Oral Pregabalin as Preemptive Analgesia in Abdominal Hysterectomy

Overview

Postoperative pain affects 80% of surgical patients and is one of the main negative symptoms resulting from surgery. It impairs the recovery of patient since it is related to chronic pain, nausea and vomiting and longer hospital stay, generating higher cost to the health system. Thus, the use of new methods to control postoperative pain is recommended and multimodal analgesia, an opioid-sparing strategies, has been widely used by several researchers. Studies show that gabapentins have beneficial effects on postoperative pain control when used as pre-anesthetic medication, also showing a reduction in opioid consumption, with few adverse effects. Among gynecological surgeries, abdominal hysterectomy is one of the procedures that generates the highest degree of acute postoperative pain. Thus, the aim of the present study is to investigate the effect of oral pregabalin (300 mg) two hours before abdominal hysterectomy procedures on postoperative pain. This study is a randomized, double-blind, placebo controlled clinical trial. Patients submitted to abdominal hysterectomy for benign pathologies will be selected and divided into two groups: the placebo controlled group (P0) and the pregabalin 300 mg group (P1). Group P0 will receive a placebo tablet one hour before the procedure, while group P1 will receive a 300 mg tablet of pregabalin identical to the placebo tablet. The reduction of postoperative pain and the best quality of patient recovery will be evaluated using the Visual Analogue Pain Scale (VAS) and the McGill Pain Questionnaire. Also, it will be evaluated the consumption of opioids as a rescue analgesic medication and the presence of adverse effects such as nausea and vomiting.

Full Title of Study: “Use of Oral Pregabalin as Preemptive Analgesia in Abdominal Hysterectomy: Evaluation of Postoperative Pain and Opioid Consumption”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Prevention
    • Masking: Triple (Participant, Care Provider, Investigator)
  • Study Primary Completion Date: December 30, 2020

Detailed Description

The sample population of this study is 102 female patients (50 already included in the study), who have undergone abdominal hysterectomy surgery for benign conditions, with or without joint oophorectomy / salpingectomy. The patients received spinal anesthesia, at hospital "Santa Casa de Alfenas" – Minas Gerais / Brazil ("Casa de Caridade Nossa Senhora do Perpétuo Socorro"). All surgeries were performed by the same team of surgeons.

All patients were evaluated and followed from the preoperative period, up to 24 hours postoperatively, passing through the intraoperative period. During all stages, patients were assisted by a properly trained multi-professional team, consisting of a doctor, nurse and nursing technician.

For the patient to be included in the study, she must have understood and agreed with the informed consent form that was explained in detail to all possible candidates in the preoperative period.

This is a double blind randomized study. The patients were randomly allocated to 02 groups, in which Group 1 received medication A (designated in the study as medication 1), whereas Group 2 received medication B (designated in the study as medication 2).

Study participants and researchers were blinded as to the use of drug / placebo to avoid measurement bias. To carry out the blinding process, an external researcher was assigned to randomize the groups and prepare the pills in opaque and closed envelopes characterized only by a control identification (A or B), which is known only to this researcher. Patients in both groups received identical sealed envelopes, 02h before the start of the anesthetic procedure, only identified as medication A or B, which contained two pills in each envelope. A second researcher is responsible for collecting data and monitoring the patient from the intraoperative period up to 24 hours after discharge from the post-anesthetic recovery room (PARR).

In the operating room, venoclysis was performed with jelco No. 18 or No. 20, and an infusion of 08 ml.kg-1 of crystalloid solution (lactated ringer). The patients were properly monitored with pulse oximetry, cardioscope, and non-invasive blood pressure monitor. After monitoring, patients were premedicated with intravenous (IV) midazolam at a dosage of 0.03 mg.kg1.

To perform spinal anesthesia, the patients were seated on the surgical stretcher by the nursing team. Asepsis and antisepsis were performed at the puncture site with alcoholic chlorhexidine solution. After placement of sterile drapes, local anesthesia was performed with 2.0% lidocaine without vasoconstrictor. The first attempt at subarachnoid puncture was performed, using the median technique, between the intervertebral levels L3-L4 or L4-L5 or L5-S1, with a 25 gauge Quincke needle for subarachnoid anesthesia. If there was a technical difficulty in the puncture, the paramedian puncture technique was chosen. The confirmation of the correct puncture was based on the aspiration of cerebrospinal fluid. Anesthesia was performed with the local anesthetic 0.5% bupivacaine at a dosage of 0.3 mg.kg-1, injected from a 5 ml disposable syringe. After anesthesia, the patients were placed in the supine position, and the correct level of anesthesia was proven with thermal sensitivity tests using cotton soaked with alcoholic solution. After the anesthesia reached the sensory level of the T4 thoracic vertebra, the surgical team was allowed to start the procedure. Prior to the beginning of the surgical incision, a delayed bladder probe was performed in all patients according to the surgeon's indication.

Hemodynamic changes in blood pressure were controlled with the use of vasoactive medications such as ephedrine or metaraminol. For prophylaxis of postoperative nausea and vomiting (PONV) ondansetron was administered at a dosage of 4 mg intravenously (IV) 30 minutes before the end of surgery. Tenoxicam was prescribed for all patients at a dosage of 20 mg IV at regular intervals every 12 hours for the purpose of anti-inflammatory and analgesic action. For analgesic relief, dipyrone IV was also prescribed at a dosage of 50 mg.kg-1 at regular intervals every 6 hours. During the surgery, and also at the end of the surgery, the patients were evaluated for the degree of sedation using the Ramsay sedation scale as a basis.

At the end of the surgery, the patients were referred to the post-anaesthesia care unit, where they were monitored again, and went through the pain assessment process using the visual analog scale (VAS) in relation to pain at rest and "movement" (the patient was asked to perform the forced cough movement), through a direct question with scale demonstration. Pains characterized as mild (0 – 2 VAS) received no medication other than those already prescribed; pain characterized as moderate (3 – 7 EVA) received IV morphine at a dosage of 0.025 mg.kg-1; and severe pain (8 – 10 VAS) received IV morphine at a dose of 0.05 mg.kg-1 every 01 h until analgesic control.

To consider themselves able to be discharged from the post-anaesthesia care unit for clinical follow-up in wards, patients should reach a score ≥ 9 on the modified Aldrete Scale and have VAS pain scores ≤ 2.

In the infirmary, patients were tested at regular intervals for pain intensity, by of a team of nurses trained and qualified to do so. The patients had pain classified as moderate (VAS ≥ 2 <8) or severe (VAS ≥ 8), receiving drugs with morphine IV in the dose of 1 mg and 2 mg respectively, according to the medical prescription.

24 h after discharge from the post-anaesthesia care unit, in the ward, all the patient was assessed by the same examiner who performed an assessment at the post-anaesthesia care unit, who stratified the patient again from the EVA and assessed using the McGill questionnaire.

During the entire hospitalization period, the use of central nervous system (CNS) depressant drugs (example: ketamine, droperidol, promethazine) and / or analgesic drugs that do not contain any study protocol was avoided. If some patients were medicated with these drugs, they were excluded from the study.

The data related to surgery (pre, trans and postoperative) were collected for statistical analysis, according to Annex II, in which a total duration of surgery in minutes; the total intravenous medication infused; the values of mean arterial pressure and heart rate in the pre, intra and postoperative period; a presence or not, as well as a quantity, of PONV in the post-anaesthesia care unit and after 24h; presence or not of dizziness as a possible side effect; among others.

All data selected through the study will be digitized and analyzed using the Statistic® 7.0 software. The data will be compared using repeated measures ANOVA, followed by Newman-Keuls post-hoc, being considered for p <0.05.

Interventions

  • Drug: Pregabalin 300mg
    • Group P1 will receive a 300 mg tablet of pregabalin, 02h before the surgical procedure
  • Other: Placebo
    • Group P0 will receive a placebo tablet, 02h before the surgical procedure

Arms, Groups and Cohorts

  • Placebo Comparator: Group P(0) – Placebo
    • Patients were randomly allocated to Group P(0) – Placebo by a double blind randomized study. Group P(0) received two placebo tablets as medication, 02h before the start of the anesthesic-surgical procedure in identical sealed envelops, only identified as medication A or B
  • Experimental: Group P(1) – Pregabalin 300mg
    • Patients were randomly allocated to Group P(1) – Pregabalin 300mg by a double blind randomized study. Group P(1) received two tablets of pregabalin 150mg, 02h before the start of the anesthesic-surgical procedure in identical sealed envelops, only identified as medication A or B

Clinical Trial Outcome Measures

Primary Measures

  • Postoperative pain assessed 24 hours after abdominal hysterectomy surgery using the visual analog scale (VAS)
    • Time Frame: End of the first postoperative day of abdominal hysterectomy surgery (24 hours after the end of surgery)
    • Postoperative pain assessment, 24 hours after abdominal hysterectomy surgery, in patients who used a single dose of pregabalin 300mg or placebo as preemptive analgesia, using the visual analog scale (VAS) consisting of a 10 cm (cm) line ) graduated in natural number intervals, starting at 0 (zero) until reaching 10 (ten), associated with the numbers, drawings related to the pain presented by the patient at the moment, in which the absence of pain (0 ) there is a happy face, and as the numerical value increases, the drawn face will represent the intensity of pain, up to the value of 10, where a face with crying characteristics is found, indicating greater pain.
  • Postoperative pain assessed 24 hours after abdominal hysterectomy surgery, using the McGill Pain Questionnaire
    • Time Frame: End of the first postoperative day of abdominal hysterectomy surgery (24 hours after the end of surgery)
    • Postoperative pain assessment, 24 hours after abdominal hysterectomy surgery, in patients who used a single 300mg dose of pregabalin or placebo as preemptive analgesia, using the McGill pain questionnaire, which consists of 20 word groups , and each group can contain from 2 to 6 descriptive words, these descriptors are placed in an increasing order of magnitude in relation to the intensity. The left of each word has a numerical value in an attempt to represent the intensity of the descriptor. For the analysis of the answers, the total number of words chosen in each subgroup by the patient was used to qualify his pain, the minimum value being equal to 0 (zero), if the patient chose not to choose any descriptor, and the maximum value would be 20, as the patient can choose only one descriptor for each subgroup. The quantitative pain index was also evaluated, which represents the sum of the values of each descriptor chosen by the patient, with a minimum value of 0 and a maximum of 78.

Secondary Measures

  • Number of doses of opioids used as analgesic rescue in the postoperative period
    • Time Frame: End of the first postoperative day of abdominal hysterectomy surgery (24 hours after the end of surgery)
    • Evaluation of the number of intravenous opioid doses used within 24 hours of postoperative abdominal hysterectomy surgery in patients who used pregabalin 300mg or not as preemptive analgesia
  • Time required for the use of the first dose of opioid as an analgesic rescue in the postoperative period
    • Time Frame: First postoperative day of abdominal hysterectomy surgery
    • • Evaluation of the time between the end of abdominal hysterectomy surgery and the patient’s request for the use of the first dose of intravenous opioid as an analgesic rescue, comparing between patients who used or not pregabalin 300mg as preemptive analgesia
  • Adverse effects comparing between the intervention and control groups
    • Time Frame: End of the first postoperative day of abdominal hysterectomy surgery (24 hours after the end of surgery) and also immediately in the post-anesthetic recovery room
    • • Assess the presence of adverse effects such as nausea and vomiting, itching and dizziness, comparing the intervention group that used pregabalin with the placebo group

Participating in This Clinical Trial

Inclusion Criteria

1. Patients who will undergo elective abdominal hysterectomy surgery due to benign pathologies;

2. Be classified as physical status by the Society of Anesthesiologists (ASA) as ASA I (healthy individual) or ASA II (patient with mild and controlled systemic disease);

Exclusion Criteria

1. Allergy or intolerance previously known to pregabalin or opioids;

2. Patients with chronic pain or fibromyalgia;

3. Patients on chronic opioid use;

4. Carriers of malignant neoplasms;

5. Pregnant women;

6. People with active uncontrolled cardiovascular disease;

7. Patients with kidney and / or liver disease;

8. Patients who have spinal deformities that make spinal anesthesia impossible;

9. Presence of coagulation disorders or anticoagulant therapy that cannot be suspended for surgery;

10. Presence of active sepsis.

Gender Eligibility: Female

Female patients

Minimum Age: 20 Years

Maximum Age: 65 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Universidade Federal de Alfenas
  • Provider of Information About this Clinical Study
    • Principal Investigator: Larissa Helena Lobo Torres Pacheco, Principal Investigator – Universidade Federal de Alfenas
  • Overall Official(s)
    • Larissa H Torres, PhD, Principal Investigator, Universidade Federal de Alfenas
    • Marcia H Podestá, PhD, Study Chair, Universidade Federal de Alfenas
    • Fabrício G Silva, BSc, Study Chair, Universidade Federal de Alfenas
    • Thayná C Silva, BSc, Study Chair, Santa Casa de Alfenas
    • Tiago M Reis, PhD, Study Chair, Universidade Federal de Alfenas
    • Denismar A Nogueira, PhD, Study Chair, Universidade Federal de Alfenas
    • Milena C Espósito, PhD, Study Chair, Universidade Federal de Alfenas
    • Danielle A Oliveira, BSc, Study Chair, Universidade Federal de Alfenas
    • Carla S Ceron, PhD, Study Chair, Universidade Federal de Alfenas
  • Overall Contact(s)
    • Larissa H Torres, PhD, + 55 (35) 3701-9513, larissa.torres@unifal-mg.edu.br

References

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As-Sanie S, Till SR, Mowers EL, Lim CS, Skinner BD, Fritsch L, Tsodikov A, Dalton VK, Clauw DJ, Brummett CM. Opioid Prescribing Patterns, Patient Use, and Postoperative Pain After Hysterectomy for Benign Indications. Obstet Gynecol. 2017 Dec;130(6):1261-1268. doi: 10.1097/AOG.0000000000002344.

Farzi F, Naderi Nabi B, Mirmansouri A, Fakoor F, Atrkar Roshan Z, Biazar G, Zarei T. Postoperative Pain After Abdominal Hysterectomy: A Randomized, Double-Blind, Controlled Trial Comparing the Effects of Tramadol and Gabapentin as Premedication. Anesth Pain Med. 2016 Jan 17;6(1):e32360. doi: 10.5812/aapm.32360. eCollection 2016 Feb.

Ghai A, Gupta M, Hooda S, Singla D, Wadhera R. A randomized controlled trial to compare pregabalin with gabapentin for postoperative pain in abdominal hysterectomy. Saudi J Anaesth. 2011 Jul;5(3):252-7. doi: 10.4103/1658-354X.84097.

Kohli M, Murali T, Gupta R, Khan P, Bogra J. Optimization of subarachanoid block by oral pregabalin for hysterectomy. J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):101-5.

Main CJ. Pain assessment in context: a state of the science review of the McGill pain questionnaire 40 years on. Pain. 2016 Jul;157(7):1387-99. doi: 10.1097/j.pain.0000000000000457. Review.

Steinberg AC, Schimpf MO, White AB, Mathews C, Ellington DR, Jeppson P, Crisp C, Aschkenazi SO, Mamik MM, Balk EM, Murphy M. Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines. Am J Obstet Gynecol. 2017 Sep;217(3):303-313.e6. doi: 10.1016/j.ajog.2017.03.013. Epub 2017 Mar 27. Review.

Tulandi T, Krishnamurthy S, Mansour F, Suarthana E, Al-Malki G, Ballesteros LER, Moore A. A Triple-Blind Randomized Trial of Preemptive Use of Gabapentin Before Laparoscopic Hysterectomy for Benign Gynaecologic Conditions. J Obstet Gynaecol Can. 2019 Sep;41(9):1282-1288. doi: 10.1016/j.jogc.2018.11.019. Epub 2019 Jan 25.

Verret M, Lauzier F, Zarychanski R, Savard X, Cossi MJ, Pinard AM, Leblanc G, Turgeon AF. Perioperative use of gabapentinoids for the management of postoperative acute pain: protocol of a systematic review and meta-analysis. Syst Rev. 2019 Jan 16;8(1):24. doi: 10.1186/s13643-018-0906-3.

Yücel A, Ozturk E, Aydoğan MS, Durmuş M, Colak C, Ersoy MÖ. Effects of 2 different doses of pregabalin on morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind clinical trial. Curr Ther Res Clin Exp. 2011 Aug;72(4):173-83. doi: 10.1016/j.curtheres.2011.06.004.

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