Evaluation of the Effectiveness, Safety, and Tolerability of Tapentadol PR Versus a Combination of Tapentadol PR and Pregabalin in Subjects With Severe Chronic Low Back Pain With a Neuropathic Pain Component
Overview
- Phase
- Phase 4
- Intervention
- Tapentadol Prolonged Release
- Conditions
- Low Back Pain
- Sponsor
- Grünenthal GmbH
- Enrollment
- 622
- Locations
- 59
- Primary Endpoint
- Change in the Average Pain Intensity Score for the Overall Low Back Pain on an 11-point Numeric Rating Scale (NRS-3)
- Status
- Completed
- Last Updated
- 6 years ago
Overview
Brief Summary
The main objective of the study is to evaluate the effectiveness, safety, and tolerability of increasing doses of tapentadol prolonged release (PR) (500 mg per day) versus a combination of tapentadol PR (300 mg per day) and pregabalin (to 300 mg per day) in subjects requiring additional analgesia after titration to tapentadol PR 300 mg per day.
This is a clinical effectiveness trial designed to establish a link between anticipated clinical outcomes and the clinical practice by means of selected measures of clinical and subject reported outcomes. Since, severe low back pain with a neuropathic component, the targeted study population, is frequently treated with a combination therapy (monotherapy is often not effective enough) it is of interest to determine if tapentadol alone (combining 2 mechanisms of action in a single molecule) could be as effective as a combination of tapentadol plus pregabalin. Furthermore, the tolerability profiles of monotherapy versus combination are of interest.
Detailed Description
Participants with a diagnosis of chronic low back pain (defined as pain lasting for at least 3 month) and requiring a strong analgesic (World Health Organization \[WHO\] Step III) as judged by the investigator and having a positive or unclear score using the painDETECT diagnostic screening questionnaire will enter the open-label titration tapentadol prolonged release (PR) period. In total participants will have 11 planned scheduled visits scheduled over 105 days. At the Enrollment Visit \[Day -14 (3 to 14 days prior to the Baseline Visit)\] the inclusion and exclusion criteria will be checked to evaluate the participant's eligibility for the trial. Participants on previous analgesics will start a washout period three days up to 2 weeks.The duration of the washout period will depend on previous opioid analgesics and co-analgesics and their respective doses, down-tapering steps. Participants who do not need a washout of previous analgesic treatment (e.g. WHO Step I analgesics), a baseline visit can be scheduled as soon as clinical laboratory monitoring results are available. At the Baseline Visit (Day 1) participants will start the 3 week open-label titration period tapentadol prolonged release (PR) at doses of 2 x 50 mg per day and will be titrated upwards in steps of 100 mg (2 x 50 mg) on a weekly basis. Participants who do not qualify for randomization may continue the trial in the open-label continuation arm if they have already reached a satisfactory level of pain relief. Participants qualifying for randomization in the comparative period (Day 22 to 77) will be allocated to 1 of 2 treatment arms and will continue treatment. Either they continue on tapentadol prolonged release (PR) with increasing doses of tapentadol PR * After the randomization visit, participants will titrate up to a total daily dose of 400 mg. * 1 week after the randomization visit, will titrate up to a total daily dose of 500 mg. Participants in this treatment arm will receive a final dose of 500 mg tapentadol PR per day. Or start on a combination of tapentadol PR 300 mg per day with pregabalin * After the randomization visit, participants will continue their previous regimen of tapentadol PR 2 x 150 mg per day plus pregabalin 2 x 75 mg (total daily dose of 150 mg pregabalin). * 1 week after the randomization visit, participants will continue their previous regimen (end of titration period) of tapentadol PR 2 x 150 mg per day plus pregabalin 2 x 150 mg (total daily dose of 300 mg pregabalin). Participants in this treatment arm will receive a final dose of 300 mg tapentadol PR and 300 mg pregabalin. Participants in the Comparative Period can be assigned to the open-label pick-up arm and will be treated with a stable dose of tapentadol PR 300 mg per day or 400 mg per day if they experience treatment emergent adverse events (at least possibly related to investigational medicinal product).The open-label pick-up period theoretically starts on Day 29, i.e. one week after the Randomization Visit. The Final Evaluation (Day 77) is planned to take place 8 weeks after randomization. After the Final Evaluation a Follow-up Period (blinded tapering down/out of IMP in Week 12 and Follow-up Visit (up to Day 91) will take place. Tapering down/out of medication will be performed according to the Summary of Product Characteristics.
Investigators
Eligibility Criteria
Inclusion Criteria
- •Subjects must have a diagnosis of chronic low back pain; chronic pain defined as pain lasting for at least 3 months.
- •Subject's pain must require a strong analgesic (defined as World Health Organization (WHO) step III) as judged by the investigator.
- •The painDETECT diagnostic screening questionnaire score must be:
- •"positive" or
- •"unclear".or If the subject is being treated with a stable regimen of centrally acting analgesics (opioids) and/or co-analgesics, even a "negative" painDETECT score (but of at least 9) at the enrollment visit will be acceptable.
- •If under regular daily pretreatment with a WHO step II/step III opioid analgesic and/or a centrally acting co-analgesic:
- •Subjects must be taking a WHO step II or step III analgesic or co- analgesic on a daily basis for at least 2 weeks prior to the enrollment visit.
- •Subjects pretreated with a WHO step II opioid analgesic and/or a centrally acting co-analgesic must have reported an average pain intensity score of at least 5 points (NRS-3≥5) during the last 3 days prior to the enrollment visit. or If under regular, daily pretreatment with a WHO step I analgesic monotherapy or if no regular analgesic pretreatment is reported:
- •Subjects must have an average pain intensity score of at least 6 points NRS-3≥6) in the last 3 days prior to the enrollment visit.
Exclusion Criteria
- •Presence of concomitant painful conditions other than low back pain that could confound the subject's trial assessments or self-evaluation of the index pain, e.g., syndromes with widespread pain such as fibromyalgia.
- •Low back pain caused by cancer and/or metastatic diseases.
- •Any painful procedures planned during the trial period (e.g., major surgery) that may, in the opinion of the investigator, affect the effectiveness or safety assessments of the Investigational Medicinal Product (IMP).
- •Pending litigation or application for insurance/governmental benefits due to chronic pain or disability and, if granted, benefits might be influenced by a successful participation in the trial.
- •Rare hereditary problems of galactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption, lactose intolerance.
Arms & Interventions
Tapentadol Prolonged Release
Tapentadol Prolonged Release (100 - 500 mg per day) Oral administration twice daily
Intervention: Tapentadol Prolonged Release
Tapentadol Prolonged Release
Tapentadol Prolonged Release (100 - 500 mg per day) Oral administration twice daily
Intervention: Tapentadol Prolonged Release open label maintenance
Tapentadol Prolonged Release with Pregabalin
Tapentadol Prolonged Release (100 - 300 mg per day) with Pregabalin (150 - 300 mg per day) Both administered orally twice a day.
Intervention: Tapentadol Prolonged Release with Pregabalin
Tapentadol Prolonged Release with Pregabalin
Tapentadol Prolonged Release (100 - 300 mg per day) with Pregabalin (150 - 300 mg per day) Both administered orally twice a day.
Intervention: Tapentadol Prolonged Release open label maintenance
Outcomes
Primary Outcomes
Change in the Average Pain Intensity Score for the Overall Low Back Pain on an 11-point Numeric Rating Scale (NRS-3)
Time Frame: Randomization (Day 22); Final Evaluation Visit (Day 77)
The primary endpoint is defined as the comparison of tapentadol prolonged release (PR) 300 mg plus 200 mg per day and the combination of tapentadol PR 300 mg per day and pregabalin 300 mg per day regarding the change in NRS-3 pain intensity scores (recalled average pain intensity score during the last 3 days on 11-point NRS, where 0 is the no pain and 10 is pain as bad as you can imagine) from the randomization visit to the final evaluation visit. Theoretically a maximum decrease of -10 and an increase of +4 in the pain intensity would have been possible. A negative sign indicates a decrease in pain intensity from the start of treatment. The higher the absolute values, the greater the change since the start of treatment (Baseline visit).
Secondary Outcomes
- End of Open-label Pick-up Period: Average Pain Intensity Score for the Overall Low Back Pain on an 11-point Numeric Rating Scale (NRS-3)(Final Evaluation Visit (Day 77))
- Double-blind Comparative Period: Change in NRS-3 Pain Intensity Score for the Radiating Pain(Randomization Visit (Day 22); End of Evaluation Visit (Day 77))
- Open-label Titration Period: Radiating Pain(Enrollment Visit (Day -14); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: painDETECT Assessments(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Latency(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Average Pain Intensity Score for the Overall Low Back Pain on an 11-point Numeric Rating Scale (NRS-3)(Enrollment (Day -14); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Change in painDETECT Final Assessment(Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Continuation Period: Average Pain Intensity Score for the Overall Low Back Pain on an 11-point Numeric Rating Scale (NRS-3)(Enrollment (Day -14); Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Double-blind Comparative Period: Change in Worst Pain Intensity Over the Past 24 Hours(Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Comparative Double-blind Period Population painDETECT Assessment(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Neuropathic Pain Symptom Inventory (NPSI) Overall Score Assessment in the Double-blind Comparative Period Population(Enrollment Visit; Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Radiating Mean Pain Intensity Score for the Comparative Period Population(Enrollment Visit (Day -14); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Comparative Double-blind Period Population Worst Mean Pain Intensity Scores Over the Past 24 Hours(Enrollment Visit (Day-12); Baseline Visit (day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Change in Short Form Health Survey (SF-12) Mental Health Composite Score (MCS)(Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Double-blind Comparative Period: Change EuroQol-5 Dimension (EQ-5D) Health Status Index(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Patient Global Impression of Change (PGIC)(Randomization Visit (Day 22) to Final Evaluation Visit (Day 77))
- Open-label Titration Period: Hospital Anxiety and Depression Scale - Anxiety in the Double-blind Comparative Period Population(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Worst Mean Pain Intensity Scores Over the Past 24 Hours(Enrollment Visit (Day -14); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Neuropathic Pain Symptom Inventory (NPSI) Overall Score Assessment(Enrollment Visit; Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Changes in the Short Form Health Survey (SF-12) Physical Health Composite Score (PCS)(Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Comparative Double-blind Period Population Short Form Health Survey (SF-12) Mental Health Composite Score (MCS)(Enrollment Visit; Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Change in Neuropathic Pain Symptom Inventory (NPSI) Sub-scores and Overall Score Assessment(Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Comparative Double-blind Period Population Short Form Health Survey (SF-12) Physical Health Composite Score (PCS)(Enrollment Visit; Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: EuroQol-5 Dimension (EQ-5D) Health Status Index Score for the Double-blind Comparative Period Population(Enrollment Visit (day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Clinician Global Impression of Change (CGIC)(Randomization Visit (Day 22) to Final Evaluation Visit (Day 77))
- Double-blind Comparative Period: Change in Hospital Anxiety and Depression Scale - Anxiety in the Double-blind Comparative Period Population(Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Hospital Anxiety and Depression Scale - Depression in the Double-blind Comparative Period Population(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Change in Hospital Anxiety and Depression Scale - Depression in the Double-blind Comparative Period Population(Baseline Visit (Day 1); Randomization Visit (Day 22); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Latency in the Double-blind Comparative Period Population(Enrollment Visit (Day -12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Sleep Evaluation - Number of Awakenings in the Double-blind Comparative Period Population(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Sleep Evaluation Questionnaire - Change in the Number of Hours Slept(Baseline Visit (Day -12); Randomization Visit (Day 1); Final Evaluation Visit (Day 77))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Overall Quality of Sleep(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Overall Quality of Sleep in the Double-blind Comparative Period Population(Randomization Visit (Day 22))
- Double-blind Comparative Period Sleep Evaluation Questionnaire: Change in Latency(Baseline Visit (Day 1); Randomization Visit (Day 22) to Final Evaluation Visit (Day 77))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Number of Awakenings(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Change in the Number of Awakenings(Baseline Visit (Day 1); Randomization Visit (Day 22) to Final Evaluation Visit (Day 77))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Time Slept(Enrollment Visit (Day-12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Open-label Titration Period: Sleep Evaluation Questionnaire - Number of Hours Slept in the Double-blind Comparative Period Population(Enrollment Visit (Day -12); Baseline Visit (Day 1); Randomization Visit (Day 22))
- Double-blind Comparative Period: Change in the Overall Quality of Sleep(Randomization Visit (Day 22) to Final Evaluation (Day 77))
- Open-label Titration Period: Subject's Satisfaction With Treatment(End of Open-label Titration Period at Randomization Visit (Day 22))
- Double-blind Comparative Period: Subject's Satisfaction With Treatment(End of Comparative Period at Final Evaluation Visit (Day 77))