YaDeau Jacques T, Mayman David J, Jules-Elysee Kethy M, Lin Yi, Padgett Douglas E, DeMeo Danya A, Gbaje Ejiro C, Goytizolo Enrique A, Kim David H, Sculco Thomas P, Kahn Richard L, Haskins Stephen C, Brummett Chad M, Zhong Haoyan, Westrich Geoffrey
Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY.
J Arthroplasty. 2022 Jun;37(6S):S147-S154. doi: 10.1016/j.arth.2022.02.022. Epub 2022 Feb 18.
Duloxetine, a serotonin-norepinephrine dual reuptake inhibitor, may improve analgesia after total knee arthroplasty (TKA). Previous studies had one primary outcome, did not consistently use multimodal analgesia, and used patient-controlled analgesia devices, potentially delaying discharge. We investigated whether duloxetine would reduce opioid consumption or pain with ambulation.
A total of 160 patients received 60 mg duloxetine or placebo daily, starting from the day of surgery and continuing 14 days postoperatively. Patients received neuraxial anesthesia, peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory drugs, and oral opioids as needed. The dual primary outcomes were Numeric Rating Scale (NRS) scores with movement on postoperative days 1, 2, and 14, and cumulative opioid consumption surgery through postoperative day 14.
Duloxetine was noninferior to placebo for both primary outcomes and was superior to placebo for opioid consumption. Opioid consumption (mean ± SD) was 288 ± 226 mg OME [94, 385] vs 432 ± 374 [210, 540] (duloxetine vs placebo) P = .0039. Pain scores on POD14 were 4.2 ± 2.0 vs 4.8 ± 2.2 (duloxetine vs placebo) P = .018. Median satisfaction with pain management was 10 (8, 10) and 8 (7, 10) (duloxetine vs placebo) P = .046. Duloxetine reduced interference by pain with walking, normal work, and sleep.
The 29% reduction in opioid use corresponds to 17 fewer pills of oxycodone, 5 mg, and was achieved without increasing pain scores. Considering the ongoing opioid epidemic, duloxetine can be used to reduce opioid usage after knee arthroplasty in selected patients that can be appropriately monitored for potential side effects of the medication.
度洛西汀是一种5-羟色胺-去甲肾上腺素双重再摄取抑制剂，可能会改善全膝关节置换术（TKA）后的镇痛效果。以往的研究只有一个主要结局，未始终采用多模式镇痛，且使用了患者自控镇痛装置，这可能会延迟出院。我们研究了度洛西汀是否会减少阿片类药物的用量或减轻行走时的疼痛。
共有160例患者从手术当天开始每天服用60mg度洛西汀或安慰剂，并持续至术后14天。患者根据需要接受椎管内麻醉、外周神经阻滞、对乙酰氨基酚、非甾体抗炎药和口服阿片类药物。两个主要结局分别为术后第1、2和14天活动时的数字评分量表（NRS）评分，以及术后第14天手术累计阿片类药物用量。
度洛西汀在两个主要结局方面均不劣于安慰剂，且在阿片类药物用量方面优于安慰剂。阿片类药物用量（均值±标准差）为288±226mg OME [94, 385]，而安慰剂组为432±374 [210, 540]（度洛西汀组对比安慰剂组），P = 0.0039。术后第14天的疼痛评分为4.2±2.0，而安慰剂组为4.8±2.2（度洛西汀组对比安慰剂组），P = 0.018。疼痛管理的中位满意度分别为10（8, 10）和8（7, 10）（度洛西汀组对比安慰剂组），P = 0.046。度洛西汀减少了疼痛对行走、正常工作和睡眠的干扰。
阿片类药物用量减少29%相当于减少了17片5mg的羟考酮，且并未增加疼痛评分。考虑到当前的阿片类药物流行情况，度洛西汀可用于减少选定患者膝关节置换术后的阿片类药物用量，这些患者可对药物的潜在副作用进行适当监测。
