Comparative Efficacy and Safety of Antidepressants for Patients with Chronic Back Pain: A Network Meta-Analysis.

Various antidepressants have introduced in clinical practice for pain management, but it is important to understand how to properly use them. We therefore performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of antidepressants for patients with chronic back pain. We identified eligible randomized controlled trials (RCTs) that investigated the efficacy and safety of antidepressants for chronic back pain from PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov, searching from inception to May 2023. Six categories of antidepressants for the treatment of chronic back pain were included, and the surface under the cumulative ranking probabilities was applied to rank the treatment strategies. Overall, we selected 19 RCTs recruiting 2903 patients for the meta-analysis. Tricyclic antidepressants presented the best relative effects for relief in pain score (surface under the cumulative ranking, 84.4%). The results of pairwise comparison analyses found the use of serotonin-noradrenaline reuptake inhibitors (SNRIs) significantly reduced pain score and low disability score compared with placebo, irrespective of treatment duration. Noradrenaline-dopamine reuptake inhibitors (relative risk [RR], 2.80; 95% confidence interval [CI], 1.30-6.03; P = .008) and SNRIs (RR, 1.17; 95% CI, 1.07-1.27; P < .001) significantly increased the risk of adverse events. SNRIs were associated with an increased risk of withdrawal due to adverse events (RR, 2.37; 95% CI, 1.64-3.43; P < .001). This study found that antidepressants are more efficacious than placebos for treating chronic back pain, and tricyclic antidepressants are the most likely medications that lead to pain relief.

Determination of vitamin D and analysis of risk factors for osteoporosis in patients with chronic pain.

BACKGROUND: Vitamin D deficiency is common in patients with chronic pain and healthy people, but the difference between the two has not been reported; thus, whether there is a relationship between vitamin D deficiency and chronic pain remains to be confirmed. Osteoporosis is a common disease in chronic pain disorders. Understanding the relationship between vitamin D and osteoporosis will provide a basis for the rational supplementation of vitamin D to prevent osteoporosis, and to understand the risk factors of bone mass change to provide a new treatment plan for early prevention of osteoporosis. AIM: To determine 25 hydroxy vitamin D (25OHD) level in patients with chronic pain to clarify its clinical significance. The relationship between vitamin D and bone mineral density (BMD) and the risk factors for bone mass change were also evaluated. METHODS: In this study, 184 patients with chronic pain were included in the study group, and 104 healthy individuals who underwent routine health checkups during the same period were included in the control group. 25OHD level was detected in both groups by enzyme-linked immunosorbent assay. According to the BMD test results, the patients in the study group were further classified into three subgroups: Normal BMD group, reduced BMD group, and osteoporosis group. Age, sex, ethnicity, living altitude, body mass index, 25OHD level, parathyroid hormone (PTH), calcium (Ca) and phosphorus levels were analyzed statistically in both groups. RESULTS: The vitamin D level in the study group was lower than that in the control group at 53.8% vs 57.7%, with no significant difference between the two groups. The proportion of patients with severe vitamin D deficiency in the study group was higher than that in the control group. The mean age was greater in the osteoporosis subgroup, and the youngest in the normal BMD subgroup. Vitamin D level in the osteoporosis subgroup was lower than that in the other two subgroups, and was not specific for the diagnosis of bone mass reduction and osteoporosis. The above results were analyzed statistically and showed significant differences (P < 0.05). There was a positive correlation between age and BMD in patients with chronic pain (R = 0.567, P < 0.001). Age, PTH and Ca were risk factors for bone mass reduction, while age, ethnicity and altitude were risk factors for osteoporosis. CONCLUSION: Vitamin D deficiency is a common phenomenon in patients with chronic pain, and severe vitamin D deficiency is not uncommon. Vitamin D level is not a risk factor for bone mass reduction and osteoporosis. Bone mass reduction is correlated with age, PTH and Ca, while osteoporosis is correlated with age, ethnicity and altitude.

Intrathecal delivery of hydromorphone vs morphine for refractory cancer pain: a multicenter, randomized, single-blind, controlled noninferiority trial.

Hydromorphone is an alternative to morphine for intrathecal drug delivery system to treat refractory cancer pain; however, there is not enough clinical evidence to prove it. In our study, 233 patients from 12 different pain management centers across China were enrolled, 121 and 112 in the intrathecal hydromorphone (ITHM) and intrathecal morphine (ITMO) groups, respectively. The primary outcome was the clinical success rate, which was defined as ratio of patients achieving ≥50% pain relief. The noninferiority margin was defined as -0.15. Other outcomes included daily visual analogue scale score, breakthrough pain (BTP) incidence, intrathecal dose change, and patient-controlled analgesia bolus count change, GAD-7/PHQ-9. Clinical success was achieved in 85 and 79 of the 121 ITHM patients (70.2%) and 112 ITMO patients (70.5%), respectively. Compared to the corresponding baseline findings, significantly decreased visual analogue scale scores and BTP incidence were noted in both groups. The dose change rate decreased and increased with time in the ITHM and ITMO groups, respectively (ITHM -3.33% vs ITMO 35.4%, P < 0.01, t test) from the third week. The patient-controlled analgesia bolus change rate was lower in the ITHM group than in the ITMO group (ITHM -19.88% vs ITMO 7.79%, P < 0.01, t test) from first week. Our result shows that ITHM is noninferior to ITMO on pain relief to treat refractory cancer pain, however, at different doses and that the doses of morphine tended to increase, whereas those of hydromorphone decreased over time. Hydromorphone offers advantage over morphine in controlling BTP.

The Diagnosis and Therapy of Degenerative Knee Joint Disease: Expert Consensus from the Chinese Pain Medicine Panel.

At present, there are many constantly updated guidelines and consensuses on the diagnosis and treatment of osteoarthritis both at home and abroad. The recommendations established using methods of evidence-based medicine has experienced strict research on controlling bias and promoting reproduction rate. As a result, the previous evidence was reevaluated, and a lot of changes were provoked in the diagnosis and treatment concept of osteoarthritis. However, several methods not recommended by foreign guidelines are still in use in the current clinical practice in China. On the one hand, Chinese experts have not reached extensive consensus on whether it is necessary to make changes according to foreign guidelines. On the other hand, almost all the current relevant guidelines are on osteoarthritis, but the lesions around knee joints which, as a whole, bear the largest weight in human body, cannot be ignored. For this purpose, Chinese Association for the Study of Pain (CASP) organized some leading experts to formulate this Chinese Pain Specialist Consensus on the diagnosis and treatment of degenerative knee osteoarthritis (DKOA) in combination with the guidelines in foreign countries and the expert experience of clinical practice in China. The consensus, which includes the definition, pathophysiology, epidemiology, clinical manifestation, diagnostic criteria, and treatments of DKOA, is intended to be used by first-line doctors, including pain physicians to manage patients with DKOA.