Hydromorphone for acute and chronic pain

 

Abstract

Background

This is an updated version of the original review, published in Issue 1, 2002. Some patients with severe cancer pain either do not achieve adequate analgesia with morphine, or suffer intolerable toxicity. For these patients alternatives such as hydromorphone are recommended. However, there appear to be gaps in our understanding of the efficacy of hydromorphone.

Objectives

The objectives were to evaluate the efficacy of hydromorphone in the management of pain.

Search methods

Randomised controlled trials (RCTs) which included hydromorphone were sought. The date of the most recent search was November 2006.

Selection criteria

RCTs which involved the administration of hydromorphone, for both acute and chronic pain conditions, in adults and children, were included.

Data collection and analysis

A data extraction form was designed for the review. The validity of each trial for inclusion was assessed and a grade was allocated to each study on the basis of allocation concealment with a checklist being used to assess blinding.

Main results

Five further trials were added to the original review. The original review reported forty three studies (2725 participants). This review now reports forty eight studies (3510 participants). Approximately half of these studies received a low quality score. In addition, the heterogeneity of the studies precluded a meta-analysis. Of the 48 included studies, 12 (989 participants) involved chronic and 36 (2521 participants) acute pain conditions. Five studies were placebo-controlled. Of the remainder, hydromorphone was compared with other opioids, bupivicaine and with itself, using different formulations. The routes of administration included intravenous, oral, spinal, intramuscular and subcutaneous. Overall, hydromorphone appears to be a potent analgesic. The current limited evidence available suggests that there is little difference between morphine and hydromorphone in terms of analgesic efficacy, adverse effect profile and patient preference. However, as most studies involved small numbers of patients, it is difficult to determine real differences between both drugs. In the context of both acute and chronic pain, the issue of equi-analgesic ratios between morphine and hydromorphone was not resolved.

Authors' conclusions

The studies were varied in terms of quality and methodology. However, the majority demonstrated that hydromorphone is a potent analgesic, that the effects of hydromorphone appear to be dose-related, and that adverse effects are similar to those of other mu opioid receptor agonists. Since the last version of this review, none of the new relevant studies have provided significant additional information.

 

Plain language summary

Hydromorphone for acute and chronic pain

While hydromorphone appears to be a potent analgesic, evidence to date does not support its superiority over morphine for the management of moderate to severe pain. Morphine is the gold standard for the management of moderate to severe cancer-related pain. Alternatives to morphine are now available, including hydromorphone. This review found that hydromorphone is a potent analgesic for the management of acute and chronic pain. In terms of analgesic efficacy and tolerability, hydromorphone behaves like other strong opioids. The limited evidence available does not demonstrate any clinically significant difference between hydromorphone and other strong opioids, such as morphine.

 

摘要

背景

以Hydromorphone治療急性及慢性疼痛

這是一篇發表於2002年第一期的回顧的更新。有些嚴重癌症疼痛的病患，使用morphine後，並沒有達到適當的止痛效果，或無法耐受其毒性。針對這些病患，建議使用hydromorphone等替代療法。然而，目前對於hydromorphone的效果並未完全了解。

目標

評估hydromorphone對於疼痛的治療效果。

搜尋策略

我們搜尋了論及hydromorphone的隨機對照試驗(RCTs)。最近一次搜尋是在2006年11月。

選擇標準

我們收錄了論及使用hydromorphone，作為成人或孩童的急性和慢性疼痛的治療的隨機對照試驗。

資料收集與分析

我們為本篇回顧設計了數據擷取的格式。評估每篇試驗的正確性，並根據分配隱藏，使用盲化清單做出評分。

主要結論

本次更新加入了5篇試驗。原本的回顧包含了43篇研究(2725位參與者)。本次回顧總共包含48篇研究(3510位參與者)。其中大約有一半的研究品質分數很低。此外，研究的異質性使我們無法進行整合分析。在這48篇收錄的研究中，12篇(989位參與者)針對慢性疼痛做討論，36篇(2521位參與者)則針對急性疼痛。5篇研究為安慰劑對照。其它的試驗則以其它鴉片類藥物、bupivicaine或hydromorphone的其它劑型和hydromorphone比較。投藥方式包括靜脈注射、口服、脊椎注射、肌肉注射及皮下注射。整體而言，hydromorphone似乎是一個有用的止痛劑。目前可得的有限證據，顯示morphine和hydromorphone在止痛效果、不良反應及病人的喜好度上，差異不大。然而，由於大多數研究包含的病患數量都不多，很難判定藥物間的差異。因此針對急性和慢性疼痛，我們仍不清楚morphine和hydromorphone的相等鎮痛比率。

作者結論

本篇回顧收錄的研究，在品質和方法上都有差異。然而，大多數研究顯示hydromorphone是一種有效的止痛劑，hydromorphone的止痛效果似乎和劑量有關，而不良反應則和其它μopioid受體作用劑相似。自從上次的回顧更新，所有找到的新的相關研究，都無法提供更多有用的資訊。

翻譯人

本摘要由朱奕蓁翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

雖然hydromorphone似乎是一個有效的止痛劑，目前可得的證據並不認為用於治療中度到嚴重疼痛時，hydromorphone比morphine更有效。Morphine是治療癌症引起的中度到嚴重疼痛的最佳標準。目前也有morphine的替代療法，hydromorphone就是其中之一。這篇回顧發現，針對急性及慢性疼痛的治療，hydromorphone是有效的止痛劑。在止痛效果及耐受性上，hydromorphone和其它強效鴉片類藥物很相似。目前有限的證據，在hydromorphone和morphine等其它強效鴉片類藥物間，並沒有發現顯著差異。