Neuropathic pain: principles of diagnosis and treatment

The combined analgesic effect of pregabalin and morphine in the treatment of pancreatic cancer pain, a retrospective study

BACKGROUND

Pregabalin is commonly used to relieve neuropathic pain. However, data are lacking on its efficacy for the treatment of chronic cancer pain. The purpose of this study was to determine the analgesic efficacy of pregabalin combined with morphine in the management of pancreatic cancer pain.

METHODS

This study reviewed patients who were prescribed morphine and 150 mg/d pregabalin between 1 January 2017 and 10 November 2018 in our institute. The primary outcomes of this study were the average pain score and dose of morphine. Secondary outcomes included characters of breakthrough cancer pain, functional interference related to pain, anxiety/depression status, and incidence of treatment-related adverse events during the study.

RESULTS

A total of 240 patients with pain related to pancreatic cancer were included in the study. The results showed that patients of both combination therapy group (pregabalin+morphine) and monotherapy group (morphine) achieved similar analgesic efficacy, demonstrated by NRS (2.4 ± 0.9 vs. 2.6 ± 0.9; combination vs. monotherapy) at the end of the study. Mean daily dose of morphine used in the combination group was significant lower compared to monotherapy group (39.5 ± 16.0 mg vs. 61.5 ± 19.3 mg, net difference 23.5, 95% CI: 18.4-28.6, p <  0.001). The change of functional interference score related to pain was significantly different between combination and monotherapy group (12.0 ± 0.4 vs. 9.8 ± 4.9; net difference, 2.3; 95% CI: 1.1-3.3; p < 0.001). Patients in combination therapy group had experienced shorter duration of breakthrough cancer pain than those in monotherapy group (X² p < 0.001, Cramer's V:0.36). The incidence of somnolence, dizziness, and cognitive dysfunction were significantly higher in the combination group compared to monotherapy group. No serious treatment-related side effects were observed.

CONCLUSIONS

The findings of this study supported the use of pregabalin with morphine to relieve pain in patients of pancreatic cancer.

Therapeutic Potential of Natural Psychoactive Drugs for Central Nervous System Disorders: A Perspective from Polypharmacology

In the drug development, the formation of highly selective ligands has been unsuccessful in the treatment of central nervous system disorders. Multi-target ligands, from the polypharmacology paradigm, are being proposed as treatments for these complex disorders, since they offer enhanced efficacy and a strong safety profile. Natural products are the best examples of multi-target compounds, so they are of high interest within this paradigm. Additionally, recent research on psychoactive drugs of natural origin, such as ayahuasca and cannabis, has demonstrated the promising therapeutic potential for the treatment of some psychiatric and neurological disorders. In this text, we describe how research on psychoactive drugs can be effectively combined with the polypharmacology paradigm, providing ayahuasca and cannabis research as examples. The advantages and disadvantages are also discussed.

A functional polymorphism in the ATP-Binding Cassette B1 transporter predicts pharmacologic response to combination of nortriptyline and morphine in neuropathic pain patients

Many genetic markers have been associated with variations in treatment response to analgesics, but none have been assessed in the context of combination therapies. In this study, the treatment effects of nortriptyline and morphine were tested for an association with genetic markers relevant to pain pathways. Treatment effects were determined for single and combination therapies. A total of 24 functional single nucleotide polymorphisms were tested within the gene loci of mu-opioid receptor (OPRM1) gene locus, ATP-Binding Cassette B1 Transporter (ABCB1), Cytochrome P450 gene family (CYP2C19 and CYP2D6), catecholamine inactivator Catechol-O-Methyl Transferase (COMT), and serotonin receptor 2A (HTR2A). Genotyping was performed in a population of neuropathic pain patients who previously participated in a clinical trial. For monotherapy, neither nortriptyline nor morphine responses were associated with single nucleotide polymorphisms. However, for nortriptyline + morphine combination therapy, the single nucleotide polymorphism rs1045642 within the drug efflux pump ABCB1 transporter significantly predicted analgesic response. The presence of the C allele accounted for 51% of pain variance in this subgroup in response to combination treatment. The T-allele homozygotes demonstrated only 20% improvement in pain scores, whereas the C-allele homozygotes 88%. There was no significant contribution of rs1045642 to the medication side effects under all treatment conditions. The UK Biobank data set was then used to validate this genetic association. Here, patients receiving similar combination therapy (opioid + tricyclic antidepressant) carrying the C allele of rs1045642 displayed 33% fewer body pain sites than patients without that allele, suggesting better pain control. In all, our results show a robust effect of the rs1045642 polymorphism in response to chronic pain treatment with a nortriptyline + morphine combination.

Spinal Hemangioblastomas and Neuropathic Pain

BACKGROUND

Spinal hemangioblastomas (SHs) are rare and benign tumors. Primary symptoms include pain, hypoesthesia, and neuropathic pain (NP). Clinical symptoms may be as a result of tumor mass effect, peritumoral effect, syrinx, or venous congestion. No studies have focused on NP in SHs. The objective of this study was to review the rate and causes of NP in patients with SHs.

METHODS

The present study comprises a retrospective analysis of 13 patients with spinal hemangioblastomas. For the retrospective analysis of the patients, we analyzed the absence or presence of NP in the pre- and postoperative periods and its relationship with the level, location, and size of the tumor, as well as the size and location of the syrinx.

RESULTS

Postoperative NP was detected in 6 out of 13 patients. All 6 patients' tumors were located at the dorsal aspect of the spinal cord. There was a predominance of rostral syrinx location in patients with NP. Tumor size and level and syrinx size and level were not found to affect the occurrence of NP.

CONCLUSIONS

The present study shows that NP is observable in both pre- and postoperative periods. Proximity of the tumor to the dorsal root entry zone, and especially the presence of rostral syrinx, are the main factors affecting postoperative NP symptomatology. It is concluded that the combination of these factors and iatrogenic injury of anatomic pathways of NP within the spinal cord are responsible for postoperative NP.

Effects of dose titration on adherence and treatment duration of pregabalin among patients with neuropathic pain: A MarketScan database study

OBJECTIVE

To examine pregabalin dose titration and its impact on treatment adherence and duration in patients with neuropathic pain (NeP).

METHODS

MarketScan database (2009-2014) was used to extract a cohort of incident adult pregabalin users with NeP who had at least 12 months of follow-up data. Any dose augmentation within 45 days following the first pregabalin claim was defined as dose titration. Adherence (measured by medication possession ratio/MPR) and persistence (measured as the duration of continuous treatment) were compared between the cohorts with and without dose titration. Logistic regressions and Cox proportional hazards models were used to identify the factors associated with adherence (MPR ≥ 0.8) and predictors of time to discontinuation.

RESULTS

Among the 5,186 patients in the analysis, only 18% of patients had dose titration. Patients who had dose titration were approximately 2.6 times as likely to be adherent (MPR ≥ 0.8) (odds ratio = 2.59, P < 0.001) than those who did not have dose titration. Kaplan-Meier analysis shows that the time to discontinuation or switch was significantly longer among patients who had dose titration (4.99 vs. 4.04 months, P = 0.009).

CONCLUSIONS

Dose titration was associated with improved treatment adherence and persistence among NeP patients receiving pregabalin. The findings will provide valuable evidence to increase physician awareness of dose recommendations in the prescribing information and to educate patients on the importance of titration and adherence.

Spinal Cord Stimulator Infection: Approach to Diagnosis, Management, and Prevention

Spinal cord stimulation (SCS) is the most utilized invasive electrical neuromodulation treatment for the management of refractory chronic pain syndromes. Infection is one of the most dreaded complications related to SCS implantation and may prevent patients from receiving adequate pain treatment, adding to the initial cost and disability. Most SCS infections present as generator pocket infection. However, delay in diagnosis may lead to complications such as meningitis, epidural abscess, and/or vertebral osteomyelitis. Early recognition of SCS-related infections and associated complications is based on clinical suspicion, laboratory testing, and appropriate diagnostic imaging. While superficial surgical site infection following SCS implant may be treated with antibiotic therapy alone, deep infection involving implant warrants device removal to achieve cure. Duration of antimicrobial therapy depends on severity of clinical presentation and presence or absence of associated complications. Several preventive strategies can be incorporated in surgical practice to reduce the risk of SCS infection.

Valproic acid mitigates spinal nerve ligation-induced neuropathic pain in rats by modulating microglial function and inhibiting neuroinflammatory response

Spinal inflammation is a pathophysiological state of neuropathic pain (NP). The subsequent microglial activation and neuroinflammatory response are contributing factors for long-lasting behavioral hypersensitivity. Valproic acid (VPA), a histone deacetylase inhibitor, has promising anti-inflammatory and neuroprotective properties for clinical use in the treatment of neurological disorders. However, the underlying mechanisms of its effects on NP have not been determined. This study aimed to clarify the possible mechanisms by which VPA alleviates NP in rat models induced by spinal nerve ligation (SNL). Intraperitoneal injection of VPA (300 mg/kg) efficiently attenuated mechanical allodynia in rats with NP. VPA exerted anti-inflammatory effects by downregulating proinflammatory cytokines (tumor necrosis factor-α, cytokines interleukin-1β, cytokines interleukin-6; TNF-α, IL-1β, and IL-6) and upregulating anti-inflammatory cytokines (transforming growth factor-β, cytokines interleukin-10, cytokines interleukin-4; TGF-β, IL-10 and IL-4). Additionally, VPA suppressed spinal microgliosis and promoted the polarization of microglia towards the M2 phenotype to further ameliorate spinal neuroinflammation. VPA also exerted neuroprotective effects by decreasing spinal cell apoptosis. The anti-inflammatory and neuroprotective effects may have depended on changes in nuclear histone deacetylase 3 (HDAC3) expression following VPA treatment. Moreover, VPA treatment inhibited nuclear factor-κB (NF-κB) p65 nuclear expression and upregulated acetylated the signal transducer and activator of transcription 1 (STAT1). In addition, VPA suppressed SNL-induced phosphorylation of Janus Kinase 2 (JAK2) and signal transducer and activator of transcription 3 (STAT3). Taken together, our results demonstrate that VPA is a promising anti-inflammatory agent suitable for NP therapy that regulates microglial function and suppresses spinal neuroinflammation via the STAT1/NF-κB and JAK2/STAT3 signaling pathways.

Effect of the conditioned medium of mesenchymal stem cells on the expression levels of P2X4 and P2X7 purinergic receptors in the spinal cord of rats with neuropathic pain

Recent studies have shown that mesenchymal stem cells (MSCs) and their conditioned medium (CM) have potential therapeutic effects in animal models of neuropathic pain (NP). However, the mechanisms underlying these effects are not fully understood. Because of the leading involvement of purinergic receptors in the pathogenesis of NP, this study aimed to investigate the effect of MSCs-CM on the expression levels of P2X4 and P2X7 receptors in a rat model of NP induced by chronic constriction injury (CCI) of the sciatic nerve. CM was prepared from the rats' bone marrow-derived MSCs culture. After that, NP rats were treated by intraperitoneal injection of CM, or Dulbecco's modified Eagle's medium (DMEM) 1 day before and 7 and 11 days after CCI surgery. The NP status was assessed in the treated animals using behavioral tests, including mechanical allodynia and thermal hyperalgesia, on days - 1, 3, 6, 9, 12, and 15 of the study. At the end of the study (Day 15), the animals were sacrificed, and the relative gene expression of P2X4 and P2X7 receptors were measured in the spinal cord using quantitative real-time PCR. The results demonstrated that in the CM-treated NP rats, mechanical allodynia and thermal hyperalgesia were significantly reduced compared with the DMEM-treated group. In addition, the expression levels of P2X4 and P2X7 receptors were noticeably prevented in the CM-treated group than the control group. These findings indicate that the antinociceptive effects of CM in the NP rats are partly mediated through preventing the upregulation of P2X4 and P2X7 receptors in the spinal cord.

Synergistic interaction between trazodone and gabapentin in rodent models of neuropathic pain

Neuropathic pain is a chronic debilitating condition caused by injury or disease of the nerves of the somatosensory system. Although several therapeutic approaches are recommended, none has emerged as an optimal treatment leaving a need for developing more effective therapies. Given the small number of approved drugs and their limited clinical efficacy, combining drugs with different mechanisms of action is frequently used to yield greater efficacy. We demonstrate that the combination of trazodone, a multifunctional drug for the treatment of major depressive disorders, and gabapentin, a GABA analogue approved for neuropathic pain relief, results in a synergistic antinociceptive effect in the mice writhing test. To explore the potential relevance of this finding in chronic neuropathic pain, pharmacodynamic interactions between low doses of trazodone (0.3 mg/kg) and gabapentin (3 mg/kg) were evaluated in the chronic constriction injury (CCI) rat model, measuring the effects of the two drugs both on evoked and spontaneous nociception and on general well being components. Two innate behaviors, burrowing and nest building, were used to assess these aspects. Besides exerting a significant antinociceptive effect on hyperalgesia and on spontaneous pain, combined inactive doses of trazodone and gabapentin restored in CCI rats innate behaviors that are strongly reduced or even abolished during persistent nociception, suggesting that the combination may have an impact also on pain components different from somatosensory perception. Our results support the development of a trazodone and gabapentin low doses combination product for optimal multimodal analgesia treatment.

Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes

PURPOSE

Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment.

METHODS

Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP.

RESULTS

Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up.

CONCLUSIONS

Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

van de Loo A, Veldstra JL, de Waard D, C. Verster J, A. Brookhuis K, Ramaekers JG. Driving performance and neurocognitive skills of long-term users of sedating antidepressants

OBJECTIVE

To assess driving performance and neurocognitive skills of long-term users of sedating antidepressants, in comparison to healthy controls.

METHODS

Thirty-eight long-term (>6 months) users of amitriptyline (n = 13) and mirtazapine (n = 25) were compared to 65 healthy controls. Driving performance was assessed using a 1-h standardised highway driving test in actual traffic, with road-tracking error (standard deviation of lateral position [SDLP]) being the primary measure. Secondary measures included neurocognitive tasks related to driving. Performance differences between groups were compared to those of blood alcohol concentrations of 0.5 mg/ml to determine clinical relevance.

RESULTS

Compared to controls, mean increase in SDLP of all antidepressant users was not significant, nor clinically relevant (+0.75 cm, 95% CI: -0.83 cm; +2.33 cm). However, users treated less than 3 years (n = 20) did show a significant and clinically relevant increase in SDLP (+2.05 cm). No significant effects were observed on neurocognitive tasks for any user group, although large individual differences were present. Most results from neurocognitive tests were inconclusive, while a few parameters confirmed non-inferiority for users treated longer than 3 years.

CONCLUSION

The impairing effects of antidepressant treatment on driving performance and neurocognition mitigate over time following long-term use of 3 years.

Status of Analgesic Drugs and Quality of Life Results for Diabetic Peripheral Neuropathy in China

OBJECTIVE

The purpose of this study is to describe the current clinical situation of patients with painful diabetic peripheral neuropathy (DPN) and related anxiety, depression, and the quality of life of patients in mainland China, and to report the current status of the use of analgesics.

METHODS

Between June 15, 2021, and October 15, 2021, a total of 401 participants participated in the study. Recruitment was carried out using a multi-level sampling method. Participants' demographics, medical history, analgesic use, Michigan Symptom Score (MNSI), Numerical Rating Scale (NRS) pain score, Patient Health Questionnaire 9 (PHQ-9) score, Generalized Anxiety Disorder 7 (GAD) -7) Score, quality of life score (SF-12) and diabetes treatment status were collected.

RESULTS

Among the participants, there were 236 male patients and female patients. Participants were 322 patients over 40 years old. Regarding the use of analgesics: 132 patients reported using analgesics, 221 patients reported not using analgesics, and 48 patients reported having used analgesics. The results of the scale showed that the scores of NRS, GAD-7, PHQ-9 and SF-12 were 5.12 ± 2.15, 6.33 ± 3.67, 8.46 ± 4.07 and 47.84 ± 19.92 for patients who used analgesics, Compared with patients who did not use analgesics (NRS: 1.99 ± 1.7, GAD-7: 1.81 ± 2.81, PHQ-9: 3.13 ± 4.10, SF-12: 78.34 ± 21.66) there are significant differences (p< 0.001). In addition, patients' NRS scores are also closely related to GAD-7, PHQ-9 and SF-12 scores.

CONCLUSION

The severity of symptoms, mental status and quality of life of patients who used analgesics were more severe than those of patients who did not use analgesics. Pregabalin is still the preferred analgesic for patients with painful DPN, and the use of opioids in my country is extremely low, which is consistent with current international guidelines. Age, diabetic duration, DPN duration, PHQ-9 score, GAD-7 score and SF-12 scores are closely related to NRS pain scores. In addition, there are still a considerable number of patients who have not used analgesics due to financial burdens and other reasons, suggesting that China still has insufficient pain management in DPN patients.

Short-chain fatty acids contribute to neuropathic pain via regulating microglia activation and polarization

Microglia activation and subsequent pro-inflammatory responses play a key role in the development of neuropathic pain. The process of microglia polarization towards pro-inflammatory phenotype often occurs during neuroinflammation. Recent studies have demonstrated an active role for the gut microbiota in promoting microglial full maturation and inflammatory capabilities via the production of Short-Chain Fatty Acids (SCFAs). However, it remains unclear whether SCFAs is involved in pro-inflammatory/anti-inflammatory phenotypes microglia polarization in the neuropathic pain. In the present study, chronic constriction injury (CCI) was used to induce neuropathic pain in mice, the mechanical withdrawal threshold, thermal hyperalgesia were accomplished. The levels of microglia markers including ionized calcium-binding adaptor molecule 1 (Iba1), cluster of differentiation 11b (CD11b), pro-inflammatory phenotype markers including CD68, interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), and anti-inflammatory phenotype markers including CD206, IL-4 in the hippocampus and spinal cord were determined on day 21 after CCI. The results showed that CCI produced mechanical allodynia and thermal hyperalgesia, and also increased the expressions of microglia markers (Iba1, CD11b) and pro-inflammatory phenotype markers (CD68, IL-1β, and TNF-α), but not anti-inflammatory phenotype marker (CD206, IL-4) in the hippocampus and spinal cord, accompanied by increased SCFAs in the gut. Notably, antibiotic administration reversed these abnormalities, and its effects was also bloked by SCFAs administration. In conclusion, data from our study suggest that CCI can lead to mechanical and thermal hyperalgesia, while SCFAs play a key role in the pathogenesis of neuropathic pain by regulating microglial activation and subsequent pro-inflammatory phenotype polarization. Antibiotic administration may be a new treatment for neuropathic pain by reducing the production of SCFAs and further inhibiting the process of microglia polarization.

Advances in the interventional management of neuropathic pain

The management of neuropathic pain, defined as pain as a result of a lesion or disease in the somatosensory nervous system, continues to be researched and explored. As conventional methods demonstrate limited long-term efficacy, there is a significant need to discover therapies that offer both longitudinal and sustained management of this highly prevalent disease, which can be offered through interventional therapies. Tricyclic antidepressants (TCAs), gabapentinoids, lidocaine, serotonin norepinephrine reuptake inhibitors (SNRIs), and capsaicin have been shown to be the most efficacious pharmacologic agents for neuropathic pain relief. With respect to infusion therapies, the use of intravenous (IV) ketamine could be useful for complex regional pain syndrome, fibromyalgia, and traumatic spinal cord injury. Interventional approaches such as lumbar epidurals are a reasonable treatment choice for up to 3 months of pain relief for patients who failed to respond to conservative treatment, with a “B” strength of recommendation and moderate certainty. Neuroablative procedures like pulsed radiofrequency ablation work by delivering electrical field and heat bursts to targeted nerves or tissues without permanently damaging these structures, and have been recently explored for neuropathic pain relief. Alternatively, neuromodulation therapy is now recommended as the fourth line treatment of neuropathic pain after failed pharmacological therapy but prior to low dose opioids. Finally, the intrathecal delivery of various pharmacologic agents, such as quinoxaline-based kappa-opioid receptor agonists, can be utilized for neuropathic pain relief. In this review article, we aim to highlight advances and novel methods of interventional management of neuropathic pain.

Conductive Hydrogel for a Photothermal-Responsive Stretchable Artificial Nerve and Coalescing with a Damaged Peripheral Nerve

Modern development of flexible electronics has made use of bioelectronic materials as artificial tissue in vivo. As hydrogels are more similar to nerve tissue, functional hydrogels have become a promising candidate for bioelectronics. Meanwhile, interfacing functional hydrogels and living tissues is at the forefront of bioelectronics. The peripheral nerve injury often leads to paralysis, chronic pain, neurologic disorders, and even disability, because it has affected the bioelectrical signal transmission between the brain and the rest of body. Here, a kind of light-stimuli-responsive and stretchable conducting polymer hydrogel (CPH) is developed to explore artificial nerve. The conductivity of CPH can be enhanced when illuminated by near-infrared light, which can promote the conduction of the bioelectrical signal. When CPH is mechanically elongated, it still has high durability of conductivity and, thus, can accommodate unexpected strain of nerve tissues in motion. Thereby, CPH can better serve as an implant of the serious peripheral nerve injury in vivo, especially in the case that the length of the missing nerve exceeds 10 mm.

Long noncoding RNA GAS5 ameliorates chronic constriction injury induced neuropathic pain in rats by modulation of the miR-452-5p/CELF2 axis

Neuropathic pain is a type of spontaneous pain that causes damage to the central nervous system. Long noncoding RNAs (lncRNAs) participate in the progression of various nervous system diseases, including neuropathic pain. However, the biological function of GAS5 in neuropathic pain remains unclear. Our findings revealed that GAS5 was downregulated in chronic constriction injury (CCI) rats. Besides, ELISA showed that the concentration of IL-6, TNF-α, and IL-1β were reduced by overexpressed GAS5 in spinal cord homogenates of CCI rats. Moreover, mechanical allodynia and thermal hyperalgesia in CCI rats were inhibited by GAS5 overexpression, suggesting that GAS5 overexpression attenuated neuropathic pain. Subsequently, we found that GAS5 served as a sponge for miR-452-5p in CCI rats and CELF2 was the downstream target of miR-452-5p. Finally, through a rescue assay, we found that GAS5 ameliorated neuropathic pain in CCI rats by sponging miR-452-5p to regulate CELF2 expression. Our study confirmed that GAS5 ameliorated neuropathic pain in rats by modulation of the miR-452-5p/CELF2 axis, which may provide some clues for neuropathic pain treatment.

Pain Modulation in WAG/Rij Epileptic Rats (A Genetic Model of Absence Epilepsy): Effects of Biological and Pharmacological Histone Deacetylase Inhibitors

Epigenetic mechanisms are involved in epilepsy and chronic pain development. About that, we studied the effects of the natural histone deacetylase (HDAC) inhibitor sodium butyrate (BUT) in comparison with valproic acid (VPA) in a validated genetic model of generalized absence epilepsy and epileptogenesis. WAG/Rij rats were treated with BUT (30 mg/kg), VPA (300 mg/kg), and their combination (BUT + VPA) daily per os for 6 months. Rats were subjected at Randall–Selitto, von Frey, hot plate, and tail flick tests after 1, 3, and 6 months of treatment to evaluate hypersensitivity to noxious and non-noxiuous stimuli. Moreover, PPAR-γ (G3335 1 mg/kg), GABA-B (CGP35348 80 mg/kg), and opioid (naloxone 1 mg/kg) receptor antagonists were administrated to investigate the possible mechanisms involved in analgesic activity. The expression of NFkB, glutathione reductase, and protein oxidation (carbonylation) was also evaluated by Western blot analysis. WAG/Rij rats showed an altered pain threshold throughout the study (p < 0.001). BUT and BUT + VPA treatment reduced hypersensitivity (p < 0.01). VPA was significantly effective only after 1 month (p < 0.01). All the three receptors are involved in BUT + VPA effects (p < 0.001). BUT and BUT + VPA decreased the expression of NFkB and enhanced glutathione reductase (p < 0.01); protein oxidation (carbonylation) was reduced (p < 0.01). No effect was reported with VPA. In conclusion BUT, alone or in coadministration with VPA, is a valuable candidate for managing the epilepsy-related persistent pain.

Pain burden, sensory profile and inflammatory cytokines of dogs with naturally-occurring neuropathic pain treated with gabapentin alone or with meloxicam

Canine neuropathic pain (NeuP) has been poorly investigated. This study aimed to evaluate the pain burden, sensory profile and inflammatory cytokines in dogs with naturally-occurring NeuP. Twenty-nine client-owned dogs with NeuP were included in a prospective, partially masked, randomized crossover clinical trial, and treated with gabapentin/placebo/gabapentin-meloxicam or gabapentin-meloxicam/placebo/gabapentin (each treatment block of 7 days; total 21 days). Pain scores, mechanical (MNT) and electrical (ENT) nociceptive thresholds and descending noxious inhibitory controls (DNIC) were assessed at baseline, days 7, 14, and 21. DNIC was evaluated using ΔMNT (after-before conditioning stimulus). Positive or negative ΔMNT corresponded to inhibitory or facilitatory pain profiles, respectively. Pain scores were recorded using the Client Specific Outcome Measures (CSOM), Canine Brief Pain Inventory (CBPI), and short-form Glasgow Composite Measure Pain Scale (CMPS-SF). Data from baseline were compared to those of sixteen healthy controls. ΔMNT, but not MNT and ENT, was significantly larger in controls (2.3 ± 0.9 N) than in NeuP (-0.2 ± 0.7 N). The percentage of dogs with facilitatory sensory profile was similar at baseline and after placebo (61.5–63%), and between controls and after gabapentin (33.3–34.6%). The CBPI scores were significantly different between gabapentin (CBPI _pain and CBPI _{overall impression}) and/or gabapentin-meloxicam (CBPI _pain and _interference) when compared with baseline, but not placebo. The CBPI scores were not significantly different between placebo and baseline. The concentration of cytokines was not different between groups or treatments. Dogs with NeuP have deficient inhibitory pain mechanisms. Pain burden was reduced after gabapentin and/or gabapentin-meloxicam when compared with baseline using CBPI and CMPS-SF scores. However, these scores were not superior than placebo, nor placebo was superior to baseline evaluations. A caregiver placebo effect may have biased the results.

Dihydromyricetin attenuates neuropathic pain via enhancing the transition from M1 to M2 phenotype polarization by potentially elevating ALDH2 activity in vitro and vivo

Background

Treatment for neuropathic pain as a refractory disease remains unsatisfactory and represents a significant clinical challenge. A highly effective drug is thus urgently needed for neuropathic pain treatment. Dihydromyricetin (DMY) is a flavonoid with a wide range of biological activities. The purpose of this research is to explore the effects of DMY on neuropathic pain and the underlying mechanism of its effect.

Methods

The effect of DMY was investigated in BV-2 cells and lipopolysaccharide (LPS)-induced BV-2 cells. A neuropathic pain model was established via spared nerve injury (SNI) surgery in mice, and the protein expression level was detected via Western blot assay. The percent of M1 and M2 phenotype polarization cells were detected via flow cytometry assay. Immunochemical staining assay was also performed to measure the marker levels of the M1 and M2 phenotype polarization cells and aldehyde dehydrogenase 2 (ALDH2) level, and mechanical pain sensitivity was evaluated via measurement of the mechanical withdrawal threshold.

Results

We found that DMY promoted the transition from M1 to M2 polarization and upregulated the ALDH2 level in vitro and vitro. ALDA-1, an ALDH2 agonist, promoted the switching from M1 to M2 polarization in vivo and vitro. DMY alleviated pain hypersensitivity induced by SNI via enhancing M2 phenotype polarization by elevating ALDH2 activity in mice. After DMY- or ALDA-1-microglia were injected into SNI-induced pain hypersensitive mice, the mechanical withdrawal threshold was increased significantly when compared with the SNI group.

Conclusions

Our data demonstrated that DMY alleviated neuropathic pain via enhancing the polarization transition from the M1 to M2 phenotype by potentially elevating ALDH2 activity in vitro and vivo. DMY- or ALDA-1-microglia may have alleviative effects on neuropathic pain. The findings herein provide a promising avenue for neuropathic pain treatment, suggesting a new target, ALDH2, in the treatment of neuropathic pain.

Analysis of Crucial Genes and Pathways Associated with Spared Nerve Injury-Induced Neuropathic Pain

Purpose. The study was aimed at elucidating the molecular mechanism underlying neuropathic pain induced by spared nerve injury (SNI). Methods. The microarray data of GSE30691 were downloaded from the Gene Expression Omnibus database, including sciatic nerve lesion samples at 3, 7, 21, and 40 days after SNI and sham control samples at 3, 7, and 21 days. Differential analysis along with Mfuzz clustering analysis was performed to screen crucial clusters and cluster genes. Subsequently, comprehensive bioinformatic analyses were performed, including functional enrichment analysis, protein-protein interaction (PPI) network and module analysis, and transcription factor- (TF-) gene and miRNA-target interaction predictions. Moreover, the screened differentially expressed genes (DEGs) were corroborated using two other microarray datasets. Results. Three clusters with different change trends over time after SNI were obtained. Protein kinase CAMP-activated catalytic subunit beta (Prkacb), complement C3 (C3), and activating transcription factor 3 (Atf3) were hub nodes in the PPI network, and fibroblast growth factor 9 (Fgf9) was found to interact with more TFs. Prkacb and Fgf9 were significantly enriched in the MAPK signaling pathway. Moreover, rno-miR-3583-5p was targeted by Fgf9, and rno-miR-1912-3p was targeted by neuregulin 1 (Nrg1). Key genes like Nrg1 and Fgf9 in cluster 1, Timp1 in cluster 2, and Atf3 and C3 in cluster 3 were screened out after corroborating microarray data with other microarray data. Conclusions. Key pathways like the MAPK signaling pathway and crucial genes like Prkacb, Nrg1, Fgf9, Timp1, C3, and Atf3 may contribute to SNI-induced neuropathic pain development in rats.

CXCL10/CXCR3 Signaling in the DRG Exacerbates Neuropathic Pain in Mice

Chemokines and receptors have been implicated in the pathogenesis of chronic pain. Here, we report that spinal nerve ligation (SNL) increased CXCR3 expression in dorsal root ganglion (DRG) neurons, and intra-DRG injection of Cxcr3 shRNA attenuated the SNL-induced mechanical allodynia and heat hyperalgesia. SNL also increased the mRNA levels of CXCL9, CXCL10, and CXCL11, whereas only CXCL10 increased the number of action potentials (APs) in DRG neurons. Furthermore, in Cxcr3^-/- mice, CXCL10 did not increase the number of APs, and the SNL-induced increase of the numbers of APs in DRG neurons was reduced. Finally, CXCL10 induced the activation of p38 and ERK in ND7-23 neuronal cells and DRG neurons. Pretreatment of DRG neurons with the P38 inhibitor SB203580 decreased the number of APs induced by CXCL10. Our data indicate that CXCR3, activated by CXCL10, mediates p38 and ERK activation in DRG neurons and enhances neuronal excitability, which contributes to the maintenance of neuropathic pain.

Mesenchymal Stem Cells Transplantation for Neuropathic Pain Induced By Peripheral Nerve Injury in Animal Models: A Systematic Review

Neuropathic pain is defined as a lesion or disease of the somatosensory system, currently remaining a challenging condition to treat. Mesenchymal stem cells (MSCs) transplantation is emerging as a promising strategy to alleviate the neuropathic pain conditions induced by peripheral nerve injury. The aim of this systematic review was to assess the efficacy and safety of MSCs transplantation in neuropathic pain induced by peripheral nerve injury in controlled animal studies, and thus to yield evidence-based decision making. Following the PRISMA guidelines, PubMed, Cochrane Central Library, Embase, and CINAHL were searched for preclinical controlled animal studies from the inception to April 16, 2020. Seventeen studies are included in this review. Substantial heterogeneity is observed regarding the animal's species, models of neuropathic pain, regimen of MSCs transplantation, and outcome of measures across the included studies. Both mechanical allodynia and thermal hyperalgesia could be significantly attenuated by transplanted MSCs. The MSCs-elicited analgesic effect is independent of the type of MSCs, time of administration, and route of delivery, and is efficiently enhanced by genetic transfection with fibroblast growth factor, proenkephalin, and glial cell line-derived neurotrophic factor. The migration of MSCs after intrathecal or intravenous injection has been shown to be directed toward the surface of dorsal spinal cord or dorsal root ganglions on the ipsilateral side of injury. No adverse effects have been reported. The accumulating evidence demonstrates the therapeutic effect of MSCs-based cell therapy on prevention and alleviation of the neuropathic pain induced by peripheral nerve injury in rat or mouse models. The robust preclinical studies are deserved to optimize the regimen of MSCs transplantation and to promote the translation of the MSCs-based therapy into clinical studies.

Investigating the Multitarget Mechanism of Traditional Chinese Medicine Prescription for Cancer-Related Pain by Using Network Pharmacology and Molecular Docking Approach

Gu-tong formula (GTF) has achieved good curative effects in the treatment of cancer-related pain. However, its potential mechanisms have not been explored. We used network pharmacology and molecular docking to investigate the molecular mechanism and the effective compounds of the prescription. Through the analysis and research in this paper, we obtained 74 effective compounds and 125 drug-disease intersection targets to construct a network, indicating that quercetin, kaempferol, and β-sitosterol were possibly the most important compounds in GTF. The key targets of GTF for cancer-related pain were Jun proto-oncogene (JUN), mitogen-activated protein kinase 1 (MAPK1), and RELA proto-oncogene (RELA). 2204 GO entries and 148 pathways were obtained by GO and KEGG enrichment, respectively, which proved that chemokine, MAPK, and transient receptor potential (TRP) channels can be regulated by GTF. The results of molecular docking showed that stigmasterol had strong binding activity with arginine vasopressin receptor 2 (AVPR2) and C-X3-C motif chemokine ligand 1 (CX3CL1) and cholesterol was more stable with p38 MAPK, prostaglandin-endoperoxide synthase 2 (PTGS2), and transient receptor potential vanilloid-1 (TRPV1). In conclusion, the therapeutic effect of GTF on cancer-related pain is based on the comprehensive pharmacological effect of multicomponent, multitarget, and multichannel pathways. This study provides a theoretical basis for further experimental research in the future.

Diabetic polyneuropathy with/out neuropathic pain in Mali: A cross-sectional study in two reference diabetes treatment centers in Bamako (Mali), Western Africa

INTRODUCTION

Diabetic polyneuropathy (DPN) with or without neuropathic pain is a frequent complication of diabetes. This work aimed to determine the prevalence of diabetic polyneuropathy, to describe its epidemiological aspects, and to analyze the therapeutic itinerary of patients with DPN.

METHODS

This was a cross-sectional, descriptive study performed synchronously over six months at two major follow-up sites for patients with diabetes in Mali. DPN was diagnosed based on the Michigan Neuropathy Screening Instrument (MNSI). The neuropathic nature of the pain and the quality of life of patients were evaluated by the DN4 and the ED-5D scale, respectively. We used three (3) different questionnaires to collect data from patients (one at inclusion and another during the follow-up consultation) and from the caregivers of patients with DPN.

RESULTS

We included 252 patients with diabetes, and DPN was found to have a healthcare facility-based prevalence of 69.8% (176/252). The sex ratio was approximately three females for every male patient. The patients were mostly 31 to 60 years of age, 83% had type 2 diabetes, and 86.9% had neuropathic pain Approximately half of the patients (48.3%) had autonomic neuropathy and they reported moderate to intense pain, which was mainly described as a burning sensation. The patients exhibited impaired exteroceptive and proprioceptive sensations in 51.7% of cases. The patients smoked tobacco in 3.4% of cases, while 36.6% of the patients were obese and had dyslipidemia. The caregivers clearly indicated that appropriate medications were not readily accessible or available for their patients with DPN.

CONCLUSION

The healthcare facility-based prevalence of DPN with or without neuropathic pain was high in our cohort. These inexpensive and easy-to-use tools (MNSI, DN4) can be used to adequately diagnose DPN in the African context. In Mali, screening and early treatment of patients at risk of DPN should allow for a reduction of the burden of the disease, while caregivers need to be adequately trained to manage DPN.

The Safety of Medications used to Treat Peripheral Neuropathic Pain, Part 2 (Opioids, Cannabinoids and Other Drugs): review of Double-Blind, Placebo-Controlled, Randomized Clinical Trials

INTRODUCTION

Peripheral neuropathic pain is a disabling condition for patients and a challenge for physicians. Although many drugs have been assessed in scientific studies, few have demonstrated clear clinical efficacy against neuropathic pain. Moreover, the paucity of data regarding their safety raises the question of the benefit-risk ratio when used in patients experiencing peripheral neuropathies.

AREAS COVERED

We conducted a review of double-blind, placebo-controlled, randomized clinical trials to assess the safety of medications used to treat peripheral neuropathic pain. This second review was focused on opioids, cannabinoids, and other medications. The aim was to provide an overview of the treatment-emergent adverse events (TEAEs) (≥10%) and the serious adverse effects described in clinical trials.

EXPERT OPINION

Opioids and cannabinoids had significantly more TEAEs than placebos. Locally administered analgesics, such as capsaicin, lidocaine, botulinum toxin A seemed to have the most acceptable safety with only local adverse effects. The results for NMDA antagonists were inconclusive since no safety report was available. Less than half of the studies included presented a good description of TEAEs that included a statistical comparison versus a placebo group. Major methodological improvements must be made to ameliorate the assessment of medication safety in future clinical trials.

Spezielle Schmerztherapie bei rheumatischen Erkrankungen

Schmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.

Clinical indicators to identify neuropathic pain in low back related leg pain: a modified Delphi study

BACKGROUND

Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain.

METHODS

A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated.

RESULTS

Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants.

CONCLUSIONS

Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made.

Long Noncoding RNA H19 Induces Neuropathic Pain by Upregulating Cyclin-Dependent Kinase 5-Mediated Phosphorylation of cAMP Response Element Binding Protein

Objective

Neuropathic pain (NP) is a debilitating condition caused by nervous system injury and chronic diseases. LncRNA H19 is upregulated in many human diseases, including NP. Cyclin-dependent kinase 5 (CDK5) aggressively worsens inflammatory action and nerve damage to cause severe NP. Phosphorylated cAMP response element binding protein (CREB) is detrimental to nerves and promotes NP progression. Herein, aim of our study was to assess the mechanism of lncRNA H19.

Methods

The NP rat model was established using chronic constriction injury (CCI). Paw withdrawal threshold (PWT) tests and paw withdrawal latency (PWL) tests were performed. Then, small interfering (si)RNA against H19 was intrathecally injected into rats to suppress H19 expression. Schwann cells were isolated from NP rats and transfected with siRNA-H19 or a lentivirus (LV)-based vector expressing H19. Inflammatory factors and glial fibrillary acidic protein (GFAP) were detected. Western blot analysis was conducted to detect CDK5/p35 and p-CREB expression. Finally, H19, CDK5 and CREB phosphorylation were tested with the combination of the CDK5 inhibitor roscovitine and transfection of LV-H19 and siRNA-H19. Finally, we investigated the binding relationships between H19 and miR-196a-5p and between miR-196a-5p and CDK5 and detected the mRNA expression of miR-196a-5p and CDK5 in rats with H19 knockdown and in Schwann cells with H19 knockdown.

Results

Highly expressed H19, CDK5/p-35 and p-CREB were observed in NP rats, accompanied by obviously decreased PWT and PWL, upregulated inflammatory factors and GFAP levels, and reduced 5-HT_2A and GABA_B2 expression. siRNA-H19 restored NP-related indexes and downregulated CDK5/p35 and p-CREB phosphorylation. siRNA-H19, together with the CDK5 inhibitor roscovitine, reduced CDK5 and p-CREB expression in Schwann cells isolated from NP rats. Binding sites between H19 and miR-196a-5p and between miR-196a-5p and CDK5 were identified. Silencing H19 upregulated miR-196a-5p expression and downregulated CDK5 levels.

Conclusion

Our study demonstrated that silencing H19 inhibited NP by suppressing CDK5/p35 and p-CREB phosphorylation via the miR-196a-5p/CDK5 axis, which may provide new insight into NP treatment.

Gut microbiota regulates neuropathic pain: potential mechanisms and therapeutic strategy

Neuropathic pain (NP) is a sustained and nonreversible condition characterized by long-term devastating physical and psychological damage. Therefore, it is urgent to identify an effective treatment for NP. Unfortunately, the precise pathogenesis of NP has not been elucidated. Currently, the microbiota-gut-brain axis has drawn increasing attention, and the emerging role of gut microbiota is investigated in numerous diseases including NP. Gut microbiota is considered as a pivotal regulator in immune, neural, endocrine, and metabolic signaling pathways, which participates in forming a complex network to affect the development of NP directly or indirectly. In this review, we conclude the current understanding of preclinical and clinical findings regarding the role of gut microbiota in NP and provide a novel therapeutic method for pain relief by medication and dietary interventions.

Gabapentin for presumed neuropathic ocular pain

Purpose

To report a case of chronic neuropathic ocular pain in a patient without visual complaints.

Observations

A 37-year-old male with a history of bilateral laser-assisted in situ keratomileusis (LASIK) presented with pain symptoms of 8 months duration in the left eye. The prior LASIK surgery was complicated by corneal ectasia in the left eye requiring penetrating keratoplasty and subsequent placement of a glaucoma drainage implant for uncontrolled, elevated intraocular pressure. The patient was evaluated with a complete clinical examination, including Goldmann applanation tonometry, dilated fundus examination, fluorescein angiography, optical coherence tomography, and magnetic resonance imaging. After 3 weeks of treatment with gabapentin 300 mg BID, the patient reported complete resolution of the ocular pain.

Conclusions and Importance

The pathophysiology of neuropathic ocular pain remains poorly understood. Clinical evaluation often reveals minimal ophthalmic exam findings, leading to an underdiagnosis of the condition by ophthalmologists. Gabapentin may be an underutilized medication in the treatment of chronic ocular pain.

Novel Agents in Neuropathic Pain, the Role of Capsaicin: Pharmacology, Efficacy, Side Effects, Different Preparations

PURPOSE OF REVIEW

Capsaicin is a natural substance used to treat neuropathic pain because of its ability to be used in a more direct form on patients and efficiently treat their pain without the amount of side effects seen in the use of oral medications.

RECENT FINDINGS

Currently, the treatments for neuropathic pain are, control of the underlying disease process, then focused on symptomatic relief with pharmacotherapy, topical analgesics, or other interventions. When all pharmacological agents fail to relieve the pain, interventional strategies can be considered, such as neural blocks, spinal cord stimulation, and intrathecal administered medications. The response to current treatment of neuropathic pain is only modest relief of symptoms. Multiple treatment options may be attempted, while ultimately leaving patients with refractory neuropathic pain. For these reasons, a better treatment approach to neuropathic pain is greatly needed. Overall, capsaicin has great potential for becoming a first- or second-line treatment for neuropathic pain, and for becoming a therapeutic option for many other neuropathic pain-related disease states.

Phospholipase A2 Inhibitor-Loaded Phospholipid Micelles Abolish Neuropathic Pain

Treating persistent neuropathic pain remains a major clinical challenge. Current conventional treatment approaches carry a substantial risk of toxicity and provide only transient pain relief. In this work, we show that the activity and expression of the inflammatory mediator secretory phospholipase-A₂ (sPLA₂) enzyme increases in the spinal cord after painful nerve root compression. We then develop phospholipid micelle-based nanoparticles that release their payload in response to sPLA₂ activity. Using a rodent model of neuropathic pain, phospholipid micelles loaded with the sPLA₂ inhibitor, thioetheramide-PC (TEA-PC), are administered either locally or intravenously at the time of painful injury or 1-2 days afterward. Local micelle administration immediately after compression prevents pain for up to 7 days. Delayed intravenous administration of the micelles attenuates existing pain. These findings suggest that sPLA₂ inhibitor-loaded micelles can be a promising anti-inflammatory nanotherapeutic for neuropathic pain treatment.

Neuropathic Pain: the Dysfunction of Drp1, Mitochondria, and ROS Homeostasis

Neuropathic pain affects the physical and mental health status of patients. Due to its complex pathogenesis and the adverse reactions to medicines, its treatment remains challenging. Among all the etiologies, increasing evidence has pointed to mitochondrial dysfunction. Dynamin-related protein 1 (Drp1)-mediated mitochondrial fragmentation leads to excess ROS generation, which is implicated in the pathogenesis of neuropathic pain. However, the exact mechanism remains unclear. Studies aiming to clarify the possible pathway and relationship between Drp1, mitochondria, ROS, and neuropathic pain may identify a good treatment for neuropathic pain in the clinic. As shown in this review, dysfunction of Drp1 and ROS homeostasis plays essential roles in neuropathic pain. We summarized a Drp1-mitochondrial fission-ROS cycle that potentially functions in neuropathic pain and is regulated by posttranslational modifications and Ca²⁺. Additionally, we further enumerated six Drp1 inhibitors, including Mdivi-1, P110, Drp1 antisense oligodeoxynucleotides, hyperbaric oxygen, melatonin, and β-hydroxybutyrate, as potential treatments, with the aim of providing guidance for novel molecules to be used in the clinic.

The role of P2X4 receptors in chronic pain: A potential pharmacological target

Chronic pain is a common symptom of most clinical diseases, which seriously affects the psychosomatic health of patients and brings some pain to patients. Due to its pathological mechanism is very complicated and the treatment of chronic pain has always been a difficult problem in clinical. Normally, drugs are usually used to relieve pain, but the analgesic effect is not good, especially for cancer pain patients, the analgesic effect is poor. Therefore, exploring the pathogenesis and treatment of chronic pain has aroused the interest of many researchers. A large number of studies have shown that the role of ATP and P2X4 receptor (P2X4R) play an important role in the pathogenesis of chronic pain. P2X4R is dependent on ATP ligand-gated ion channel receptor, which can be activated by ATP and plays an important role in the information transmission of nerve system and the formation of pain. Therefore, in this paper, we comprehensively described the structure and biological functions of P2X4R, and outlined behavioral evaluation methods of chronic pain models. Moreover, we also explored the inherent relationship between P2X4R and chronic pain, and described the therapeutic effect of P2X4R antagonist on chronic pain, and provided some valuable help for the treatment of chronic pain.

Long-term postoperative pain evaluation in dogs with thoracolumbar intervertebral disk herniation after hemilaminectomy

BACKGROUND

Chronic neuropathic pain is a common complication in people with spinal cord injury (SCI) but has not been investigated in dogs.

OBJECTIVE

To determine the reliability of measuring spinal mechanical sensory thresholds (MSTs) in dogs and to compare MSTs of healthy dogs and dogs with SCI caused by acute thoracolumbar intervertebral disk extrusion after hemilaminectomy over a 1-year period.

STUDY DESIGN

Prospective study.

ANIMALS

Thirty-two healthy and 40 SCI dogs.

METHODS

Dogs were divided into group 1 (healthy Dachshunds), group 2 (healthy dogs including several breeds), and SCI group. The MSTs were measured using algometry at an incision (thoracolumbar) and control site. Dogs in group 1 were tested once; those in group 2 were tested for 5 consecutive days; and SCI dogs were tested on days 7, 14, 28, 42, 180, and 365 postoperatively. The MSTs were compared among days in healthy and SCI dogs and between SCI and healthy dogs using mixed effect models. P < .05 was considered significant.

RESULTS

At the incision site of SCI dogs, MST was significantly lower than in healthy dogs for 42 days postoperatively, but not subsequently. However, 4/27 dogs had control site MST below the reference range 1 year after surgery.

CONCLUSIONS AND CLINICAL IMPORTANCE

Mechanical sensory thresholds normalize by 6 months after surgery in most dogs with SCI. Approximately 15% of SCI dogs may develop chronic neuropathic pain. Improving long-term pain assessment of SCI dogs is important for offering treatment options and advising owners.

Exploring the role and mechanisms of diallyl trisulfide and diallyl disulfide in chronic constriction-induced neuropathic pain in rats

Background

Garlic oil is a rich source of organosulfur compounds including diallyl disulfide and diallyl trisulfide. There have been studies showing the neuroprotective actions of these organosulfur compounds. However, the potential of these organosulfur compounds in neuropathic pain has not been explored. The present study was aimed at investigating the pain attenuating potential of diallyl disulfide and diallyl trisulfide in chronic constriction injury (CCI)-induced neuropathic pain in rats. The study also explored their pain-attenuating mechanisms through modulation of H₂S, brain-derived neurotrophin factor (BDNF) and nuclear factor erythroid 2-related factor 2 (Nrf2).

Methods

The rats were subjected to CCI injury by ligating the sciatic nerve in four places. The development of neuropathic pain was measured by assessing mechanical hyperalgesia (Randall–Selittotest), mechanical allodynia (Von Frey test), and cold allodynia (acetone drop test) on 14th day after surgery.

Results

Administration of diallyl disulfide (25 and 50 mg/kg) and diallyl trisulfide (20 and 40 mg/kg) for 14 days led to a significant reduction in pain in CCI-subjected rats. Moreover, treatment with these organosulfur compounds led to the restoration of H₂S, BDNF and Nrf2 levels in the sciatic nerve and dorsal root ganglia. Co-administration of ANA-12 (BDNF blocker) abolished pain attenuating actions as well as BDNF and the Nrf2 restorative actions of diallyl disulfide and diallyl trisulfide, without modulating H₂S levels.

Conclusions

Diallyl disulfide and diallyl trisulfide have the potential to attenuate neuropathic pain in CCI-subjected rats possibly through activation of H₂S-BDNF-Nrf2 signaling pathway.

Three-Year Outcomes After Dorsal Root Ganglion Stimulation in the Treatment of Neuropathic Pain After Peripheral Nerve Injury of Upper and Lower Extremities

OBJECTIVES

Traumatic peripheral nerve injuries (PNI) often result in severe neuropathic pain which typically becomes chronic, is recalcitrant to common analgesics, and is associated with sleep disturbances, anxiety, and depression. Pharmacological treatments proven to be effective against neuropathic pain are not well tolerated due to side effects. Neuromodulative interventions such as peripheral nerve or spinal cord stimulation have generated mixed results and may be limited by reduced somatotopic specificity. Dorsal root ganglion (DRG) stimulation may be more effective in this etiology.

MATERIALS AND METHODS

Twenty-seven patients were trialed with a DRG neurostimulation system for PNI; trial success (defined as ≥50% pain relief) was 85%, and 23 patients received a permanent stimulator. However, 36-month outcome data was only available for 21 patients. Pain, quality of life, mental and physical function, and opioid usage were assessed at baseline and at 3-, 6-, 12-, 18-, 24-, and 36 months post-permanent implant. Implant-related complications were also documented.

RESULTS

Compared to baseline, we observed a significant pain relief (p < 0.001) at 3 (58%), 12 (66%), 18 (69%), 24 (71%), and 36 months (73%) in 21 patients (52.5 ± 14.2 years; 12 female), respectively. Mental and physical function showed immediate and sustained improvements. Participants reported improvements in quality of life. Opioid dosage reduced significantly (p < 0.001) at 3 (30%), 12 (93%), 18 (98%), 24 (99%), and 36 months (99%), and 20 of 21 patients were completely opioid-free after 36 months. There were five lead migrations and two electrode fractures (corrected by surgical intervention) and one wound infection (conservatively managed).

CONCLUSIONS

DRG neuromodulation appears to be a safe, effective, and durable option for treating neuropathic pain caused by PNI. The treatment allows cessation of often ineffective pharmacotherapy (including opioid misuse) and significantly improves quality of life.

Identification of the Hub Genes Related to Nerve Injury-Induced Neuropathic Pain

Background

The reactivity enhancement of pain sensitive neurons in the nervous system is a feature of the pathogenesis for neuropathic pain (NP), yet the underlying mechanisms need to be fully understood. In this study, we made an attempt to clarify the NP-related hub genes and signaling pathways so as to provide effective diagnostic and therapeutic methods toward NP.

Methods

Microarray expression profile GSE30691 including the mRNA-seq data of the spared nerve injury (SNI)-induced NP rats was accessed from the GEO database. Then, genes associated with NP development were screened using differential analysis along with random walk with restart (RWR). GO annotation and KEGG pathway analyses were performed to explore the biological functions and signaling pathways where the genes were activated. Afterward, protein-protein interaction (PPI) analysis and GO analysis were conducted to further identify the hub genes which showed an intimate correlation with NP development.

Results

Totally 94 genes associated with NP development were screened by differential analysis and RWR analysis, and they were observed to be predominantly enriched in hormone secretion and transport, cAMP signaling pathway and other NP occurrence associated functions and pathways. Thereafter, the 94 genes were subjected to PPI analysis to find the genes much more associated with NP and a functional module composed of 48 genes were obtained. 8 hub genes including C3, C1qb, Ccl2, Cxcl13, Timp1, Fcgr2b, Gal, and Lyz2 were eventually identified after further association and functional enrichment analyses, and the expression of these 8 genes were all higher in SNI rats by comparison with those in Sham rats.

Conclusion

Based on the data collected from GEO database, this study discovered 8 hub genes that were closely related to NP occurrence and development, which help to provide potent theoretical basis for NP treatment.

Ketamine induces rapid and sustained antidepressant-like effects in chronic pain induced depression: Role of MAPK signaling pathway

Chronic pain produces psychologic distress, which often leads to mood disorders such as depression. Co-existing chronic pain and depression pose a serious socio-economic burden and result in disability affecting millions of individuals, which urges the development of treatment strategies targeting this comorbidity. Ketamine, a noncompetitive antagonist of the N-methyl-d-aspartate (NMDA) receptor, is shown to be efficient in treating both pain and depression-related symptoms. However, the molecular characteristics of its role in chronic pain-induced depression remain largely unexplored. Hence, we studied the behavioral and molecular effects of a single systemic administration of ketamine (15 mg/kg, i.p.) on mechanical hypersensitivity and depressive-like consequences of chronic neuropathic pain. We showed that ketamine transiently alleviated mechanical hypersensitivity (lasting <24 h), while its antidepressant effect was observed even 72 h after administration. In addition, ketamine normalized the upregulated expression of the mitogen activated protein kinase (MAPK) phosphatase 1 (MKP-1) and the downregulated phosphorylation of extracellular signal-regulated kinase (pERK) in the anterior cingulate cortex (ACC) of mice displaying neuropathic pain-induced depressive-like behaviors. This effect of ketamine on the MKP-1 was first detected 30 min after the ketamine administration and persisted until up to 72 h. Altogether, these findings provide insight into the behavioral and molecular changes associated with single ketamine administration in the comorbidity of chronic pain and depression.

Using RNA-Seq to Explore the Repair Mechanism of the Three Methods and Three-Acupoint Technique on DRGs in Sciatic Nerve Injured Rats

Objective

To study the effects of the three methods and three-acupoint technique on DRG gene expression in SNI model rats and to elucidate the molecular mechanism of the three methods and three-acupoint technique on promoting recovery in peripheral nerve injury.

Methods

27 male SD rats were randomly divided into three groups: a Sham group, the SNI group, and the Tuina group. The Tuina group was treated with a tuina manipulation simulator to simulate massage on points, controlling for both quality and quantity. Point-pressing, plucking, and kneading methods were administered quantitatively at Yinmen (BL37), Chengshan (BL57), and Yanglingquan (GB34) points on the affected side once a day, beginning 7 days after modeling. Intervention was applied once a day for 10 days, then 1 day of rest, followed by 10 more days of intervention, totally equaling 20 times of intervention. The effect of the three methods and three-point technique on the recovery of injured rats was evaluated using behavior analysis. RNA sequencing (RNA-Seq) analysis of differentially expressed genes in DRGs of the three groups of rats was also performed. GO and KEGG enrichment was analyzed and verified using real-time PCR.

Results

RNA-Seq combined with database information showed that the number of differentially expressed genes in DRG was the largest in the Tuina group compared with the SNI group, totaling 226. GO function is enriched in the positive regulation of cell processes, ion binding, protein binding, neuron, response to pressure, response to metal ions, neuron projection, and other biological processes. GO function is also enriched in the Wnt, IL-17, and MAPK signaling pathways in the KEGG database. PCR results were consistent with those of RNA sequencing, suggesting that the results of transcriptome sequencing were reliable.

Conclusion

The three methods and three-acupoint technique can promote the recovery of SNI model rats by altering the gene sequence in DRGs.

Evidence of new-onset depression among persons with migraine after discontinuing antidepressants

Antidepressants have been hypothesized to cause tardive dysphoria-the delayed development of negative emotional symptoms. We assessed the risk of tardive dysphoria in a cohort of persons with migraine taking anti-migraine antidepressants with no known diagnosis of any mood or anxiety disorder. We included all outpatient encounters in a university hospital system for migraine from January 2008 through October 2018, excluding subjects with prior psychiatric diagnoses. Kaplan-Meier survival curves and multivariable Cox proportional hazards analyses were conducted. 13,048 subjects were included; 1191 took an antidepressant; 402 discontinued an antidepressant. In multivariable analyses examining the first year after exposure, antidepressant use was not significantly associated with risk of a depression, any mood disorder (including depression, mania, and other mood disorders), or anxiety. Antidepressant discontinuation was significantly associated with increased risk of depression, but not any mood disorder or anxiety. Among persons with migraine with no known psychiatric diagnosis, antidepressants did not appear to be associated with indicators of tardive dysphoria. Antidepressant discontinuation, however, was associated with increased risk of a depression diagnosis.

Comparison of the use of opioids only and pregabalin add-on for the treatment of neuropathic pain in cervical myelopathy patients: a pilot trial

Among patients with cervical myelopathy who were diagnosed with neuropathic pain (NP) by the LANSS test, the study participants were randomly assigned to one of the two study groups. The participants in one study group received opioids only, while those in the other group received opioids and pregabalin. Thirty-nine patients were analyzed in the study (20 patients in the opioid-only group and 19 in the pregabalin add-on group). The LANSS, neck pain, and arm pain scores in the pregabalin add-on group improved significantly compared with those in the opioid-only group after the first 4 weeks (p = 0.005, 0.001 and 0.035, respectively), but there was no significant difference between the two groups during the next 4 weeks (p = 0.615, 0.377 and 0.716, respectively). There was no significant difference in the neck disability index and EuroQol-5Dimension scores after four weeks and eight weeks of follow-up. Adverse events were reported by four patients (20.0%) in the opioid-only group and five patients (26.3%) in the pregabalin add-on group (p = 0.716). However, over time, the occurrence of side effects and dropouts increased in the pregabalin add-on group. This exploratory pilot study suggests that pregabalin add-on treatment is more efficient than the use of opioids alone at the beginning of NP treatment in cervical myelopathy patients. However, prescribing pregabalin add-on treatment for more than four weeks should be done cautiously.

The role of P2X4 receptor in neuropathic pain and its pharmacological properties

Neuropathic pain (NPP) is a common symptom of most diseases in clinic, which seriously affects the mental health of patients and brings certain pain to patients. Due to its pathological mechanism is very complicated, and thus, its treatment has been one of the challenges in the field of medicine. Therefore, exploring the pathogenesis and treatment approach of NPP has aroused the interest of many researchers. ATP is an important energy information substance, which participates in the signal transmission in the body. The P2 × 4 receptor (P2 × 4R) is dependent on ATP ligand-gated cationic channel receptor, which can be activated by ATP and plays an important role in the transmission of information in the nervous system and the formation of pain. In this paper, we provide a comprehensive review of the structure and function of the P2 × 4R gene. We also discuss the pathogenesis of NPP and the intrinsic relationship between P2 × 4R and NPP. Moreover, we explore the pharmacological properties of P2 × 4R antagonists or inhibitors used as targeted therapies for NPP.

Opioids in Older Adults: Indications, Prescribing, Complications, and Alternative Therapies for Primary Care

The fact that opioids are valuable tools for the management of pain has been known and used for thousands of years. Currently, millions of Americans are treated annually with opioids, and many of these patients are elderly. Opioids present risks to geriatric patients, some of which are unique to the population, and providers should have a good grasp of those risks. An understanding of how to select appropriate medications for the management of pain and of the myriad of alternatives available for pain management is vital to the care of older patients. This article presents a review, for primary care providers, of issues unique to opioid management in older adults.

Evaluation of Treatment Patterns and Direct Costs Associated with the Management of Neuropathic Pain

Background

Neuropathic pain has a prevalence of 2-17% in the general population. Diagnosis and treatment of neuropathic pain are not fully described in different populations. The aim was to determine the treatment patterns and direct costs of care associated with the management of neuropathic pain from the onset of the first symptom to up to two years after diagnosis.

Methods

From a drug-claim database, a cohort of randomly selected outpatients diagnosed with neuropathic pain was obtained from an insurer in Colombia and followed up for two years after diagnosis. The clinical records were reviewed individually to identify the study variables, including the time needed to make the diagnosis, the medical and paraclinical resources used, the pharmacological therapy for pain management, and the direct costs associated with care.

Results

We identified 624 patients in 49 cities, with a mean age of 50.3 ± 14.1 years, of which 324 were men (51.9%). An average of 90 days passed from the initial consultation until the diagnosis of neuropathic pain, the most frequent being lumbosacral radiculopathy (57.9%). 34.5% of the cohort had at least one diagnostic imaging procedure, and 16% had an electromyography. On average, they were treated by a general practitioner twice. 91.7% received initial treatment with tramadol, carbamazepine, amitriptyline, imipramine, or pregabalin, and 60.4% received combined therapy. The mean cost of care for two years for each patient was US$246.3.

Conclusions

Patients with neuropathic pain in Colombia are being diagnosed late, are using therapeutic agents not recommended as first-line treatment by clinical practice guidelines, and are being treated for short periods of time.

Bone-Marrow-Derived Mononuclear Cells Relieve Neuropathic Pain after Spinal Nerve Injury in Mice

Treating neuropathic pain is a critical clinical issue. Although numerous therapies have been proposed, effective treatments have not been established. Therefore, safe and feasible treatment methods are urgently needed. In this study, we investigated the therapeutic effects of autologous intrathecal administration of bone-marrow-derived mononuclear cells (MNCs) on neuropathic pain. We generated a mouse model of neuropathic pain by transecting the spinal nerve and evaluated neuropathic pain by measuring the mechanical threshold in the following 14 days. Mice in the MNC injection group had a higher mechanical threshold than those in the buffer group. We assessed the effect of MNC treatment on the dorsal root ganglia and spinal cord by immunohistochemistry, mRNA expression, and cytokine assay. The migration and accumulation of microglia were significantly suppressed in the MNC group, and the mRNA expression of inflammatory cytokines such as interleukin (IL)-6, IL-1β, and tumor necrosis factor alpha (TNF-α) was markedly downregulated. Furthermore, MNC administration tended to suppress various cytokines in the cerebrospinal fluid of the model mice. In conclusion, our results suggest that intrathecal injection of MNCs relieves neuropathic pain and might be a promising cell therapy for the treatment of this condition.