Jamison Falk1, Betsy Thomas2, Jessica Kirkwood3, Christina S Korownyk4, Adrienne J Lindblad5, Joey Ton6, Samantha Moe7, G Michael Allan8, James McCormack9, Scott Garrison4, Nicolas Dugré10, Karenn Chan11, Michael R Kolber12, Anthony Train13, Liesbeth Froentjes14, Logan Sept15, Michael Wollin15, Rodger Craig15, Danielle Perry16. 1. Associate Professor in the College of Pharmacy at the University of Manitoba in Winnipeg. jamison.falk@umanitoba.ca. 2. Pharmacist in Edmonton, Alta, and Clinical Evidence Expert for the College of Family Physicians of Canada. 3. Family physician and Assistant Professor at the University of Alberta. 4. Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta. 5. Pharmacist, Clinical Evidence Expert Lead for the College of Family Physicians of Canada, and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta. 6. Pharmacist in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada. 7. Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada. 8. Family physician, Director of Programs and Practice Support at the College of Family Physicians of Canada, and Adjunct Professor in the Department of Family Medicine at the University of Alberta. 9. Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver. 10. Pharmacist at the CIUSSS du Nord-de-l'lle-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal in Quebec. 11. Care of the elderly physician and Assistant Professor in the Department of Family Medicine at the University of Alberta. 12. Family physician and Professor in the Department of Family Medicine at the University of Alberta. 13. Assistant Professor in the Department of Family Medicine at Queen's University in Kingston, Ont. 14. Research assistant at the University of Alberta. 15. Medical student at the University of Alberta. 16. Nurse in Edmonton and Clinical Evidence Expert for the College of Family Physicians of Canada.
Abstract
OBJECTIVE: To determine the proportion of patients with neuropathic pain who achieve a clinically meaningful improvement in their pain with the use of different pharmacologic and nonpharmacologic treatments. DATA SOURCES: MEDLINE, EMBASE, the Cochrane Library, and a gray literature search. STUDY SELECTION: Randomized controlled trials that reported a responder analysis of adults with neuropathic pain-specifically diabetic neuropathy, postherpetic neuralgia, or trigeminal neuralgia-treated with any of the following 8 treatments: exercise, acupuncture, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), topical rubefacients, opioids, anticonvulsant medications, and topical lidocaine. SYNTHESIS: A total of 67 randomized controlled trials were included. There was moderate certainty of evidence that anticonvulsant medications (risk ratio of 1.54; 95% CI 1.45 to 1.63; number needed to treat [NNT] of 7) and SNRIs (risk ratio of 1.45; 95% CI 1.33 to 1.59; NNT = 7) might provide a clinically meaningful benefit to patients with neuropathic pain. There was low certainty of evidence for a clinically meaningful benefit for rubefacients (ie, capsaicin; NNT = 7) and opioids (NNT = 8), and very low certainty of evidence for TCAs. Very low-quality evidence demonstrated that acupuncture was ineffective. All drug classes, except TCAs, had a greater likelihood of deriving a clinically meaningful benefit than having withdrawals due to adverse events (number needed to harm between 12 and 15). No trials met the inclusion criteria for exercise or lidocaine, nor were any trials identified for trigeminal neuralgia. CONCLUSION: There is moderate certainty of evidence that anticonvulsant medications and SNRIs provide a clinically meaningful reduction in pain in those with neuropathic pain, with lower certainty of evidence for rubefacients and opioids, and very low certainty of evidence for TCAs. Owing to low-quality evidence for many interventions, future high-quality trials that report responder analyses will be important to strengthen understanding of the relative benefits and harms of treatments in patients with neuropathic pain.
OBJECTIVE: To determine the proportion of patients with neuropathic pain who achieve a clinically meaningful improvement in their pain with the use of different pharmacologic and nonpharmacologic treatments. DATA SOURCES: MEDLINE, EMBASE, the Cochrane Library, and a gray literature search. STUDY SELECTION: Randomized controlled trials that reported a responder analysis of adults with neuropathic pain-specifically diabetic neuropathy, postherpetic neuralgia, or trigeminal neuralgia-treated with any of the following 8 treatments: exercise, acupuncture, serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), topical rubefacients, opioids, anticonvulsant medications, and topical lidocaine. SYNTHESIS: A total of 67 randomized controlled trials were included. There was moderate certainty of evidence that anticonvulsant medications (risk ratio of 1.54; 95% CI 1.45 to 1.63; number needed to treat [NNT] of 7) and SNRIs (risk ratio of 1.45; 95% CI 1.33 to 1.59; NNT = 7) might provide a clinically meaningful benefit to patients with neuropathic pain. There was low certainty of evidence for a clinically meaningful benefit for rubefacients (ie, capsaicin; NNT = 7) and opioids (NNT = 8), and very low certainty of evidence for TCAs. Very low-quality evidence demonstrated that acupuncture was ineffective. All drug classes, except TCAs, had a greater likelihood of deriving a clinically meaningful benefit than having withdrawals due to adverse events (number needed to harm between 12 and 15). No trials met the inclusion criteria for exercise or lidocaine, nor were any trials identified for trigeminal neuralgia. CONCLUSION: There is moderate certainty of evidence that anticonvulsant medications and SNRIs provide a clinically meaningful reduction in pain in those with neuropathic pain, with lower certainty of evidence for rubefacients and opioids, and very low certainty of evidence for TCAs. Owing to low-quality evidence for many interventions, future high-quality trials that report responder analyses will be important to strengthen understanding of the relative benefits and harms of treatments in patients with neuropathic pain.
Authors: Howard Balshem; Mark Helfand; Holger J Schünemann; Andrew D Oxman; Regina Kunz; Jan Brozek; Gunn E Vist; Yngve Falck-Ytter; Joerg Meerpohl; Susan Norris; Gordon H Guyatt Journal: J Clin Epidemiol Date: 2011-01-05 Impact factor: 6.437
Authors: Robert H Dworkin; Dennis C Turk; Kathleen W Wyrwich; Dorcas Beaton; Charles S Cleeland; John T Farrar; Jennifer A Haythornthwaite; Mark P Jensen; Robert D Kerns; Deborah N Ader; Nancy Brandenburg; Laurie B Burke; David Cella; Julie Chandler; Penny Cowan; Rozalina Dimitrova; Raymond Dionne; Sharon Hertz; Alejandro R Jadad; Nathaniel P Katz; Henrik Kehlet; Lynn D Kramer; Donald C Manning; Cynthia McCormick; Michael P McDermott; Henry J McQuay; Sanjay Patel; Linda Porter; Steve Quessy; Bob A Rappaport; Christine Rauschkolb; Dennis A Revicki; Margaret Rothman; Kenneth E Schmader; Brett R Stacey; Joseph W Stauffer; Thorsten von Stein; Richard E White; James Witter; Stojan Zavisic Journal: J Pain Date: 2007-12-11 Impact factor: 5.820
Authors: Nanna B Finnerup; Simon Haroutounian; Ralf Baron; Robert H Dworkin; Ian Gilron; Maija Haanpaa; Troels S Jensen; Peter R Kamerman; Ewan McNicol; Andrew Moore; Srinivasa N Raja; Niels T Andersen; Emily S Sena; Blair H Smith; Andrew S C Rice; Nadine Attal Journal: Pain Date: 2018-11 Impact factor: 7.926