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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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
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.