Prescrire international
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Prescrire international · Dec 2009
Complex regional pain syndrome type 1. Some treatments assessed versus placebo, limited efficacy.
(1) Complex regional pain syndrome type 1 generally occurs after trauma and usually affects a limb; (2) How is complex regional pain syndrome type 1 diagnosed? What is its natural course? How safe and effective are available treatments? To answer these questions, we reviewed the literature using the standard Prescrire methodology; (3) Diagnosis is mainly based on clinical features, including pain disproportionate to the initial trauma, associated with cutaneous vasomotor, trophic and sweating disorders; (4) Some clinical signs call for additional examinations to help rule out another vascular, neurological, infectious or rheumatic disorder. Radiological evidence of bone demineralisation supports the diagnosis, but radiography, magnetic resonance imaging (MRI) and scintigraphy generally contribute little to the diagnosis of complex regional pain syndrome; (5) Some patients recover spontaneously after a few weeks, while others develop chronic pain or even severe disability after a period of years; (6) The results of small placebo-controlled trials suggest that corticosteroids are effective during the initial phase of this syndrome; (7) A very high oral dose of alendronic acid provided sustained pain relief in a randomised trial. Other studies suggest that bisphosphonates have some impact. ⋯ These methods have not been comparatively evaluated; (14) In practice, there is no truly effective treatment for complex regional pain syndrome. The few beneficial treatments have not been directly compared with one another. The advantages and disadvantages of the various treatment options must be discussed with each patient.
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(1) New marketing authorizations continue to be granted for treatments of multiple myeloma, and new trials and meta-analyses continue to be published. This review re-examines our previous conclusions based on data published between 2003 and 2008. We again used the standard Prescrire methodology to review the latest data; (2) In patients who are symptomatic but who do not qualify for haematopoietic stem cell transplantation (especially people aged over 65), the results of five comparative trials suggest that adding thalidomide to the melphalan-prednisone combination delays myeloma progression by an additional 5 to 10 months. ⋯ Initial treatment with two successive transplantation procedures has a negative risk-benefit balance. (4) The optimal chemotherapy regimen prior to autologous stem cell transplantation is controversial. It is unclear which combination (vincristine + doxorubicin + dexamethasone, cyclophosphamide + dexamethasone, cyclophosphamide + dexamethasone, or bortezomib + dexamethasone, etc.) has a better risk-benefit balance in terms of survival and quality of life; (5) According to a meta-analysis of three clinical trials, thalidomide maintenance therapy appears to improve overall survival after Autologous stem cell transplantation; (6) Despite their inadequate evaluation, lenalidomide and pegylated liposomal doxorubicin are licensed for use in patients who relapse or who are refractory to initial treatment. In view of their major adverse effects, we consider that these drugs should only be used in clinical trials.
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Prescrire international · Oct 2009
Prasugrel: new drug. After angioplasty and stenting: continue to use aspirin + clopidogrel.
(1) For patients with acute coronary syndromes who have undergone percutaneous angioplasty and stenting, the best-assessed treatment for preventing relapses is a combination of aspirin and clopidogrel; (2) Prasugrel, an antiplatelet drug belonging the same chemical class as clopidogrel, is authorized in the EU for use in this indication; (3) Clinical evaluation is based on a randomized double-blind trial comparing prasugrel + aspirin versus clopidogrel + aspirin in 13 608 patients with acute coronary syndromes, half of whom were treated for at least 15 months. Prasugrel did not reduce overall mortality (about 3%) or the incidence of non-fatal stroke after 15 months (1% of patients). ⋯ Haemorrhages associated with revascularisation were also significantly more numerous with prasugrel (11.3% and 3.6%); (5) Subgroup analyses suggest that the risk-benefit balance of prasugrel is unfavourable in patients weighing less than 60 kg, patients over 75 years of age, and patients with a history of transient ischaemic attack or stroke; (6) The trial comparing prasugrel versus clopidogrel, as well as some animal studies, raise the possibility that prasugrel might increase the risk of cancer. In the main trial, prasugrel caused fewer cases of neutropenia than clopidogrel, but more cases of respiratory failure, hypotension and atrial flutter were observed; (7) In practice, for secondary prevention in patients with acute coronary syndromes treated with angioplasty and stenting, the risk-benefit balance of prasugrel, used in combination with aspirin, appears to be no better than that of clopidogrel + aspirin.
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Prescrire international · Oct 2009
Fentanyl effervescent buccal tablets: new formulation. For cancer patients with breakthrough pain: a second buccal formulation with minimal evaluation.
There is no firm evidence that patients with breakthrough cancer pain respond better to fentanyl effervescent buccal than to the "lollipop" formulation.
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Prescrire international · Oct 2009
Renal colic in adults: NSAIDs and morphine are effective for pain relief.
(1) Renal colic is an acute syndrome involving unilateral flank pain, linked to an obstruction in the upper urinary tract. The pain is often intense. After having considered other diagnoses and checked for signs of complication (fever, oligoanuria), the first step is to control the pain; (2) Which non-invasive treatments have a positive risk-benefit balance in relieving this type of pain? To answer this question, we reviewed the available evidence, based on the standard Prescrire methodology; (3) According to a meta-analysis of 20 trials, nonsteroidal antiinflammatory drugs (NSAIDs) and strong opioid analgesics have comparable efficacy. ⋯ Morphine is given intravenously; subcutaneous administration is an alternative although it has not been evaluated in renal colic; (4) In clinical trials, NSAIDs were associated with fewer adverse effects than opioids, which cause vomiting in about 20% of patients (versus about 6% with an NSAID); (5) NSAIDs expose patients to a risk of functional renal impairment, especially in patients with heart failure, renal artery stenosis, dehydration, renal impairment or ongoing treatment with a nephrotoxic drug, and the very elderly. NSAIDs should never be used during pregnancy; (6) According to one trial in 130 patients, the analgesic effect of the morphine and NSAID combination was greater than either agent used alone, in about 10% of patients; (7) Paracetamol has not been evaluated in comparative trials of renal colic, even for moderate pain; (8) Scopolamine is the only antispasmodic to have been evaluated in a comparative trial. Adding scopolamine to morphine did not seem to provide additional efficacy; (9) Other drugs, which have not been adequately tested as of early 2009, have no documented benefit in the treatment of the pain associated with renal colic; tamsulosin, nifedipine, desmopressin; (10) Among the non-drug measures tested, local active warming, taking care to avoid burns, was effective against pain according to one trial; pain was reduced by at least 50% using a device delivering 42 degrees C to the abdomen or lower back; (11) In pregnant women, morphine carries a lower risk of adverse effects than NSAIDs; (12) In practice, the treatment of renal colic is mainly based on taking an NSAID, or morphine when the NSAID does not adequately control the pain or when it is better to avoid using NSAIDs.