of drugs administered for the prevention of chronic pain after surgery. Search methods: We identified randomized controlled trials (RCTs) of various systemically administered drugs for the prevention of chronic pain after surgery from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 17 July 2013. Selection criteria: Included studies were double‐blind, placebo‐controlled, randomized trials involving adults and evaluating one or more drugs administered systemically before, during or after surgery, or both, which measured pain three months or more after surgery. Data collection and analysis: Data collected from each study included the study drug name, dose, route, timing and duration of dosing; surgical procedure; proportion of patients reporting any pain three months or more after surgery, reporting at least 4/10 or moderate to severe pain three months or more after surgery; and proportion of participants dropping out of the study due to treatment‐emergent adverse effects. Main results: We identified 40 RCTs of various pharmacological interventions including intravenous ketamine (14 RCTs), oral gabapentin (10 RCTs), oral pregabalin (5 RCTs), non‐steroidal anti‐inflammatories (3 RCTs), intravenous steroids (3 RCTs), oral N‐methyl‐D‐aspartate (NMDA) blockers (3 RCTs), oral mexiletine (2 RCTs), intravenous fentanyl (1 RCT), intravenous lidocaine (1 RCT), oral venlafaxine (1 RCT) and inhaled nitrous oxide (1 RCT). Meta‐analysis suggested a modest but statistically significant reduction in the incidence of chronic pain after surgery following treatment with ketamine but not gabapentin or pregabalin. Results with ketamine should be viewed with caution since most of the included trials were small (that is Mención de responsabilidad : Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I Referencia : Cochrane Database Syst Rev. 2013 Jul 24;(7):CD008307. DOI (Digital Object Identifier) : 10.1002/14651858.CD008307.pub2 En línea : https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008307.pub2/full Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3718 Pharmacotherapy for the prevention of chronic pain after surgery in adults [documento electrónico] / Luis Enrique Chaparro Gómez,  . - 2013. Obra : Cochrane Database of Systematic Reviews Idioma : Francés (fre) Resumen : Background: Chronic pain can often occur after surgery, substantially impairing patients’ health and quality of life. It is caused by complex mechanisms that are not yet well understood. The predictable nature of most surgical procedures has allowed for the conduct of randomized controlled trials of pharmacological interventions aimed at preventing chronic postsurgical pain. Objectives: The primary objective was to evaluate the efficacy of systemic drugs for the prevention of chronic pain after surgery by examining the proportion of patients reporting pain three months or more after surgery. The secondary objective was to evaluate the safety of drugs administered for the prevention of chronic pain after surgery. Search methods: We identified randomized controlled trials (RCTs) of various systemically administered drugs for the prevention of chronic pain after surgery from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 17 July 2013. Selection criteria: Included studies were double‐blind, placebo‐controlled, randomized trials involving adults and evaluating one or more drugs administered systemically before, during or after surgery, or both, which measured pain three months or more after surgery. Data collection and analysis: Data collected from each study included the study drug name, dose, route, timing and duration of dosing; surgical procedure; proportion of patients reporting any pain three months or more after surgery, reporting at least 4/10 or moderate to severe pain three months or more after surgery; and proportion of participants dropping out of the study due to treatment‐emergent adverse effects. Main results: We identified 40 RCTs of various pharmacological interventions including intravenous ketamine (14 RCTs), oral gabapentin (10 RCTs), oral pregabalin (5 RCTs), non‐steroidal anti‐inflammatories (3 RCTs), intravenous steroids (3 RCTs), oral N‐methyl‐D‐aspartate (NMDA) blockers (3 RCTs), oral mexiletine (2 RCTs), intravenous fentanyl (1 RCT), intravenous lidocaine (1 RCT), oral venlafaxine (1 RCT) and inhaled nitrous oxide (1 RCT). Meta‐analysis suggested a modest but statistically significant reduction in the incidence of chronic pain after surgery following treatment with ketamine but not gabapentin or pregabalin. Results with ketamine should be viewed with caution since most of the included trials were small (that is Mención de responsabilidad : Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I Referencia : Cochrane Database Syst Rev. 2013 Jul 24;(7):CD008307. DOI (Digital Object Identifier) : 10.1002/14651858.CD008307.pub2 En línea : https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008307.pub2/full Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=3718

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Combination pharmacotherapy for the treatment of neuropathic pain in adults / Luis Enrique Chaparro Gómez  

Público ISBD Título : Combination pharmacotherapy for the treatment of neuropathic pain in adults Tipo de documento : documento electrónico Autores : Luis Enrique Chaparro Gómez, Fecha de publicación : 2012 Títulos uniformes : Cochrane Database of Systematic Reviews Idioma : Inglés (eng) Resumen : Background: Pharmacotherapy remains an important modality for the treatment of neuropathic pain. However, as monotherapy current drugs are associated with limited efficacy and dose‐related side effects. Combining two or more different drugs may improve analgesic efficacy and, in some situations, reduce overall side effects (e.g. if synergistic interactions allow for dose reductions of combined drugs). Objectives: This review evaluated the efficacy, tolerability and safety of various drug combinations for the treatment of neuropathic pain. Search methods: We identified randomised controlled trials (RCTs) of various drug combinations for neuropathic pain from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 9 April 2012. Selection criteria: Double‐blind, randomised studies comparing combinations of two or more drugs (systemic or topical) to placebo and/or at least one other comparator for the treatment of neuropathic pain. Data collection and analysis: Data extracted from each study included: proportion of participants a) reporting ≥ 30% pain reduction from baseline OR ≥ moderate pain relief OR ≥ moderate global improvement; b) dropping out of the trial due to treatment‐emergent adverse effects; c) reporting each specific adverse effect (e.g. sedation, dizziness) of ≥ moderate severity. The primary comparison of interest was between study drug(s) and one or both single‐agent comparators. We combined studies if they evaluated the same drug class combination at roughly similar doses and durations of treatment. We used RevMan 5 to analyse data for binary outcomes. Main results: We identified 21 eligible studies: four (578 participants) evaluated the combination of an opioid with gabapentin or pregabalin; two (77 participants) evaluated an opioid with a tricyclic antidepressant; one (56 participants) of gabapentin and nortriptyline; one (120 participants) of gabapentin and alpha‐lipoic acid, three (90 participants) of fluphenazine with a tricyclic antidepressant; three (90 participants) of an N‐methyl‐D‐aspartate (NMDA) blocker with an agent from a different drug class; five (604 participants) of various topical medications; one (313 participants) of tramadol with acetaminophen; and another one (44 participants) of a cholecystokinin blocker (L‐365,260) with morphine. The majority of combinations evaluated to date involve drugs, each of which share some element of central nervous system (CNS) depression (e.g. sedation, cognitive dysfunction). This aspect of side effect overlap between the combined agents was often reflected in similar or higher dropout rates for the combination and may thus substantially limit the utility of such drug combinations. Meta‐analysis was possible for only one comparison of only one combination, i.e. gabapentin + opioid versus gabapentin alone. This meta‐analysis involving 386 participants from two studies demonstrated modest, yet statistically significant, superiority of a gabapentin + opioid combination over gabapentin alone. However, this combination also produced significantly more frequent side effect‐related trial dropouts compared to gabapentin alone. Authors' conclusions: Multiple, good‐quality studies demonstrate superior efficacy of two‐drug combinations. However, the number of available studies for any one specific combination, as well as other study factors (e.g. limited trial size and duration), preclude the recommendation of any one specific drug combination for neuropathic pain. Demonstration of combination benefits by several studies together with reports of widespread clinical polypharmacy for neuropathic pain surely provide a rationale for additional future rigorous evaluations. In order to properly identify specific drug combinations which provide superior efficacy and/or safety, we recommend that future neuropathic pain studies of two‐drug combinations include comparisons with placebo and both single‐agent components. Given the apparent adverse impact of combining agents with similar adverse effect profiles (e.g. CNS depression), the anticipated development and availability of non‐sedating neuropathic pain agents could lead to the identification of more favourable analgesic drug combinations in which side effects are not compounded. Mención de responsabilidad : Luis Enrique Chaparro, Philip J Wiffen, R Andrew Moore, Ian Gilron Referencia : Cochrane Database Syst Rev. 2012 Jul 11;2012(7):CD008943. DOI (Digital Object Identifier) : 10.1002/14651858.CD008943.pub2 PMID : 22786518 En línea : https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008943.pub2/full Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=4503 Combination pharmacotherapy for the treatment of neuropathic pain in adults [documento electrónico] / Luis Enrique Chaparro Gómez,  . - 2012. Obra : Cochrane Database of Systematic Reviews Idioma : Inglés (eng) Resumen : Background: Pharmacotherapy remains an important modality for the treatment of neuropathic pain. However, as monotherapy current drugs are associated with limited efficacy and dose‐related side effects. Combining two or more different drugs may improve analgesic efficacy and, in some situations, reduce overall side effects (e.g. if synergistic interactions allow for dose reductions of combined drugs). Objectives: This review evaluated the efficacy, tolerability and safety of various drug combinations for the treatment of neuropathic pain. Search methods: We identified randomised controlled trials (RCTs) of various drug combinations for neuropathic pain from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 9 April 2012. Selection criteria: Double‐blind, randomised studies comparing combinations of two or more drugs (systemic or topical) to placebo and/or at least one other comparator for the treatment of neuropathic pain. Data collection and analysis: Data extracted from each study included: proportion of participants a) reporting ≥ 30% pain reduction from baseline OR ≥ moderate pain relief OR ≥ moderate global improvement; b) dropping out of the trial due to treatment‐emergent adverse effects; c) reporting each specific adverse effect (e.g. sedation, dizziness) of ≥ moderate severity. The primary comparison of interest was between study drug(s) and one or both single‐agent comparators. We combined studies if they evaluated the same drug class combination at roughly similar doses and durations of treatment. We used RevMan 5 to analyse data for binary outcomes. Main results: We identified 21 eligible studies: four (578 participants) evaluated the combination of an opioid with gabapentin or pregabalin; two (77 participants) evaluated an opioid with a tricyclic antidepressant; one (56 participants) of gabapentin and nortriptyline; one (120 participants) of gabapentin and alpha‐lipoic acid, three (90 participants) of fluphenazine with a tricyclic antidepressant; three (90 participants) of an N‐methyl‐D‐aspartate (NMDA) blocker with an agent from a different drug class; five (604 participants) of various topical medications; one (313 participants) of tramadol with acetaminophen; and another one (44 participants) of a cholecystokinin blocker (L‐365,260) with morphine. The majority of combinations evaluated to date involve drugs, each of which share some element of central nervous system (CNS) depression (e.g. sedation, cognitive dysfunction). This aspect of side effect overlap between the combined agents was often reflected in similar or higher dropout rates for the combination and may thus substantially limit the utility of such drug combinations. Meta‐analysis was possible for only one comparison of only one combination, i.e. gabapentin + opioid versus gabapentin alone. This meta‐analysis involving 386 participants from two studies demonstrated modest, yet statistically significant, superiority of a gabapentin + opioid combination over gabapentin alone. However, this combination also produced significantly more frequent side effect‐related trial dropouts compared to gabapentin alone. Authors' conclusions: Multiple, good‐quality studies demonstrate superior efficacy of two‐drug combinations. However, the number of available studies for any one specific combination, as well as other study factors (e.g. limited trial size and duration), preclude the recommendation of any one specific drug combination for neuropathic pain. Demonstration of combination benefits by several studies together with reports of widespread clinical polypharmacy for neuropathic pain surely provide a rationale for additional future rigorous evaluations. In order to properly identify specific drug combinations which provide superior efficacy and/or safety, we recommend that future neuropathic pain studies of two‐drug combinations include comparisons with placebo and both single‐agent components. Given the apparent adverse impact of combining agents with similar adverse effect profiles (e.g. CNS depression), the anticipated development and availability of non‐sedating neuropathic pain agents could lead to the identification of more favourable analgesic drug combinations in which side effects are not compounded. Mención de responsabilidad : Luis Enrique Chaparro, Philip J Wiffen, R Andrew Moore, Ian Gilron Referencia : Cochrane Database Syst Rev. 2012 Jul 11;2012(7):CD008943. DOI (Digital Object Identifier) : 10.1002/14651858.CD008943.pub2 PMID : 22786518 En línea : https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008943.pub2/full Enlace permanente : https://hospitalpablotobon.cloudbiteca.com/pmb/opac_css/index.php?lvl=notice_display&id=4503

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