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Grand Rounds

Do Compounded Analgesic Creams Alleviate Chronic Pain?

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BACKGROUND AND PURPOSE:

  • Topical creams to reduce chronic pain are commonly used
  • There is evidence to support the use of topical NSAIDs, capsaicin and lidocaine but data for other topical pain creams remains limited
    • A recent Cochrane review found topical NSAIDs only helpful for knee osteoarthritis
  • CMS (Medicaid/Medicare) spent >$500,000,000 on topical compounded pain creams in 2015, resulting in a call for an assessment of prescribing practices and effectiveness
    • Department of Defense spent approximately $6,000,000 per day
  • Brutcher et al. (Annals of Internal Medicine, 2019) assessed the efficacy of compounded creams for chronic pain

METHODS:

  • Randomized, double-blind controlled trial
  • Three types of chronic pain were included
    • neuropathic
    • nociceptive (nonneuropathic)
    • mixed
  • Patients received either
    • Pain creams compounded for neuropathic pain (ketamine, gabapentin, clonidine, and lidocaine)
    • Nociceptive pain (ketoprofen, baclofen, cyclobenzaprine, and lidocaine)
    • Mixed pain (ketamine, gabapentin, diclofenac, baclofen, cyclobenzaprine, and lidocaine)
    • Placebo
  • Cream applied to affected areas 3 times per day
  • Primary outcome measure: Average pain score at 1 month after treatment
    • Positive categorical response was a reduction in pain score of ≥2  plus a score >3 on a 5-point satisfaction scale
  • Secondary outcomes included
    • Short Form-36 Health Survey score | Satisfaction | Categorical response

RESULTS:

  • 133 people were included in each pain type group
  • Primary outcome: No differences were found in the mean reduction in average pain scores between the treatment and control groups
    • Neuropathic pain: −0.1 points (95% CI, −0.8 to 0.5 points)
    • Nociceptive pain: −0.3 points (CI, −0.9 to 0.2 points)
    • Mixed pain: −0.3 points (CI, −0.9 to 0.2 points)
    • All patients: −0.3 points (CI, −0.6 to 0.1 points)
  • At 1 month, positive outcomes were observed in all groups
    • Treatment groups: 36%
    • Control group: 28%
    • Risk difference: 8% (95% CI, −1% to 17%)
  • Side effects were similar between all groups, with no serious adverse events
    • Irritation was higher in the treatment groups vs placebo (7% vs 2%)

CONCLUSION:

  • While acknowledging short follow-up, the authors conclude that topical compounded pain creams are not superior to placebo in the management of chronic pain
  • No significant differences were observed in
    • Pain scores | Functional improvement | Satisfaction
  • Many of the drugs found in compounded pain medications are ligands for CNS receptors and may not reach active sites via transdermal application
  • NSAIDs and lidocaine included in these compounds may not exert their effect due to dilution in the overall compounded cream

Learn More – Primary Sources:

Compounded Topical Pain Creams to Treat Localized Chronic Pain: A Randomized Controlled Trial

Now You Can Get ObG Clinical Research Summaries Direct to Your Phone

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Related ObG Topics:

Managing Pain in the Postpartum Period: Recommendations Using the Multimodal Approach
Should Opioid Medications Be Left Out of the Treatment Plan?

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