Phil Wiffen

Quantitive systematic review of topically applied non-steroidal anti-inflammatory drugs

Abstract Objective: To review the effectiveness and safety of topical non-steroidal anti-inflammatory drugs in acute and chronic pain conditions. Design: Quantitive systematic review of randomised controlled trials. Data sources: 86 trials involving 10 160 patients. Main outcome measures: Measures of treatment success approximating at least 50% reduction in pain, local and systemic adverse effects. Analysis at 1 week for acute and 2 weeks for chronic conditions with relative benefit and number needed to treat. Results: In acute pain conditions (soft tissue trauma, strains, and sprains) placebo controlled trials had a relative benefit of 1.7 (1.5 to 1.9), the number needed to treat was 3.9 (3.4 to 4.4). With analysis by drug (at least three trials), ketoprofen (number needed to treat 2.6), felbinac (3.0), ibuprofen (3.5), and piroxicam (4.2) had significant efficacy. Benzydamine and indomethacin were no different from placebo. In chronic pain conditions (osteoarthritis, tendinitis) placebo controlled trials had a relative benefit of 2.0 (1.5 to 2.7); the number needed to treat was 3.1 (2.7 to 3.8). Small trials (<40 treated patients) exaggerated effectiveness of topical non-steroidals by 33% in acute conditions but not in chronic conditions. There was no relation between trial quality and treatment effect. In both acute and chronic pain local and systemic adverse events and withdrawal from the study related to the drug had a low incidence and were no different from placebo. Conclusion: Topical non-steroidal anti-inflammatory drugs are effective in relieving pain in acute and chronic conditions. Key messages Topical non-steroidal anti-inflammatory drugs are widely thought to be ineffective, despite licensed status To evaluate their effectiveness and safety we conducted a quantitive systematic review of all relevant randomised trials In acute conditions like strains and sprains topical non-steroidals were significantly better than placebo over 1 week with a number needed to treat of 3.9 (3.4 to 4.4). For drugs with at least three placebo controlled trials ketoprofen (number needed to treat 2.6), felbinac (3.0), ibuprofen (3.5), and piroxicam (4.2) had significant efficacy In chronic conditions like arthritis and rheumatism topical non-steroidals were significantly better than placebo over 2 weeks with a number needed to treat of 3.1 (2.7 to 3.8) In both acute and chronic pain local and systemic adverse events and withdrawal related to tested drug had a low incidence and were no different from placebo

Andrew Moore and colleagues reply to Des Spence

Spence’s polemic on duloxetine loses power because most of what it is based on is wrong.1 Making pronouncements in respected journals about good and bad medicine comes with the responsibility of knowing what you are talking about. Bad scholarship helps no one, especially those in pain; research in genetics, neurobiology, and psychology has contributed to huge advances in knowledge about the bio-psycho-social origins of pain. Chronic pain is defined as pain of moderate or severe intensity that lasts for three months or more (think of a really bad headache lasting from Christmas to Easter). It affects one in five adults. Painful conditions are among the most prevalent conditions and are five of the top 11 in terms of years living with disability. Chronic pain destroys …

Could you be a peer reviewer

Most authors and readers of scientific papers agree that peer review is an important part of the publishing process. However, getting peer reviewers is an increasing challenge for many journals including European Journal of Hospital Pharmacy ( EJHP ). In an editorial around 4 years ago, I mentioned that we frequently contact seven or more potential reviewers in order to obtain peer review reports. Since then, things have worsened, and now it is not uncommon to approach up to 15 potential reviewers in order to obtain sufficient reports. As an editorial team, we are incredibly grateful for those who undertake peer review for us, many of whom submit high-quality reports. However, we do need more peer reviewers so this is a call to sign up! For this journal, peer review is a key stage in the consideration of a paper … Correspondence to Professor Phil Wiffen, Pain Research Unit, Churchill Hospital, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk

Pain leads the way: the development of evidence-based medicine for pain relief.

This paper describes the development of evidence based methods in pain medicine since the 1980s at the Pain Research Department of the Nuffield Department of Clinical Neurosciences, Oxford University. Pain medicine can be said to have led the way in terms of developing registers of randomized controlled trials (RCTs) and in developing appropriate methodology for assessing clinical trials and developing metanalytical techniques. This paper tells the story of that development which occurred in conjunction with the development of the Cochrane Collaboration. Pain has a larger body of evidence than many medical specialties with more than 30,000 RCTs and over 2,500 published systematic reviews. Our work continues to raise methodological challenges and a number of key ones are described: Size: We have added to the existing literature to show that small studies overestimate treatment effects. We consider studies with less than 50 participants per treatment group to be at high risk of bias. Mean pain scores: We have shown these to be unhelpful and misleading. We illustrate that response to analgesics is a U-shaped curve with a larger proportion of participants having either a poor response or a good response. Imputation: We discuss the problems of current methods. Tiers of evidence: We propose a way to assess evidence for pain studies. Duplicate publication of data can lead to inflated benefits in systematic reviews. In addition we touch on fraud, pharmaceutical company funding. The final sections cover developments in several areas of pain medicine, and suggest some developments going forward.

A tribute to Professor Per Hartvig Honoré: one of a kind

Sadly Per Hartvig died in December last year aged 70 years old. Per was a long-standing member of the EJHP editorial board initially as editor for EJHP science and then as an associate editor on the combined science and practice journal. As the previous editor of the science part of the journal, he fought hard to ensure that science remained as a key part of what was published in EJHP . Early in my career, I was greatly influenced by a pharmacist who was a scientist at heart. He was … Correspondence to Professor Phil Wiffen, Pain Research Unit, Churchill Hospital, Old Rd, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk

Anti-epileptics and anti-depressants for neuropathic pain: Lessons from Cochrane overviews and systematic reviews

Spinal cord stimulation (SCS) is an effective therapy for persistent back and leg pain and has demonstrated success in a variety of chronic intractable conditions. SCS consists of stimulating electrodes implanted in the epidural space and an electrical pulse generator. Many troubles can be observed while electrode placement in the epidural space. In this case, we present a patient with persistent tinnitus symptom after SCS replacement.Glossopharyngeal nerve (GPN) blocking is an interventional technique that has occasionally been used for the palliative treatment of pain due to head-neck malignancies and glossopharyngeal neuralgia (1). In clinical practice, GPN blocking was first used as an aid for awake endotracheal intubation in the late 1950s (2). In 1910, Wisenburg (2) identified pain in the distribution of the glossopharyngeal nerve in a patient with a cerebellopontine angle tumor. In 1921, Harris (2) reported the first idiopathic case and coined the term glossopharyngeal neuralgia. However, there are very few articles and case presentations on GPN blocking. Therefore, we present a patient with cancer of the tongue base who underwent bilateral GPN neurolysis using alcohol.Introduction: N-methyl-D-aspartate (NMDA) receptors are ligand-gated receptor complexes that have been associated with learning and memory, pain transmission, depression, schizophrenia and neurodegenerative disorders. Magnesium, noncompetitive NMDA receptor antagonists, has been demonstrated analgesic efficacy against neuropathic pain (1), but results on inflammatory pain are controversial. This study aimed at evaluating the systemic and local effects of magnesium sulfate (MS) in carrageenan (Carr)-induced mechanical hyperalgesia using von Frey anesthesiometer test.M pain and myofascial pain syndrome are often discussed with regard to chronic pain. Indeed they are also commonly recognized and treated with trigger point injections, prolotherapy, and myofascial release techniques. Treatment can be done by experts in physical therapy, acupuncture, massage therapy, rolfing, prolotherapy, trigger point injections, chiropractic, and more. Myofascial pain patterns from trigger points in muscle and fascia are well documented in medical texts (Travell/Simons). It is often thought that myofascial pain has to be due to an underlying problem that may be undiagnosed or not understood. With the advent of “fascia sparing dissection” techniques, the anatomy of fascia in the body has helped to provide for a new understanding of myofascial pain and its underlying injuries and pathology. Indeed the predominant injury most of the time is to muscle and fascia rather than disc and joint. The interaction of muscle, fascia, and free small fiber nerve endings notifies the brain of these injuries as myofascial pain. Video recording of fascia-sparing cadaver dissection illustrates the body-wide continuity of fascia, and also helps to elucidate the referral patterns and enigmatic nature of myofascial pain. This new understanding of anatomy helps us to realize how radiating pain and other sensations can be caused by injury to fascia and muscle. It also provides clues as to how to help the body heal from such injuries in order to relieve chronic pain.Cervical disc hernia is a pathological condition which usually causes pain on the neck, shoulders and arms, while radiculopathy and myelopathy caused by compression of spinal cord are rare. In this study, we aimed to retrospectively investigate the clinical effects of Discogel® Radiopaque Gelified Ethanol application in the patients with cervical disc hernia who had chronic pain and weakness on the neck, shoulders and arms.A and anti-depressants are widely used to manage a variety of neuropathic pain conditions. Using wellestablished evidence based medicine approach a resume will be given of the development of overviews to summarize systematic reviews and make information more accessible to practitioners.The session will discuss the randomized controlled trial literature and present the results of two major Cochrane overviews on these classes of medicines. These show that not all anti-epileptics or anti-depressants are equal and that some of the mainstays of neuropathic pain treatments such as carbamazepine are largely unsupported by good quality evidence. The session will end with a view of the flaws in many of the published randomized trials together with some suggestions for grading evidence in order to stimulate higher quality research into effectiveness.Tolga Ergonenc2, Serbulent Gokhan Beyaz1, Jalan Şerbetcigil Ergonenc2, Ozlem Sonmez3, Unal Erkorkmaz4 and Fatih Altintoprak5 1Department of Anesthesiology and Pain Medicine, Sakarya University Medical School, Turkey 2Department of Anesthesiology, Sakarya University Training Research Hospital, Turkey 3Department of Oncolgy, Yeditepe University Medical School, Turkey 4Department of Biostatistics, Sakarya University Medical School, Turkey 5Department of General Surgery, Sakarya University Medical School, Turkey

Palliative Care Formulary 5th edition

Robert Twycross, Andrew Wilcock, Paul Howard, Eds. 2014, £50.00, p. 880. ISBN: 978 0 9552547 9 6 ![Graphic][1] The Palliative Care Formulary (PCF5) published in the UK is aimed at clinical staff working in the palliative care and hospice environment. The work is supported by a large team of editors based in the UK, Europe and Australia. The layout will be familiar to users of the British National Formulary (BNF). The softback book is a reproduction of a continuously updated resource at http://www.palliativedrugs.com/ that can be accessed for a fee. The text is evidence based where possible throughout the text, though in this area of medicine much is based on wisdom. There is discussion of an evidence hierarchy at the beginning of the book, but this is not explicitly … [1]: /embed/inline-graphic-1.gif

What's in a congress?

Its congress time again and I started to think about how this years congress will affect my thinking. How do we use these few days of intense activity marked by long days and late nights? Some of us will try and get to everything possible, some will seek to widen our knowledge and look for new ideas we can take on board, for others it is an opportunity to renew acquaintances and enjoy the social aspects while others love to work the exhibition and collect bags of ‘stuff’. In practice it is probably a range of these. For me the conference used to be a place where I kept in touch with developments in my specialty—more often than not attending medical rather that pharmacy meetings. … Correspondence to Professor Phil Wiffen, Pain Research Unit, Old Rd, Churchill Hospital, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk

How much is enough in making clinical decisions

I have just returned from teaching systematic review methods in China (one of my other jobs). Part of the training involves teaching critical appraisal skills for systematic reviews. The reviews I use are chosen to be controversial in terms of methodology, numbers and/or outcomes, all designed to get candidates thinking about what matters (for more on critical appraisal, see Chapter 5 of Evidence-based Pharmacy 1). One of the key issues for me is that appraisal of systematic reviews, or any evidence, is not just an academic activity but, ultimately, should affect our decisions about the care of either an individual or, for many pharmacists, the care of large numbers … Correspondence to Professor Phil Wiffen, Pain Research Unit, Churchill Hospital, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk

Don't cross the (invisible) line

A recent undercover investigator for The Telegraph newspaper1 in the UK uncovered some worrying practices. Allegedly some senior pharmacists set up their own advisory boards and sold their services to pharmaceutical companies. The meetings were held in various locations such as Dubai with charges of up to UK £15 000 being charged to the pharma companies in addition to lavish expenses related to flights, top hotels and meals. It is alleged that the board meetings resulted in increased use of the drugs under discussion. One of the pharmacists involved subsequently resigned and another has been suspended. There is said to be an inquiry at the highest level by the NHS England fraud department.2 ,3 Pharmacists have expertise in a wide range of issues … Correspondence to Professor Phil Wiffen, Pain Research Unit, Churchill Hospital, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk