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Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:70–72.

Copyright © 2014 Informa Healthcare USA, Inc.
ISSN: 1536-0288 print / 1536-0539 online
DOI: 10.3109/15360288.2013.877114

EVIDENCE-BASED PAIN MANAGEMENT AND PALLIATIVE CARE

Systematic Reviews Published in the October 2013 Issue
of The Cochrane Library
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by HINARI on 04/18/14
For personal use only.

Philip J. Wiffen
AB STRACT
The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online (http://
www.thecochranelibrary.com). The October 2013 issue (fourth DVD for 2013) contains 5737 complete reviews,
2352 protocols for reviews in production, and 26,000 short summaries of systematic reviews published in the
general medical literature. In addition, there are citations of 714,000 randomized controlled trials, and 15,700
cited papers in the Cochrane Methodology Register. The Health Technology Assessment database contains
some 12,000 citations. One hundred and six new reviews have been published in the previous 3 months, of
which seven have potential relevance for practitioners in pain and palliative medicine. The impact factor of the
Cochrane Library stands at 5.715. Readers are encouraged to access the full report for any articles of interest, as only a brief commentary is provided. Systematic reviews published in the October 2013 Issue of the
Cochrane Library address anticonvulsants for fibromyalgia, naproxen with or without an antiemetic for acute
migraine headaches in adults, sumatriptan plus naproxen for acute migraine attacks in adults, pharmacological
treatment for pain in Guillain-Barre´ syndrome, transdermal fentanyl for cancer pain, interventions for the reduction of prescribed opioid use in chronic noncancer pain, and topiramate for neuropathic pain and fibromyalgia
in adults.
KEYWORDS antiepileptic agents, cancer pain, chronic pain, fentanyl, fibromyalgia, gabapentin, Guillain´ migraine, naproxen, opioids, oxycodone, palliative care, pregabalin, prescribing, sumatriptan, topiraBarre,
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sleep problems and fatigue. It disproportionately affects the female gender. Anticonvulsants (antiepileptic drugs) are drugs frequently used for the treatment
of chronic pain syndromes, including FM.
The authors aimed to assess the benefits and harms
of anticonvulsants for treating FM symptoms. They
used a standard Cochrane approach with a comprehensive search strategy. Eight studies were identified:
five with pregabalin and one each of gabapentin, lacosamide, and levetiracetam. A total of 2480 people
were included in the antiepileptic groups and 1099
people in placebo groups. The median time phase
was 13 weeks, which is good—too many chronic pain
studies are unhelpfully short.
That said, no conclusions could safely be made
about the use of gabapentin, lacosamide, and levetiracetam in FM. The data on pregabalin were better.
All pregabalin studies had a low risk of bias. Reporting a 50% or greater reduction in pain gave a number needed to treat (NNT) of 12 (95% confidence

ANTICONVULSANTS FOR
FIBROMYALGIA
¨ ¸ eyler N, SomThis review should be cited as: Uc
mer C, Walitt B, H¨auser W. Anticonvulsants for
fibromyalgia. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD010782. DOI:
10.1002/14651858.CD010782.
Fibromyalgia (FM) is a clinically well-defined
chronic condition of unknown etiology characterized
by chronic widespread pain often associated with
Philip J. Wiffen, BPharm, MSc, is a Member of the Oxford Regional
Pain Relief Unit, an Editor of the Cochrane Collaboration Pain Palliative
and Supportive Care Collaborative Review Group, and formerly Director
of Operations and Training at the UK Cochrane Center. He is a Visiting
Professor at the Department of Pharmacy and Pharmacology, University
of Bath, Bath, UK. He now runs a consultancy firm that provides training
and support for those undertaking systematic reviews.
Address correspondence to: Philip J. Wiffen, Pain Research Unit, Churchill
Hospital, and Oxford, OX3 7LG, United Kingdom (E-mail: phil.wiffen@ndcn.
ox.ac.uk).

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A good example of where clinical significance is more important than statistical significance. CD009455.1002/14651858. Aldington D. Moore RA.1002/14651858. Issue 10. and society.com by HINARI on 04/18/14 For personal use only. the same author team looked at a combination of sumatriptan plus naproxen. Cole P. DOI: 10. No. Cochrane Database of Systematic Reviews 2013. The authors aimed to determine the efficacy and tolerability of naproxen. Sumatriptan plus naproxen for acute migraine attacks in adults.CD008541. Wiffen interval [CI]: 9–21). but we will not know until the studies are done.pub2. DOI: 10. Issue 10. This study overlaps significantly with an earlier Cochrane review (Wiffen PJ. Naproxen with or without an antiemetic for acute migraine headaches in adults. There are better treatments. Treating early. Many sufferers rely on over-the-counter analgesics. At 2 hours.9 when baseline pain was moderate or severe. the NNT of 11 for pain-free response at 2 hours suggests that it is not a clinically useful treatment. This review aimed at assessing the efficacy and safety of pharmacological treatments for various pain symptoms associated with Guillain-Barr´e syndrome (GBS). The quality of the studies was unclear due to poor reporting and the primary outcome of patient reported pain was not used. Lunn MP. or 825 mg to treat attacks of moderate or severe pain intensity. compared with placebo and other active interventions in the treatment of acute migraine headaches in adults. Issue 10.CD 010567. The authors concluded that although naproxen is statistically  C 2014 Informa Healthcare USA. SUMATRIPTAN PLUS NAPROXEN FOR ACUTE MIGRAINE ATTACKS IN ADULTS This review should be cited as: Law S. The use of 50 mg of sumatriptan.pub2). DOI: 10. 500 mg. Kalso EA. 2013. There was little effect on fatigue and a small effect on sleep. Cochrane Database Syst Rev.pub2.: CD009455. Derry S. disabling condition and a burden for the individual. J. Derry S.(11):CD010567. was significantly better than treating once pain was moderate or severe for pain-free responses at 2 hours and during the 24 hours post dose. Adding in an antiemetic should help to reduce the nausea and vomiting commonly associated with migraine headaches. No. its efficacy in acute migraine has not been established by systematic reviews.1 when the baseline pain was mild and 4. Moore RA. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID). as he is the lead author on this overview. PHARMACOLOGICAL TREATMENT FOR PAIN IN GUILLAIN-BARRE´ SYNDROME This review should be cited as: Liu J. with an NNT of 13 (95% CI: 9–23). the NNT for pain-free response was 11. P. Art. during both the acute and convalescent phases. It is possible that the antiepileptic drugs may be of value here. DOI: 10. Derry S. Following on from the review above. Wang LN.) NAPROXEN WITH OR WITHOUT AN ANTIEMETIC FOR ACUTE MIGRAINE HEADACHES IN ADULTS This review should be cited as: Law S. Moore RA. A useful clinical message here is to treat early on in a migraine attack for greater benefit. Inc. which suggests a more robust way of assessing evi¨ ¸ eyler et al. review dence that is missing from the Uc described above. the NNT for painfree response was 3. Those who reported being “much” or “very much” improved was higher with pregabalin than with placebo giving an NNT of 9 (95% CI: 7–15). A comprehensive search led to six studies (2735 participants) using naproxen 275 mg. Adverse events were mostly mild or moderate in severity. Cochrane Database of Systematic Reviews 2013. alone or in combination with an antiemetic. Cochrane Database of Systematic Reviews 2013. Dropouts rate due to adverse events was higher with pregabalin than with placebo (not surprisingly).: CD009950. Art. which enrolled 277 randomized participants with acute phase GBS. Haanpaa M.CD009950. moderate. or severe pain intensity.pub2.J Pain Palliat Care Pharmacother Downloaded from informahealthcare. They included 12 studies (9291 participants) using sumatriptan 85 mg or 50 mg plus naproxen 500 mg to treat attacks of mild. At 2 hours. Hamunen K. Pharmacological treatment for pain in Guillain-Barr´e syndrome.1002/14651858. Migraine is a common. 71 superior. (Note: The author of this report has a conflict of interest here. in the combination did not significantly change the result. No. were included. health services. Just three short-term randomized controlled trials (RCTs). rather than 85 mg. Antiepileptic drugs for neuropathic pain and fibromyalgia—an overview of Cochrane reviews.: CD008541. Art. Naproxen (500 mg and 825 mg) was better than placebo for pain-free response and headache relief. when pain was still mild. . McNicol ED.1002/14651858. Rice AS.

1002/14651858. No. No study provided first-tier evidence for an efficacy outcome. high levels of attrition. Cochrane Database of Systematic Reviews 2013. CD010323.pub3. Moore RA. There were major sources of potential bias. Lunn MPT. 36 with methadone.: CD010323. One was using electroacupuncture. The authors estimate that most participants would have had no worse than mild pain on treatment. We are pretty sure that topiramate has little value in treating pain associated with painful diabetic neuropathy. We know that patients with who are prescribed and are taking opioids can have a history of long-term high-dose opioid use without effective pain relief. and 221 with paracetamol plus codeine. Cochrane Database of Systematic Reviews 2013. There were insufficient comparable data for metaanalysis to be undertaken or to produce numbers needed to treat (NNT) for the analgesic effect. 600 participants were treated with transdermal fentanyl patches. Stannard C. There was no convincing evidence for efficacy of topiramate at 200 to 400 mg/day over placebo. so there is evidence of effectiveness. DOI: 10. INTERVENTIONS FOR THE REDUCTION OF PRESCRIBED OPIOID USE IN CHRONIC NONCANCER PAIN This review should be cited as: Windmill J. Wiffen PJ. Issue 8. Many societies are concerned about the prescribing of opioids in chronic nonmalignant pain (CNMP). Three parallel-group placebo comparisons were in painful diabetic neuropathy (1643 participants). All studies had one or more sources of potential major bias. Derry S. Overall.CD010270. Fisher E. Eccleston C. Issue 9. 382 with various formulations of morphine. Doses of topiramate were titrated up to 200 or 400 mg/day. The quality of existing studies is disappointing in terms of rigor.pub2. Moore RA. Derry S. As part of a suite of reviews on opioids in cancer pain. the other on cognitive behavioral therapy.72 Journal of Pain & Palliative Care Pharmacotherapy J Pain Palliat Care Pharmacother Downloaded from informahealthcare. as they either used last observation carried forward (LOCF) imputation or were of small size. Topiramate for neuropathic pain and fibromyalgia in adults.pub2. DOI: 10. No. The author alone is responsible for the content and writing of the paper. Derry S.: CD008314.CD008 314. Art. TRANSDERMAL FENTANYL FOR CANCER PAIN This review should be cited as: Hadley G. including lack of blinding. and to assess adverse events. Journal of Pain & Palliative Care Pharmacotherapy . Art.1002/14651858. and inconsistent reporting.1002/14651858. Topiramate is an antiepileptic drug with multiple possible mechanisms of action.: CD010270. Transdermal fentanyl is an important product in the treatment of cancer pain. Nine studies (1244 participants) met the inclusion criteria. Cochrane Database of Systematic Reviews 2013. Issue 10. and one crossover study with diphenhydramine as an active placebo (41 participants) was in lumbar radiculopathy. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Art. this one set out to determine the analgesic efficacy of transdermal fentanyl for relief of cancer pain. No. Transdermal fentanyl for cancer pain. Fewer participants experienced constipation with transdermal fentanyl (28%) than with oral morphine (46%).com by HINARI on 04/18/14 For personal use only. Declaration of interest: The author reports no conflicts of interest. TOPIRAMATE FOR NEUROPATHIC PAIN AND FIBROMYALGIA IN ADULTS This review should be cited as: Wiffen PJ. The studies were too small and too biased to give any reliable answers. DOI: 10. Are there any useful strategies to reduce usage in such patients? The answer is not yet! Two studies provided information on 86 participants. this one was undertaken to add to the suite of reviews that formed an overview of reviews on antiepileptics. Given the role of antiepileptic drugs in neuropathic pain. Moore RA. Four studies with 1684 participants were included. small size. Knaggs R.