NEW YORK (Reuters Health) – The gabapentinoids pregabalin and gabapentin are not effective in treating chronic low back pain (CLBP), according to a systematic review and meta-analysis.
“Most surprising was the limited number of controlled studies that have looked at the effects of gabapentinoids in CLBP, despite their widespread and increasing use,” Dr. Harsha Shanthanna from St. Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada, told Reuters Health by email. “There is not even a single placebo-controlled study looking at the effect of pregabalin in CLBP. It is also interesting to note that gabapentin showed only a minimal change in pain scores even when compared with placebo.”
Gabapentinoids are very effective for treating neuropathic pain, but studies of their therapeutic potential for other pain conditions have yielded mixed results.
Dr. Shanthanna’s team assessed the benefits of gabapentin and pregabalin in treating CLBP of more than 3 months’ duration in their systematic review and meta-analysis of 8 trials, including 3 comparing gabapentin with placebo and 5 that used pregabalin.
Most of the studies had significant risks of selection bias or detection bias, according to the August 15 PLoS Medicine online report.
Compared with placebo, gabapentin was associated with average pain reduction of only 0.22 units on a 0- to 10-point scale. Similarly, and according to very low-quality evidence, pregabalin improved pain ratings by only 0.42 units compared with an active analgesic.
Adverse events were more common with both drugs than with placebo or active comparators. Dizziness, fatigue, difficulties with mentation, and visual disturbances were more common with gabapentin, whereas dizziness was more common with pregabalin.
“As physicians look out for medications to decrease pain in CLBP patients, they have expanded their treatments and decreased their thresholds to commonly include atypical analgesics,” Dr. Shanthanna explained by email. “This has led to a substantial increase in the use of daily gabapentinoids, which require slow titration to therapeutic doses and establishing maintenance on a long-term basis.”
“With prolonged treatment, the potential gain over possible adverse effects and risks becomes unclear,” he said. “Our report shows that they do not help to reduce pain but can potentially increase the chances of side effects such as dizziness, fatigue, visual disturbances, and difficulties in thinking. Physicians who plan to prescribe gabapentinoids for CLBP need to keep this in mind, especially at a time when we have realized the risks of using opioids and need to maximize non-opioids.”
“Gabapentinoids do have a role in noncancer chronic pain management,” Dr. Shanthanna concluded. “However, their indiscriminate use in CLBP patients is not supported by evidence.”
Dr. J. H. Atkinson from VA San Diego Healthcare System and the University of California, San Diego, La Jolla, who earlier found gabapentin to be ineffective for CLBP without a radiating component, told Reuters Health by email that he sees no role for these drugs in treating CLBP. “The issue of efficacy for classic radicular pain with associated motor weakness, diminished tendon reflexes, diminished sensation is not well studied. But it would be a surprise if these agents were effective for this difficult-to-treat subset of chronic back pain patients.”
Dr. Atkinson advised, “Forget gabapentin and pregabalin for chronic back pain.”
Dr. Steven Cohen from Johns Hopkins School of Medicine, Baltimore, who has also studied the use of gabapentin for lumbosacral radicular pain, told Reuters Health by email, “Gabapentin is a first-line drug for neuropathic pain, and it works for neuropathic pain because it’s a membrane stabilizer. But most back pain is not neuropathic in nature. It’s mechanical in nature, and there are other treatments that may work better for non-neuropathic pain.”
“Gabapentinoids may prevent pain after spine surgery, when given preemptively in high-risk people,” he said. “There may also be a small subset of patients with neuropathic back pain who respond very well to gabapentin. But clearly, people with nonspecific back pain shouldn’t routinely be put on gabapentinoids.”
SOURCE: http://bit.ly/2vAWG5B
PLoS Med 2017.
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