Comparative Efficacy and Safety of Different Pharmacological Treatments for Postherpetic Neuralgia Pain: A Systematic Review and Network Meta-analysis
Amir Attia1, Kareem Raafat2, Mohamed Ezz3, Amira Aboali4, Ahmed Amin1, Ahmed Elsekhary1, Ehab Naser5, Mostafa Bakr6, Ram Saha7, Ahmad Shaheen7
1Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt., 2Faculty of Medicine, Suez Canal University, Ismailia, Egypt., 3Faculty of Medicine, Tanta University, Tanta, Egypt., 4Faculty of Medicine, Alexandria University, Alexandria, Egypt., 5Faculty of Physical Therapy, Al Salam University, Tanta, Egypt., 6MTI University, School of Medicine, Cairo, Egypt., 7Department of Neurology, Virginia Commonwealth University, Richmond, VA
Objective:
To evaluate the efficacy and safety of various pharmacological interventions for managing Postherpetic Neuralgia (PHN) pain through a comprehensive network meta-analysis (NMA) and systematic review.
Background:
PHN, a common complication of herpes zoster, affects 5% to 30% of patients, causing severe pain that impacts physical function, psychological well-being, and quality of life. The effectiveness of available treatments varies, complicating management strategies. This NMA aims to provide the most comprehensive evidence for PHN management.
Design/Methods:
Databases were systematically searched up to April 2024 for RCTs comparing pharmacological interventions for PHN. Pain reduction was the primary outcome, assessed by SMD with a 95% CI. Safety outcomes were evaluated using RR with a 95% CI, employing random-effects models and inverse variance statistics.
Results:
Twenty-three RCTs with 6514 patients and 17 pharmacological interventions (6 classes including placebo) were analyzed.
Efficacy:
Week 1: Local anesthetics (Lidocaine) showed the highest efficacy (SMD -2.27, 95%CI -3.00: -1.53), followed by opioids (Hydromorphone) (SMD -1.28, 95%CI -1.96: -0.61) and anticonvulsants (Pregabalin, Gabapentin) (SMD -0.80 to -0.38).
Week 2: Lidocaine remained most effective (SMD -2.95, 95%CI -3.66: -2.24), followed by anticonvulsants (SMD -1.01 to -0.56).
Week 4: Lidocaine (SMD -1.54, 95%CI -2.18: -0.90) and Hydromorphone (SMD -1.30, 95%CI -2.10: -0.49) were most effective. Anticonvulsants (SMD -1.11 to -0.65).
Week 8: our analysis of Anticonvulsants, opioids, antidepressants, and placebo showed that Anticonvulsants (notably Pregabalin (high-dose))(SMD -1.15, 95%CI -1.58: -0.73) and Hydromorphone (SMD -1.14, 95%CI -1.71: -0.57) have the highest efficacy.
Safety:
All interventions showed non-statistically significant differences in safety compared to placebo, including discontinuation rates and common side effects.
Conclusions:
Local anesthetics are most effective for pain reduction, followed by opioids and anticonvulsants. Antidepressants and COX-2 inhibitors were not significantly effective compared to placebo. Pregabalin, especially at moderate to high doses, was the most effective among anticonvulsants. All interventions had similar safety profiles.
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