Terapias medicamentosas para manejo da dor em pacientes amputados: revisão sistemática e metanálise de rede

Abstract

Introduction: Pain is the most prevalent clinical manifestation after amputation. Approximately 70% of amputees experience some type of pain, and even at low intensity, it causes suffering and changes their lives in some way. There is no consensus in scientific literature on the most appropriate way to manage this event, and there are numerous promising drug therapies. Evidence analysis is important to support safe therapeutic choices for the patient and to promote nursing practice based on scientific evidence. Given that the philosophical dimension permeates all nursing care, this study was developed in line with some ideas contained in the work Critique of Pure Reason by philosopher Immanuel Kant. Objective: to evaluate the efficacy and safety of drug therapies for pain management in amputee patients. Methodology: this is an overview of a systematic review and network meta-analysis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses (PRISMA-NMA) and registered in the International prospective register of systematic reviews (PROSPERO) database (CRD42024500600). The search was carried out in September 2024, by two researchers, independently and simultaneously, in the databases: Cochrane Library, Latin American and Caribbean Literature on Health Sciences (LILACS), National Library of Medicine and National Institutes of Health (PUBMED), Scientific Electronic Library Online (SciELO), Science Direct, Web of Science, Elsevier's Scopus (SCOPUS), CINAHL and Google Scholar. A total of 2,352 texts were identified. The study included all Cochrane Systematic Reviews (CSRs) and non-Cochrane Systematic Reviews (non-CSRs) with or without meta-analysis that described the population aged 18 years or older, with the use of pharmacological therapies for pain management in patients undergoing amputation surgeries. There was no restriction on time or language of publications, and duplicate texts were excluded using Rayyan®. Results: 17 systematic reviews were included for analysis. With a population mainly of males, ages between 19 and 92 years, with amputations of extremities and presence of Residual Pain (RD) or Phantom Limb Pain (PLP), pain assessment was performed using various scales. To analyze the methodological quality, the Assessment of Multiple Systematic Reviews (AMSTAR 2) was used, and the studies were considered according to overall reliability as: “moderate”, 7 (41.2%); “critically low”, 7 (41.2%); and “low”, 3 (17.7%). Seven systematic reviews of randomized clinical trials were filtered for the network meta-analysis; the analyses were conducted using the netmeta package, through the R® software. Two outcomes were analyzed for meta-analysis and elaboration of network and sub-network diagrams: DR and DMF. The therapies contained in the three subnetworks created did not obtain statistical significance for direct and indirect comparisons. In the first sub-network, for phantom limb pain, the therapies most likely to have better results were transcranial magnetic stimulation (p-score 0.6949), followed by memantine (p-score 0.5309) and, in the second sub-network for DMF, mirror therapy (p-score 0.6058) and transcutaneous electrical nerve stimulation (0.5916). The third subnetwork was designed for residual pain and gabapentin obtained the first position in the ranking. Conclusion: given the results and limitations, the hypothesis that drug therapies do not present sufficient scientific evidence to guarantee the efficacy and safety of use for pain management in adult amputee patients, compared with the administration of placebos and/or other therapies, is accepted.