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Pain in the Frail or Elderly Patient: Does Tapentadol Have a Role?

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Abstract

Persistent pain affects the elderly disproportionally, occurring in 50 % of elderly community-dwelling patients and 80 % of aged care residents. The management of pain in the elderly and frail patient is complicated because of the risks posed by changes in pharmacokinetics and pharmacodynamics, polypharmacy, and drug–disease interactions. Trials evaluating the efficacy of analgesics have often excluded elderly patients and universally excluded frail patients; therefore, the true efficacy and side-effect profiles in these population groups are largely unknown, especially for long-term use. A stepwise approach is recommended to managing pain, commencing with paracetamol and adding on opioids when needed to manage pain. However, because of the short duration of clinical trials, exclusion of frail patients, and minimal inclusion of elderly patients, the decision as to which opioid should be added on to paracetamol is a difficult one. This article reviews the evidence surrounding a newer opioid, tapentadol. Tapentadol acts on both the mu receptors and on neuronal reuptake of noradrenaline, and has no significant analgesically active metabolites, which theoretically presents some advantages, particularly in comparison with tramadol. However, the evidence to support tapentadol is weak and the trials were often methodologically poor and sponsored almost universally by the drug company. Currently, there is insufficient evidence to support the use of tapentadol over other opioids, which have been on the market longer, are less expensive, and have better established safety profiles. As a first-line agent after the failure of paracetamol alone, morphine, oxycodone, fentanyl, or buprenorphine are still the preferred evidence-based choices for add-on opioid therapy for elderly or frail patients.

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References

  1. Merskey H, Bogduk N. Classification of chronic pain. 2nd ed. Seattle: IASP Press; 1994.

    Google Scholar 

  2. Siddall P. Is chronic pain a disease? Pain Med. 2013;14:1289–90.

    Article  PubMed  Google Scholar 

  3. Chai E, Horton JR. Managing pain in the elderly population: pearls and pitfalls. Curr Pain Headache Rep. 2010;14:409–17.

    Article  PubMed  Google Scholar 

  4. Lukas A, Mayer B, Fialova D, Topinkova E, Gindin J, Onder G, et al. Treatment of pain in European nursing homes: results from the Services and Health for Elderly in Long TERm Care (SHELTER) study. J Am Med Dir Assoc. 2013;14:821–31.

    Article  PubMed  Google Scholar 

  5. Lukas A, Mayer B, Fialova D, Topinkova E, Gindin J, Onder G, et al. Pain characteristics and pain control in European nursing homes: cross-sectional and longitudinal results from the Services and Health for Elderly in Long TERm care (SHELTER) study. J Am Med Dir Assoc. 2013;14:421–8.

    Article  PubMed  Google Scholar 

  6. Atkinson TJ, Fudin J, Pandula A, Mirza M. Medication pain management in the elderly: unique and underutilized analgesic treatment options. Clin Ther. 2013;35:1669–89.

    Article  PubMed  Google Scholar 

  7. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain in Older Persons. J Am Geriatr Soc. 2009;57:1331–46.

    Article  Google Scholar 

  8. Barber JB, Gibson SJ. Treatment of chronic non-malignant pain in the elderly: safety considerations. Drug Saf. 2009;32:457–74.

    Article  CAS  PubMed  Google Scholar 

  9. Schmader KE, Baron R, Haanpää ML, Mayer J, O’Connor AB, Rice AS, et al. Treatment considerations for elderly and frail patients with neuropathic pain. Mayo Clin Proc. 2010;85:s26–32.

    Article  PubMed Central  PubMed  Google Scholar 

  10. de Leon-Casasola OA. Opioids for chronic pain: new evidence, new strategies, safe prescribing. Am J Med. 2013;126(3 Suppl 1):S3–11.

    Article  PubMed  Google Scholar 

  11. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56.

    Article  CAS  PubMed  Google Scholar 

  12. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59:255–63.

    Article  PubMed  Google Scholar 

  13. Lowsky DJ, Olshansky SJ, Bhattacharya J, Goldman DP. Heterogeneity in healthy aging. J Gerontol A Biol Sci Med Sci. 2014;69:640–9.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Fine PG. Chronic pain management in older adults: special considerations. J Pain Symptom Manag. 2009;38(Suppl):S4–14.

    Article  Google Scholar 

  15. Prommer E, Ficek B. Management of pain in the elderly at the end of life. Drugs Aging. 2012;29:285–305.

    Article  CAS  PubMed  Google Scholar 

  16. Auret K, Schug SA. Underutilisation of opioids in elderly patients with chronic pain: approaches to correcting the problem. Drugs Aging. 2005;22:641–54.

    Article  CAS  PubMed  Google Scholar 

  17. Landi F, Onder G, Cesari M, Gambassi G, Steel K, Russo A, et al. Pain management in frail, community-living elderly patients. Arch Intern Med. 2001;161:2721–4.

    Article  CAS  PubMed  Google Scholar 

  18. Veal FC, Bereznicki LR, Thompson AJ, Peterson GM. Pharmacological management of pain in Australian aged care facilities. Age Ageing. 2014;43:851–6.

    Article  PubMed  Google Scholar 

  19. Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, et al. Guidance on the management of pain in older people. Age Ageing. 2013;42(Suppl 1):i1–57.

    Article  PubMed  Google Scholar 

  20. Pergolizzi J, Boger RH, Budd K, Dahan A, Erdine S, Hans G, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;8:287–313.

    Article  PubMed  Google Scholar 

  21. van Ojik AL, Jansen PA, Brouwers JR, van Roon EN. Treatment of chronic pain in older people: evidence-based choice of strong-acting opioids. Drugs Aging. 2012;29:615–25.

    Article  PubMed  Google Scholar 

  22. Hubbard RE, O’Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol. 2013;69:319–26.

    Article  PubMed  Google Scholar 

  23. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589–94.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. Ochsner J. 2010;10:179–87.

    PubMed Central  PubMed  Google Scholar 

  25. Fine PG. Treatment guidelines for the pharmacological management of pain in older persons. Pain Med. 2012;13(s2):s57–66.

    Article  PubMed  Google Scholar 

  26. Rastogi R, Meek BD. Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control. Clin Interv Aging. 2013;8:37–46.

    Article  PubMed Central  PubMed  Google Scholar 

  27. The Australian Pain Society. Pain in residential aged care facilities: management strategies. Sydney: 2005. https://www.apsoc.org.au/PDF/Publications/Pain_in_Residential_Aged_Care_Facilities_Management_Strategies.pdf. Accessed 22 Feb 2015.

  28. Solomon DH, Rassen JA, Glynn RJ, Garneau K, Levin R, Lee J, et al. The comparative safety of opioids for nonmalignant pain in older adults. Arch Intern Med. 2010;170:1979–86.

    Article  PubMed  Google Scholar 

  29. Solomon DH, Rassen JA, Glynn RJ, Lee J, Levin R, Schneeweiss S. The comparative safety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170:1968–76.

    Article  PubMed  Google Scholar 

  30. National Institute for Clinical Excellence. Osteoarthritis: Care and management in adults. 2014. http://www.nice.org.uk/guidance/cg177. Accessed 22 Feb 2015.

  31. McCleane G. Pain perception in the elderly patient. Clin Geriatr Med. 2008;24:203–11.

    Article  PubMed  Google Scholar 

  32. Claridge LC, Eksteen B, Smith A, Shah T, Holt AP. Acute liver failure after administration of paracetamol at the maximum recommended daily dose in adults. BMJ. 2010;341:c6764.

    Article  PubMed  Google Scholar 

  33. Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Tox. 2015;89:193–9.

    Article  CAS  Google Scholar 

  34. Mitchell SJ, Kane AE, Hilmer SN. Age-related changes in the hepatic pharmacology and toxicology of paracetamol. Curr Gerontol Geriatr Res. 2011. doi:10.1155/2011/624156.

  35. Mitchell SJ, Hilmer SN, Murion BP, Matthews S. Hepatoxicity of therapeutic short-course paracetamol in hospital inpatients: impact of ageing and frailty. J Clin Pharm Ther. 2011;36:327–35.

    Article  CAS  PubMed  Google Scholar 

  36. Graf J. Analgesic use in the elderly: the “pain” and simple truth. Arch Intern Med. 2010;170:1976–8.

    Article  PubMed  Google Scholar 

  37. McLachlan AJ, Bath S, Naganathan V, Hilmer SN, Le Couteur DG, Gibson SJ, et al. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Br J Clin Pharmacol. 2011;71:351–64.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  38. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health pathways to prevention workshop. Ann Intern Med. 2015;162:276–86.

    Article  PubMed  Google Scholar 

  39. Tracy B, Morrison RS. Pain management in older adults. Clin Ther. 2013;35:1659–68.

    Article  PubMed  Google Scholar 

  40. Ackerman SJ, Knight T, Schein J, Carter C, Staats P. Risk of constipation in patients prescribed fentanyl transdermal system or oxycodone hydrochloride controlled-release in a California Medicaid population. Consult Pharm. 2004;19:118–32.

    Article  PubMed  Google Scholar 

  41. Lugo RA, Satterfield KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliative Care Pharm. 2005;19:13–24.

    Article  Google Scholar 

  42. Ray WA, Chung CP, Murray KT, Cooper WO, Hall K, Stein CM. Out-of-hospital mortality among patients receiving methadone for noncancer pain. JAMA Intern Med. 2015. doi:10.1001/jamainternmed.2014.6294.

  43. Janssen Ortho. Ultram® (tramadol hydrochloride) tablets: full prescription information. 2008. http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020281s032s033lbl.pdf. Accessed 18 April 2015.

  44. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbiditiy: a literature review. Arch Intern Med. 2003;163:2433–45.

    Article  PubMed  Google Scholar 

  45. Seyfried O, Hester J. Opioids and endocrine dysfunction. Br J Pain. 2012;6:17–24.

    Article  Google Scholar 

  46. Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA. 2010;302:2214–21.

    Article  Google Scholar 

  47. National Institute for Clinical Excellence. Neuropathic pain: pharmacological management: the pharmacological management of neuropathic pain in adults in non-specialists settings. London: NICE; 2013. https://www.nice.org.uk/guidance/cg173. Accessed 22 Feb 2015.

  48. Taylor R, Pergolizzi JV, Raffa RB. Tapentadol extended release for chronic pain patients. Adv Ther. 2013;30:14–27.

    Article  CAS  PubMed  Google Scholar 

  49. Camilleri M. Opioid-induced constipation: challenges and therapeutic opportunities. Am J Gastroenterol. 2011;106:835–42.

    Article  CAS  PubMed  Google Scholar 

  50. Raffa RB, Buschmann H, Christoph T, Eichenbaum G, Englberger W, Flores CM, et al. Mechanistic and functional differentiation of tapentadol and tramadol. Expert Opin Pharmacother. 2012;13:1437–49.

    Article  CAS  PubMed  Google Scholar 

  51. Scottish Medicines Consortium. Resubmission: tapentadol, 50, 100, 150, 200 and 250 mg prolonged-release tablets (palexia® SR). Glasgow: SIGN; 2011. http://www.scottishmedicines.org.uk/files/advice/tapentadol_Palexia_SR_RESUBMISISON_FINAL_MAY_2011_for_website.pdf. Accessed 22 Feb 2015.

  52. Janssen Pharmaceuticals INC. Highlights of prescribing information—Nucynta ER. 2012. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/200533s001lbl.pdf. Accessed 22 Feb 2015.

  53. Pharmaceutical Benefits Advisory Committee. Tapentadol, tablet, 50 mg, 100 mg, 150 mg, 200 mg and 250 mg (as hydrochloride) (sustained release), Palexia SR® public summary document. Department of Health, editor. Canberra: Australian Government; 2013. http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/psd/2013-11/tapentadol. Accessed 22 Feb 2015.

  54. Afilalo M, Etropolski MS, Kuperwasser B, Kelly K, Okamoto A, Van Hove I, et al. Efficacy and safety of tapentadol extended release compared with oxycodone controlled release for the management of moderate to severe chronic pain related to osteoarthritis of the knee: a randomized, double-blind, placebo- and active-controlled phase III study. Clin Drug Investig. 2010;30:489–505.

    Article  CAS  PubMed  Google Scholar 

  55. Buynak R, Shapiro DY, Okamoto A, Van Hove I, Rauschkolb C, Steup A, et al. Efficacy and safety of tapentadol extended release for the management of chronic low back pain: results of a prospective, randomized, double-blind, placebo- and active-controlled phase III study. Expert Opin Pharmacother. 2010;11:1787–804.

    Article  CAS  PubMed  Google Scholar 

  56. National Prescribing Service. Tapentadol sustained release (Palexia SR) for chronic, severe disabling pain; Canberra; 2014. http://www.nps.org.au/publications/health-professional/nps-radar/2014/june-2014/tapentadol. Accessed 22 Feb 2015.

  57. Lange B, Kuperwasser B, Okamoto A, Steup A, Haufel T, Ashworth J, et al. Efficacy and safety of tapentadol prolonged release for chronic osteoarthritis pain and low back pain. Adv Ther. 2010;27:381–99.

    Article  CAS  PubMed  Google Scholar 

  58. Therapeutic Goods Administration. Australian public assessment report for tapentadol Palexia SR. Department of Health Australian Government, editor. Canberra: 2011. http://www.tga.gov.au/file/1393/download. Accessed 22 Feb 2015.

  59. Riemsma R, Forbes C, Harker J, Worthy G, Misso K, Schafer M, et al. Systematic review of tapentadol in chronic severe pain. Curr Med Res Opin. 2011;27:1907–30.

    Article  CAS  PubMed  Google Scholar 

  60. Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011. http://www.cochrane-handbook.org. Accessed 22 Feb 2015.

  61. Mercadante S, Porzio G, Ferrera P, Aielli F, Adile C, Ficorella C, et al. Tapentadol in cancer pain management: a prospective open-label study. Curr Med Res Opin. 2012;28:1775–9.

    Article  CAS  PubMed  Google Scholar 

  62. Schikowski A, Krings D, Schwenke K. Tapentadol prolonged release for severe chronic cancer-related pain: effectiveness, tolerability, and influence on quality of life of the patients. J Pain Res. 2015;8:1–8.

    PubMed Central  PubMed  Google Scholar 

  63. Kress HG, Koch ED, Kosturski H, Steup A, Karcher K, Lange B, et al. Tapentadol prolonged release for managing moderate to severe, chronic malignant tumor-related pain. Pain Physician. 2014;17:329–43.

    PubMed  Google Scholar 

  64. Desai B, Freeman E, Huang E, Hung A, Knapp E, Breunig IM, et al. Clinical value of tapentadol extended-release in painful diabetic peripheral neuropathy. Exp Rev Clin Pharmacol. 2014;7:203–9.

    Article  CAS  Google Scholar 

  65. Obradovic M, Ikenberg R, Hertel N, Antonanzas F, Galvez R, Liedgens H. Cost-effectiveness of tapentadol in severe chronic pain in Spain: a cost analysis of data from RCTs. Clin Ther. 2012;34:926–43.

    Article  PubMed  Google Scholar 

  66. Coluzzi F, Ruggeri M. Clinical and economic evaluation of tapentadol extended release and oxycodone/naloxone extended release in comparison with controlled release oxycodone in musculoskeletal pain. Curr Med Res Opin. 2014;30:1139–51.

    Article  CAS  PubMed  Google Scholar 

  67. Ikenberg R, Hertel N, Moore RA, Obradovic M, Baxter G, Conway P, et al. Cost-effectiveness of tapentadol prolonged release compared with oxycodone controlled release in the UK in patients with severe non-malignant chronic pain who failed 1st line treatment with morphine. J Med Econ. 2012;15:724–36.

    Article  PubMed  Google Scholar 

  68. Scarpignato C, Gatta L. Comparing tapentadol to oxycodone/naloxone combination: building castles in the air. Curr Med Res Opin. 2015;31:335–8.

    Article  PubMed  Google Scholar 

  69. National Health Service. NHS Electronic Drug Tarriff. 2015. http://www.ppa.org.uk/edt/January_2015/mindex.htm. Accessed 21 Jan 2015.

  70. Guay DR. Is tapentadol an advance on tramadol? Consult Pharm. 2009;24:833–40.

    Article  PubMed  Google Scholar 

  71. Anonymous. Tapentadol. Acute or chronic pain: no therapeutic advance. Prescrire Int. 2014;23:121–4.

  72. Anonymous. Tapentadol (Palexia) for moderate to severe acute pain. Drug Ther Bull. 2012;50:30–3.

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F. C. Veal and G. M. Peterson declare no conflicts of interest.

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Authors and Affiliations

  1. Unit for Medication Outcomes Research and Education (UMORE), Discipline of Pharmacy, Faculty of Health, School of Medicine, University of Tasmania, Hobart, TAS, Australia

    Felicity C. Veal & Gregory M. Peterson

  2. Health Services Innovation Tasmania, Faculty of Health, School of Medicine, University of Tasmania, Private Bag 99, Hobart, TAS, 7001, Australia

    Gregory M. Peterson

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  1. Felicity C. Veal
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Correspondence to Gregory M. Peterson.

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Veal, F.C., Peterson, G.M. Pain in the Frail or Elderly Patient: Does Tapentadol Have a Role?. Drugs Aging 32, 419–426 (2015). https://doi.org/10.1007/s40266-015-0268-7

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