Transdermal fentanyl for the treatment of pain caused by osteoarthritis of the knee or hip: an open, multicentre study

BACKGROUND: This study was designed to evaluate the utility of transdermal fentanyl (TDF, Durogesic(®)) for the treatment of pain due to osteoarthritis (OA) of the knee or hip, which was not adequately controlled by non-opioid analgesics or weak opioids. The second part of the trial, investigating TDF in patients with rheumatoid arthritis (RA) is reported separately. METHODS: Current analgesia was optimised during a 1-week run-in. Patients then received 28 days treatment with TDF starting at 25 μg/hr, with the option to increase the dose until adequate pain control was achieved. Metoclopramide was taken during the first week and then as needed. RESULTS: Of the 159 patients recruited, 75 with OA knee and 44 with OA hip completed the treatment phase, 30 knee and 18 hip patients entered the one-week taper-off phase. The most frequently used maximum dose of TDF was 25 μg/hr. The number of patients with adequate pain control increased during the run-in period from 4% to 27%, and further increased during TDF treatment to 88% on day 28. From baseline to endpoint, there were significant reductions in pain (p < 0.001) and improvements in functioning (p < 0.001) and physical (p < 0.001) and mental (p < 0.05) health. Scores for 'pain right now' decreased significantly within 24 hours of starting TDF treatment. TDF was assessed favourably and 84% of patients would recommend it for OA-related pain. Nausea and vomiting were the most common adverse events (reported by 32% and 26% of patients respectively), despite prophylaxis with metoclopramide, which showed limited efficacy in this setting. CONCLUSION: TDF significantly increased pain control, and improved functioning and quality of life. Metoclopramide appeared to be of limited value in preventing nausea and vomiting; more effective anti-emetic treatment may enable more people to benefit from strong opioids such as TDF. This study suggests that four weeks is a reasonable period to test the benefit of adding TDF to improve pain control in OA patients and that discontinuing therapy in cases of limited benefit creates no major obstacles

Significance of preoperative MRI in establishing levels of augmentation for percutaneous vertebroplasty

Paul J Graziotti,1 Cherie R Graziotti,1 Adele M Sangster21Cambridge Pain Management, Wembly, WA, Australia; 2St John of God Hospital, Wembley WA, AustraliaObjectives: To determine whether X-ray, computed tomography (CT), bone scan, and clinical impression accurately reflect the level of vertebral fracture in patients about to undergo vertebroplasty.Design: Retrospective observational study, utilizing patient inpatient notes, referral correspondence, and clinicians&rsquo; private notes.Setting: Single center &ndash; all patients referred to one pain medicine physician for vertebroplasty who subsequently had the procedure.Participants: All patients referred to a pain physician (PJG) over a 4-year period, who had a presumptive diagnosis of vertebral fracture(s) from the referring consultant physician, based on imaging other than magnetic resonance imaging (MRI) and clinical impression. Participants then had an MRI and subsequent vertebroplasty under the care of the pain physician. Participants were identified retrospectively from the vertebroplasty procedure list.Intervention: Nil.Main outcome measure: Number of cases in which the MRI identified a different level of pathology than X-ray, CT, bone scan, and clinical impression.Results: In 50% (28/56) of patients MRI identified a fracture at a different level to that which was presumed to be the cause of patient pain on the basis of X-ray, CT, and clinical impression.Conclusion: MRI is an essential investigation to determine accurately the level of fracture in osteoporotic patients. Studies on the effectiveness of treatment of vertebral fractures that do not utilize MRI in every case are unlikely to be accurate.Keywords: vertebroplasty, back pain, osteoporosis, crush fractur