title: Radioisotopes for metastatic bone pain.
abstract: BACKGROUND
  This is an update of the review published in Issue 4, 2003. Bone metastasis cause severe pain as well as pathological fractures, hypercalcaemia and spinal cord compression. Treatment strategies currently available to relieve pain from bone metastases include analgesia, radiotherapy, surgery, chemotherapy, hormone therapy, radioisotopes and bisphosphonates.
  
  
  OBJECTIVE
  To determine efficacy and safety of radioisotopes in patients with bone metastases to improve metastatic pain, decrease number of complications due to bone metastases and improve patient survival.
  
  
  METHODS
  We sought randomised controlled trials (RCTs) in MEDLINE, EMBASE, CENTRAL, and the PaPaS Trials Register up to October 2010.
  
  
  METHODS
  Studies selected had metastatic bone pain as a major outcome after treatment with a radioisotope, compared with placebo or another radioisotope.
  
  
  METHODS
  We assessed the risk of bias of included studies by their sequence generation, allocation concealment, blinding of study participants, researchers and outcome assessors, and incomplete outcome data. Two review authors extracted data. We performed statistical analysis as an "available case" analysis, and calculated global estimates of effect using a random-effects model. We also performed an intention-to-treat (ITT) sensitivity analysis.
  
  
  RESULTS
  This update includes 15 studies (1146 analyzed participants): four (325 participants) already included and 11 new (821 participants). Only three studies had a low risk of bias. We observed a small benefit of radioisotopes for complete relief (risk ratio (RR) 2.10, 95% CI 1.32 to 3.35; Number needed to treat to benefit (NNT) = 5) and complete/partial relief (RR 1.72, 95% CI 1.13 to 2.63; NNT = 4) in the short and medium term (eight studies, 499 participants). There is no conclusive evidence to demonstrate that radioisotopes modify the use of analgesia with respect to placebo. Leucocytopenia and thrombocytopenia are secondary effects significantly associated with the administration of radioisotopes (RR 5.03; 95% CI 1.35 to 18.70; Number needed to treat to harm (NNH) = 13). Pain flares were not higher in the radioisotopes group (RR 0.74; 95% CI 0.27 to 2.06). There are scarce data of moderate quality when comparing Strontium-89 ((89)Sr) with Samarium-153 ((153)Sm), Rhenium-186 ((186)Re) and Phosphorus-32 ((32)P). We observed no significant differences between treatments. Similarly, we observed no differences when we compared different doses of (153)Sm (0.5 versus 1.0 mCi).
  
  
  CONCLUSIONS
  This update adds new evidence on efficacy of radioisotopes versus placebo, (89)Sr compared with other radioisotopes, and dose-comparisons of (153)Sm and (188)Re. There is some evidence indicating that radioisotopes may provide complete reduction in pain over one to six months with no increase in analgesic use, but severe adverse effects (leucocytopenia and thrombocytopenia) are frequent.
authors: Iberoamerican Cochrane Centre. Institute of Biomedical Research (IIB Sant Pau), Barcelona, CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Sant Antoni Maria Claret 171, Edifici Casa de Convalescència, Barcelona, Catalunya, Spain, 08041.
authors: Marta
authors: M
authors: Roqué I Figuls
authors: Maria José
authors: MJ
authors: Martinez-Zapata
authors: Martin
authors: M
authors: Scott-Brown
authors: Pablo
authors: P
authors: Alonso-Coello
mesh_terms: D001859:Bone Neoplasms / Q000532:radiotherapy* / Q000556:secondary*; D050723:Fractures, Bone / Q000532:radiotherapy; D006801:Humans; D006934:Hypercalcemia / Q000532:radiotherapy; D010146:Pain / Q000532:radiotherapy*; D010147:Pain Measurement; D010761:Phosphorus Radioisotopes / Q000627:therapeutic use; D011868:Radioisotopes / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D012429:Ruthenium Radioisotopes / Q000627:therapeutic use; D012493:Samarium / Q000627:therapeutic use; D013117:Spinal Cord Compression / Q000532:radiotherapy; D013326:Strontium Radioisotopes / Q000627:therapeutic use
chemical_list: D010761:Phosphorus Radioisotopes; D011868:Radioisotopes; D012429:Ruthenium Radioisotopes; D013326:Strontium Radioisotopes; D012493:Samarium