In the JournalsPerspective

Duloxetine may reduce pain after TKA in patients with central sensitization

Patients undergoing total knee arthroplasty with preoperatively identified central sensitization may experience reduced postoperative pain and improved quality of recovery without increased risk of adverse medication effects when prescribed duloxetine prior to and after surgery, according to published results.

Researchers randomly assigned 80 patients undergoing TKA and were identified as being centrally sensitized to either be prescribed 30 mg of duloxetine (Cymbalta, Eli Lilly) 1 day before surgery and for 6 weeks after surgery or to a control group that did not receive duloxetine. Researchers used the brief pain inventory, the SF-36 and the Hamilton Depression Scale to assess pain and quality of recovery. Researchers also noted the prevalence of adverse medication effects.

During the initial 2- to 12-week postoperative period, results showed better performance across pain metrics in the duloxetine group compared with the control group. Researchers found emotional and physical functioning indicated superior quality of recovery 2 weeks after TKA in the duloxetine group, as well as greater satisfaction with pain control and their daily activity. No differences were found in the prevalence of adverse events between the two groups, according to results.

“Surgeons should be aware that chronic osteoarthritis of the knee causes central sensitization in a substantial proportion of patients and use of the [central sensitization inventory] CSI before TKA is integral to an appropriately tailored perioperative pain management protocol,” the authors wrote. “The selective incorporation of duloxetine into a multimodal pain management protocol for patients with central sensitization might ameliorate unexplained pain after TKA.” – by Casey Tingle

Disclosures: The authors report no relevant financial disclosures.

Patients undergoing total knee arthroplasty with preoperatively identified central sensitization may experience reduced postoperative pain and improved quality of recovery without increased risk of adverse medication effects when prescribed duloxetine prior to and after surgery, according to published results.

Researchers randomly assigned 80 patients undergoing TKA and were identified as being centrally sensitized to either be prescribed 30 mg of duloxetine (Cymbalta, Eli Lilly) 1 day before surgery and for 6 weeks after surgery or to a control group that did not receive duloxetine. Researchers used the brief pain inventory, the SF-36 and the Hamilton Depression Scale to assess pain and quality of recovery. Researchers also noted the prevalence of adverse medication effects.

During the initial 2- to 12-week postoperative period, results showed better performance across pain metrics in the duloxetine group compared with the control group. Researchers found emotional and physical functioning indicated superior quality of recovery 2 weeks after TKA in the duloxetine group, as well as greater satisfaction with pain control and their daily activity. No differences were found in the prevalence of adverse events between the two groups, according to results.

“Surgeons should be aware that chronic osteoarthritis of the knee causes central sensitization in a substantial proportion of patients and use of the [central sensitization inventory] CSI before TKA is integral to an appropriately tailored perioperative pain management protocol,” the authors wrote. “The selective incorporation of duloxetine into a multimodal pain management protocol for patients with central sensitization might ameliorate unexplained pain after TKA.” – by Casey Tingle

Disclosures: The authors report no relevant financial disclosures.

    Perspective

    This article is interesting and broaches a rarely studied approach to pain management. It further highlights a little-known aspect in pain management, central sensitization. We have made improvements in trying to treat many aspects of the pain cascade, including peripherally with nerve blocks, locally with periarticular injections and centrally with multimodal pain cocktails. However, patients still struggle with pain after total knee replacement surgery, evidenced by the fact many people opt to avoid the second side after getting the first knee reconstructed. Similarly, patients require highly variable amounts of pain medication after surgery. Adverse side effects, such as nausea and vomiting, that are encountered with traditional opioids further complicate pain control, and when the pain gets out of control, it may be hard to recover. We have begun to explore other alternative forms of pain control using cannabinoids as well, and this article further demonstrates more investigation into variable approaches to pain needs to be done.

    Reference:

    Hickernell TR, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.07.027.

    • Jeffrey A. Geller, MD
    • Nas S. Eftekar Professor of Orthopedic Surgery
      Chief of orthopedic surgery, New York Presbyterian, Lawrence Hospital Westchester
      Chief, division of hip & knee reconstruction, Columbia University Irving Medical Center
      Vice chair of finance
      Director of research, Center for Hip & Knee Replacement
      New York

    Disclosures: Geller reports no relevant financial disclosures.