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Ganesh R, Munipalli B. Long COVID and hypermobility spectrum disorders have shared pathophysiology. Front Neurol 2024; 15:1455498. [PMID: 39301475 PMCID: PMC11410636 DOI: 10.3389/fneur.2024.1455498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 08/02/2024] [Indexed: 09/22/2024] Open
Abstract
Hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) are the most common joint hypermobility conditions encountered by physicians, with hypermobile and classical EDS accounting for >90% of all cases. Hypermobility has been detected in up to 30-57% of patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, postural orthostatic tachycardia syndrome (POTS), and long COVID (LC) compared to the general population. Extrapulmonary symptoms, including musculoskeletal pain, dysautonomia disorders, cognitive disorders, and fatigue, are seen in both LC and HSD. Additionally, ME/CFS has overlapping symptoms with those seen in HSD. Mast cell activation and degranulation occurring in both LC and ME/CFS may result in hyperinflammation and damage to connective tissue in these patients, thereby inducing hypermobility. Persistent inflammation may result in the development or worsening of HSD. Hence, screening for hypermobility and other related conditions including fibromyalgia, POTS, ME/CFS, chronic pain conditions, joint pain, and myalgia is essential for individuals experiencing LC. Pharmacological treatments should be symptom-focused and geared to a patient's presentation. Paced exercise, massage, yoga, and meditation may also provide benefits.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Bala Munipalli
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, United States
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2
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Liedtke W. [Additional experience with medicinal treatment of trigeminal nerve pain]. Schmerz 2024:10.1007/s00482-024-00820-2. [PMID: 39141098 DOI: 10.1007/s00482-024-00820-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 08/15/2024]
Affiliation(s)
- Wolfgang Liedtke
- US Facial Pain Association, 7778 McGinnis Ferry Road, 30024, Suwanee, GA, USA.
- Department of Neurology, Anesthesiology and Neurobiology, Duke University, Durham, NC, USA.
- Department of Molecular Pathobiology - Dental Pain Research, New York University, College of Dentistry, New York, NY, USA.
- New York University, Pain Research Center, New York, NY, USA.
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3
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Clauw DJ. From fibrositis to fibromyalgia to nociplastic pain: how rheumatology helped get us here and where do we go from here? Ann Rheum Dis 2024:ard-2023-225327. [PMID: 39107083 DOI: 10.1136/ard-2023-225327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/16/2024] [Indexed: 08/09/2024]
Abstract
Rheumatologists and rheumatology have had a prominent role in the conceptualisation of nociplastic pain since the prototypical nociplastic pain condition is fibromyalgia. Fibromyalgia had been previously known as fibrositis, until it became clear that this condition could be differentiatied from autoimmune disorders because of a lack of systemic inflammation and tissue damage. Nociplastic pain is now thought to be a third descriptor/mechanism of pain, in addition to nociceptive pain (pain due to peripheral damage or inflammation) and neuropathic pain. Nociplastic pain can occur in isolation, or as a co-morbidity with other mechanisms of pain, as commonly occurs in individuals with autoimmune disorders. We now know that the cardinal symptoms of nociplastic pain are widespread pain (or pain in areas not without evidence of inflammation/damage), accompanied by fatigue, sleep and memory issues. There is objective evidence of amplification/augmentation of pain, as well as of non-painful stimuli such as the brightness of lights and unpleasantness of sound or odors. Nociplastic pain states can be triggered by a variety of stressors such as trauma, infections and chronic stressors. Together these features suggest that the central nervous system (CNS) is playing a major role in causing and maintaining nociplastic pain, but these CNS factors may in some be driven by ongoing peripheral nociceptive input. The most effective drug therapies for nociplastic pain are non-opioid centrally acting analgesics such as tricyclics, serotonin-norepinephrine reuptake inhibitors and gabapentinoids. However the mainstay of therapy of nociplastic pain is the use of a variety of non-pharmacological integrative therapies, especially those which improve activity/exercise, sleep and address psychological co-morbidities.
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Affiliation(s)
- Daniel J Clauw
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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4
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Pogue J, Johnson D, Burch A. A Utilization Review of Patients That Respond to Low-Dose Naltrexone (LDN) for Chronic Pain at a Single Institution. J Pain Palliat Care Pharmacother 2024:1-8. [PMID: 38836814 DOI: 10.1080/15360288.2024.2358941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/20/2024] [Indexed: 06/06/2024]
Abstract
Studies have demonstrated the benefits of LDN for various pain indications. This review describes the utilization of and response to LDN in patients with chronic pain within the William S. Middleton Memorial Veterans Hospital (Madison VA). This was a retrospective, single center, chart review of patients that were prescribed LDN for chronic pain. The primary outcome, change in subjective pain report via numeric rating scale (NRS), was analyzed through Wilcoxon Signed Rank Test and descriptive statistics. A total of 136 participants were included. Patients had an average pain score of 7.1 per NRS at baseline. At the initial follow up visit, participants had an average pain of 6.4 (p < 0.001). Additionally, 17.1% of patients had a greater than or equal to 30% pain reduction from baseline. At subsequent follow up, patients reported an average pain of 5.5 (p < 0.0001) per NRS. At the end of the study, 31.6% of patients were maintained on LDN at an average dose of 3.8 mg. This retrospective review demonstrated that LDN may be an effective modality for some chronic pain indications. Reported pain scores were significantly lower at initial follow up compared to baseline for the total population, and for patients with fibromyalgia (FM) specifically.
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Affiliation(s)
- Joshua Pogue
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Diane Johnson
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Andrew Burch
- Salisbury VA Health Care System, Salisbury, NC, USA
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Kaplan CM, Kelleher E, Irani A, Schrepf A, Clauw DJ, Harte SE. Deciphering nociplastic pain: clinical features, risk factors and potential mechanisms. Nat Rev Neurol 2024; 20:347-363. [PMID: 38755449 DOI: 10.1038/s41582-024-00966-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 05/18/2024]
Abstract
Nociplastic pain is a mechanistic term used to describe pain that arises or is sustained by altered nociception, despite the absence of tissue damage. Although nociplastic pain has distinct pathophysiology from nociceptive and neuropathic pain, these pain mechanisms often coincide within individuals, which contributes to the intractability of chronic pain. Key symptoms of nociplastic pain include pain in multiple body regions, fatigue, sleep disturbances, cognitive dysfunction, depression and anxiety. Individuals with nociplastic pain are often diffusely tender - indicative of hyperalgesia and/or allodynia - and are often more sensitive than others to non-painful sensory stimuli such as lights, odours and noises. This Review summarizes the risk factors, clinical presentation and treatment of nociplastic pain, and describes how alterations in brain function and structure, immune processing and peripheral factors might contribute to the nociplastic pain phenotype. This article concludes with a discussion of two proposed subtypes of nociplastic pain that reflect distinct neurobiological features and treatment responsivity.
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Affiliation(s)
- Chelsea M Kaplan
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Eoin Kelleher
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Anushka Irani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Division of Rheumatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Andrew Schrepf
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Steven E Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
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Sarzi-Puttini P, Giorgi V, Sirotti S, Bazzichi L, Lucini D, Di Lascio S, Pellegrino G, Fornasari D. Pharmacotherapeutic advances in fibromyalgia: what's new on the horizon? Expert Opin Pharmacother 2024; 25:999-1017. [PMID: 38853631 DOI: 10.1080/14656566.2024.2365326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION This review delves into Fibromyalgia Syndrome (FMS), a chronic pain condition demanding thorough understanding for precise diagnosis and treatment. Yet, a definitive pharmacological solution for FMS remains elusive. AREAS COVERED In this article, we systematically analyze various pharmacotherapeutic prospects for FMS treatment, organized into sections based on the stage of drug development and approval. We begin with an overview of FDA-approved drugs, discussing their efficacy in FMS treatment. Next, we delve into other medications currently used for FMS but still undergoing further study, including opioids and muscle relaxants. Further, we evaluate the evidence behind medications that are currently under study, such as cannabinoids and naltrexone. Lastly, we explore new drugs that are in phase II trials. Our research involved a thorough search on PUBMED, Google Scholar, and clinicaltrials.gov. We also discuss the action mechanisms of these drugs and their potential use in specific patient groups. EXPERT OPINION A focus on symptom-driven, combination therapy is crucial in managing FMS. There is also a need for ongoing research into drugs that target neuroinflammation, immunomodulation, and the endocannabinoid system. Bridging the gap between benchside research and clinical application is challenging, but it holds potential for more targeted and effective treatment strategies.
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Affiliation(s)
- Piercarlo Sarzi-Puttini
- Rheumatology Unit, IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Valeria Giorgi
- Unità di Ricerca Clinica, Gruppo Ospedaliero Moncucco, Lugano, Switzerland
| | - Silvia Sirotti
- Rheumatology Unit, IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
| | - Laura Bazzichi
- Rheumatology Unit, IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
| | - Daniela Lucini
- BIOMETRA Department, University of Milan, Milan, Italy
- IRCCS Istituto Auxologico Italiano, Exercise Medicine Unit, Milan, Italy
| | - Simona Di Lascio
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
| | - Greta Pellegrino
- Rheumatology Unit, IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
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Sasso EM, Muraki K, Eaton-Fitch N, Smith P, Jeremijenko A, Griffin P, Marshall-Gradisnik S. Investigation into the restoration of TRPM3 ion channel activity in post-COVID-19 condition: a potential pharmacotherapeutic target. Front Immunol 2024; 15:1264702. [PMID: 38765011 PMCID: PMC11099221 DOI: 10.3389/fimmu.2024.1264702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 04/09/2024] [Indexed: 05/21/2024] Open
Abstract
Introduction Recently, we reported that post COVID-19 condition patients also have Transient Receptor Potential Melastatin 3 (TRPM3) ion channel dysfunction, a potential biomarker reported in natural killer (NK) cells from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients. As there is no universal treatment for post COVID-19 condition, knowledge of ME/CFS may provide advances to investigate therapeutic targets. Naltrexone hydrochloride (NTX) has been demonstrated to be beneficial as a pharmacological intervention for ME/CFS patients and experimental investigations have shown NTX restored TRPM3 function in NK cells. This research aimed to: i) validate impaired TRPM3 ion channel function in post COVID-19 condition patients compared with ME/CFS; and ii) investigate NTX effects on TRPM3 ion channel activity in post COVID-19 condition patients. Methods Whole-cell patch-clamp was performed to characterize TRPM3 ion channel activity in freshly isolated NK cells of post COVID-19 condition (N = 9; 40.56 ± 11.26 years), ME/CFS (N = 9; 39.33 ± 9.80 years) and healthy controls (HC) (N = 9; 45.22 ± 9.67 years). NTX effects were assessed on post COVID-19 condition (N = 9; 40.56 ± 11.26 years) and HC (N = 7; 45.43 ± 10.50 years) where NK cells were incubated for 24 hours in two protocols: treated with 200 µM NTX, or non-treated; TRPM3 channel function was assessed with patch-clamp protocol. Results This investigation confirmed impaired TRPM3 ion channel function in NK cells from post COVID-19 condition and ME/CFS patients. Importantly, PregS-induced TRPM3 currents were significantly restored in NTX-treated NK cells from post COVID-19 condition compared with HC. Furthermore, the sensitivity of NK cells to ononetin was not significantly different between post COVID-19 condition and HC after treatment with NTX. Discussion Our findings provide further evidence identifying similarities of TRPM3 ion channel dysfunction between ME/CFS and post COVID-19 condition patients. This study also reports, for the first time, TRPM3 ion channel activity was restored in NK cells isolated from post COVID-19 condition patients after in vitro treatment with NTX. The TRPM3 restoration consequently may re-establish TRPM3-dependent calcium (Ca2+) influx. This investigation proposes NTX as a potential therapeutic intervention and TRPM3 as a treatment biomarker for post COVID-19 condition.
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Affiliation(s)
- Etianne Martini Sasso
- The National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Consortium Health International for Myalgic Encephalomyelitis, National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD, Australia
| | - Katsuhiko Muraki
- Consortium Health International for Myalgic Encephalomyelitis, National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Laboratory of Cellular Pharmacology, School of Pharmacy, Aichi-Gakuin University, Nagoya, Japan
| | - Natalie Eaton-Fitch
- The National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Consortium Health International for Myalgic Encephalomyelitis, National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Peter Smith
- Consortium Health International for Myalgic Encephalomyelitis, National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Clinical Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Andrew Jeremijenko
- The National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Consortium Health International for Myalgic Encephalomyelitis, National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Paul Griffin
- Department of Medicine and Infectious Diseases, Mater Hospital and Mater Medical Research Institute, Brisbane, QLD, Australia
| | - Sonya Marshall-Gradisnik
- The National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- Consortium Health International for Myalgic Encephalomyelitis, National Centre for Neuroimmunology and Emerging Diseases, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
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Green M, Veltri CA, Grundmann O. Nalmefene Hydrochloride: Potential Implications for Treating Alcohol and Opioid Use Disorder. Subst Abuse Rehabil 2024; 15:43-57. [PMID: 38585160 PMCID: PMC10999209 DOI: 10.2147/sar.s431270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/16/2024] [Indexed: 04/09/2024] Open
Abstract
Nalmefene hydrochloride was first discovered as an opioid antagonist derivative of naltrexone in 1975. It is among the most potent opioid antagonists currently on the market and is differentiated from naloxone and naltrexone by its partial agonist activity at the kappa-opioid receptor which may benefit in the treatment of alcohol use disorder. Oral nalmefene has been approved in the European Union for treatment of alcohol use disorder since 2013. As of 2023, nalmefene is available in the United States as an intranasal spray for reversal of opioid overdose but is not approved for alcohol or opioid use disorder as a maintenance treatment. The substantially longer half-life of nalmefene and 5-fold higher binding affinity to opioid receptors makes it a superior agent over naloxone in the reversal of high potency synthetic opioids like fentanyl and the emerging nitazenes. Nalmefene presents with a comparable side effect profile to other opioid antagonists and should be considered for further development as a maintenance treatment for opioid and other substance use disorders.
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Affiliation(s)
- MeShell Green
- College of Pharmacy, Department of Pharmaceutical Sciences, Midwestern University, Glendale, AZ, USA
| | - Charles A Veltri
- College of Pharmacy, Department of Pharmaceutical Sciences, Midwestern University, Glendale, AZ, USA
| | - Oliver Grundmann
- College of Pharmacy, Department of Pharmaceutical Sciences, Midwestern University, Glendale, AZ, USA
- College of Pharmacy, Department of Medicinal Chemistry, University of Florida, Gainesville, FL, USA
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Klifto KM, Hultman CS. Pain Management in Burn Patients: Pharmacologic Management of Acute and Chronic Pain. Clin Plast Surg 2024; 51:267-301. [PMID: 38429049 DOI: 10.1016/j.cps.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Burn-related pain can contribute to decreased quality of life and long-term morbidity, limiting functional recovery. Burn-related pain should be assessed first by chronicity (acute or chronic), followed by type (nociceptive, neuropathic, nociplastic), to guide multimodal pharmacologic management in a stepwise algorithm approach. Combination therapies increase the efficacy and reduce toxicity by offering a multimodal approach that targets different receptors in the peripheral nervous system and central nervous system. When multimodal pharmacologic management is ineffective, etiologies of burn-related pain amenable to surgical interventions must be considered. It is important to know when to refer a patient to pain management.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri Health Care, 1 Hospital Drive, Columbia, MO 65212, USA.
| | - C Scott Hultman
- Department of Plastic and Reconstructive Surgery, WPP Plastic and Reconstructive Surgery, WakeMed Health and Hospitals, 3000 New Bern Avenue, Raleigh, NC 27610, USA
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10
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N Irwin M, A Cooke D, Berland D, D Marshall V, A Smith M. Efficacy and Safety of Low Dose Naltrexone for Chronic Pain. J Pain Palliat Care Pharmacother 2024; 38:13-19. [PMID: 38301136 DOI: 10.1080/15360288.2024.2302550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 12/28/2023] [Indexed: 02/03/2024]
Abstract
Naltrexone is a mu-opioid receptor antagonist increasingly used as an analgesic for chronic pain at low doses. This retrospective, observational cohort study was conducted at an academic medical center to evaluate low-dose naltrexone (LDN) efficacy and describe its use in routine clinical practice. Adults receiving LDN, doses <10 mg for ≥1 month, seen at an outpatient pain clinic from January 1, 2014 to April 1, 2022 were included. The primary outcome was change in the Pain, Enjoyment of Life, and General Activity (PEG) score after LDN. Thirty-one patients were included. Median age was 50 years and 71% were female. Median duration of pain at baseline was 5 years. Mean PEG scores were 7.27 ± 1.39 and 6.62 ± 2.04 at baseline and follow-up, respectively. Mean difference was 0.66 (95% CI [0.10-1.21], p = 0.022). Eighty-seven percent (27) of patients discontinued LDN, 52% (16) for lack of benefit, 23% (7) for loss of benefit, 10% (3) for side effects, and 3% (1) for other reasons. Seven (23%) reported side effects. LDN was associated with a statistically significant reduction in PEG in adult chronic pain patients, however the clinical significance is unclear as over 75% of patients discontinued LDN due to lack of benefit.
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Affiliation(s)
- Madison N Irwin
- Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- University of Michigan Health Department of Pharmacy, Ann Arbor, Michigan, USA
| | - David A Cooke
- University of Michigan Health System, Division of General Medicine, Ann Arbor, Michigan, USA
| | - Daniel Berland
- University of Michigan Health System, Division of General Medicine, Ann Arbor, Michigan, USA
| | - Vincent D Marshall
- Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Michael A Smith
- Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- University of Michigan Health Department of Pharmacy, Ann Arbor, Michigan, USA
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11
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Tsui JI, Rossi SL, Cheng DM, Bendiks S, Vetrova M, Blokhina E, Winter M, Gnatienko N, Backonja M, Bryant K, Krupitsky E, Samet JH. Pilot RCT comparing low-dose naltrexone, gabapentin and placebo to reduce pain among people with HIV with alcohol problems. PLoS One 2024; 19:e0297948. [PMID: 38408060 PMCID: PMC10896547 DOI: 10.1371/journal.pone.0297948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 01/10/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND To estimate the effects on pain of two medications (low-dose naltrexone and gabapentin) compared to placebo among people with HIV (PWH) with heavy alcohol use and chronic pain. METHODS We conducted a pilot, randomized, double-blinded, 3-arm study of PWH with chronic pain and past-year heavy alcohol use in 2021. Participants were recruited in St. Petersburg, Russia, and randomized to receive daily low-dose naltrexone (4.5mg), gabapentin (up to 1800mg), or placebo. The two primary outcomes were change in self-reported pain severity and pain interference measured with the Brief Pain Inventory from baseline to 8 weeks. RESULTS Participants (N = 45, 15 in each arm) had the following baseline characteristics: 64% male; age 41 years (SD±7); mean 2 (SD±4) heavy drinking days in the past month and mean pain severity and interference were 3.2 (SD±1) and 3.0 (SD±2), respectively. Pain severity decreased for all three arms. Mean differences in change in pain severity for gabapentin vs. placebo, and naltrexone vs. placebo were -0.27 (95% confidence interval [CI] -1.76, 1.23; p = 0.73) and 0.88 (95% CI -0.7, 2.46; p = 0.55), respectively. Pain interference decreased for all three arms. Mean differences in change in pain interference for gabapentin vs. placebo, and naltrexone vs. placebo was 0.16 (95% CI -1.38, 1.71; p = 0.83) and 0.40 (95% CI -1.18, 1.99; p = 0.83), respectively. CONCLUSION Neither gabapentin nor low-dose naltrexone appeared to improve pain more than placebo among PWH with chronic pain and past-year heavy alcohol use. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT4052139).
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Affiliation(s)
- Judith I. Tsui
- Department of Medicine, Division of General Internal Medicine University of Washington School of Medicine/Harborview Medical Center, Seattle, Washington, United States of America
| | - Sarah L. Rossi
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, Massachusetts, United States of America
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, Unites States of America
| | - Sally Bendiks
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, Massachusetts, United States of America
| | | | | | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, Massachusetts, United States of America
| | - Miroslav Backonja
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Kendall Bryant
- HIV/AIDS Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Evgeny Krupitsky
- Pavlov University, St. Petersburg, Russian Federation
- Department of Addictions, V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, St. Petersburg, Russian Federation
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine/Boston Medical Center, Clinical Addiction Research and Education (CARE) Unit, Boston, Massachusetts, United States of America
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, United States of America
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12
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Seton KA, Espejo-Oltra JA, Giménez-Orenga K, Haagmans R, Ramadan DJ, Mehlsen J. Advancing Research and Treatment: An Overview of Clinical Trials in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Future Perspectives. J Clin Med 2024; 13:325. [PMID: 38256459 PMCID: PMC10816159 DOI: 10.3390/jcm13020325] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/22/2023] [Accepted: 12/30/2023] [Indexed: 01/24/2024] Open
Abstract
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, debilitating, and multi-faceted illness. Heterogenous onset and clinical presentation with additional comorbidities make it difficult to diagnose, characterize, and successfully treat. Current treatment guidelines focus on symptom management, but with no clear target or causative mechanism, remission rates are low, and fewer than 5% of patients return to their pre-morbid activity levels. Therefore, there is an urgent need to undertake robust clinical trials to identify effective treatments. This review synthesizes insights from clinical trials exploring pharmacological interventions and dietary supplements targeting immunological, metabolic, gastrointestinal, neurological, and neuroendocrine dysfunction in ME/CFS patients which require further exploration. Additionally, the trialling of alternative interventions in ME/CFS based on reported efficacy in the treatment of illnesses with overlapping symptomology is also discussed. Finally, we provide important considerations and make recommendations, focusing on outcome measures, to ensure the execution of future high-quality clinical trials to establish clinical efficacy of evidence-based interventions that are needed for adoption in clinical practice.
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Affiliation(s)
- Katharine A. Seton
- Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UQ, UK;
| | - José A. Espejo-Oltra
- Max Delbrück Center for Molecular Medicine, Robert-Rössle-Straße 10, 13125 Berlin, Germany;
- Department of Pathology, School of Health Sciences, Universidad Católica de Valencia, San Vicente Mártir, 46001 Valencia, Spain
| | - Karen Giménez-Orenga
- Escuela de Doctorado, Universidad Católica de Valencia, San Vicente Mártir, 46001 Valencia, Spain;
| | - Rik Haagmans
- Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UQ, UK;
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Donia J. Ramadan
- Department of Medical Genetics, Oslo University Hospital and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway;
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark;
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Due Bruun K, Christensen R, Amris K, Vaegter HB, Blichfeldt-Eckhardt MR, Bye-Møller L, Holsgaard-Larsen A, Toft P. Naltrexone 6 mg once daily versus placebo in women with fibromyalgia: a randomised, double-blind, placebo-controlled trial. THE LANCET. RHEUMATOLOGY 2024; 6:e31-e39. [PMID: 38258677 DOI: 10.1016/s2665-9913(23)00278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Low-dose naltrexone is used to treat fibromyalgia despite minimal evidence for its efficacy. This trial aimed to investigate whether 12-week treatment with 6 mg low-dose naltrexone was superior to placebo for reducing pain in women with fibromyalgia. METHODS We did a single-centre, randomised, double-blind, placebo-controlled trial in Denmark. We enrolled women aged 18-64 years who were diagnosed with fibromyalgia. Participants were randomly assigned 1:1 to receive low-dose naltrexone (6 mg) or an identical-appearing placebo, using a computerised algorithm with no stratifications applied. Participants, investigators, outcome assessors, and statistical analysts were all masked to treatment allocation. The primary outcome was change in pain intensity on an 11-point numeric rating scale from baseline to week 12, in the intention-to-treat population. Safety was assessed in participants in the intention-to-treat population who received at least one dose of their allocated intervention. This trial was registered with ClincalTrials.gov (NCT04270877) and EudraCT (2019-000702-30). FINDINGS We screened 158 participants for eligibility from Jan 6, 2021, to Dec 27, 2022, and 99 patients were randomly assigned to low-dose naltrexone (n=49) or placebo (n=50). The mean age was 50·6 years (SD 8·8), one (1%) of 99 participants was Arctic Asian and 98 (99%) were White. No participants were lost to follow-up. The mean change in pain intensity was -1·3 points (95% CI -1·7 to -0·8) in the low-dose naltrexone group and -0·9 (-1·4 to -0·5) in the placebo group, corresponding to a between-group difference of -0·34 (-0·95 to 0·27; p=0·27, Cohen's d 0·23). Discontinuations due to adverse events were four (8%) of 49 in the low-dose naltrexone group and three (6%) of 50 in the placebo group. 41 (84%) of 49 patients in the low-dose naltrexone group had an adverse event versus 43 (86%) of 50 in the placebo group. One serious adverse event occurred in the placebo group and no deaths occurred. INTERPRETATION This study did not show that treatment with low-dose naltrexone was superior to placebo in relieving pain. Our results indicate that low-dose naltrexone might improve memory problems associated with fibromyalgia, and we suggest that future trials investigate this further. FUNDING The Danish Rheumatism Association, Odense University Hospital, Danielsen's Foundation, and the Oak Foundation.
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Affiliation(s)
- Karin Due Bruun
- Pain Research Group, Pain Center, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
| | - Robin Christensen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Kirstine Amris
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Henrik Bjarke Vaegter
- Pain Research Group, Pain Center, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Rune Blichfeldt-Eckhardt
- Pain Research Group, Pain Center, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Lars Bye-Møller
- Patient Panel, Pain Center, Odense University Hospital, Odense, Denmark
| | - Anders Holsgaard-Larsen
- Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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14
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Henley P, Martins T, Zamani R. Assessing Ethnic Minority Representation in Fibromyalgia Clinical Trials: A Systematic Review of Recruitment Demographics. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7185. [PMID: 38131736 PMCID: PMC10742509 DOI: 10.3390/ijerph20247185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
The under-representation of non-White participants in Western countries in clinical research has received increased attention, due to recognized physiological differences between ethnic groups, which may affect the efficacy and optimal dosage of some treatments. This review assessed ethnic diversity in pharmaceutical trials for fibromyalgia, a poorly understood chronic pain disorder. We also investigated longitudinal change to non-White participant proportions in trials and non-White participants' likelihood to discontinue with fibromyalgia research between trial stages (retention). First, we identified relevant trials conducted in the United States and Canada between 2000 and 2022, by searching PubMed, Web of Science, Scopus, and the Cochrane Library databases. In trials conducted both across the United States and Canada, and exclusively within the United States, approximately 90% of participants were White. A longitudinal analysis also found no change in the proportion of non-White participants in trials conducted across the United States and Canada between 2000 and 2022. Finally, we found no significant differences in trial retention between White and non-White participants. This review highlights the low numbers of ethnic minorities in fibromyalgia trials conducted in the United States and Canada, with no change to these proportions over the past 22 years. Furthermore, non-White participants were not more likely to discontinue with the fibromyalgia research once they were recruited.
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Affiliation(s)
| | | | - Reza Zamani
- Medical School, College of Medicine and Health, University of Exeter, Exeter EX1 2LU, UK (T.M.)
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15
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Jones C, Parkitny L, Strath L, Wagener BM, Barker A, Younger J. Altered response to Toll-like receptor 4 activation in fibromyalgia: A low-dose, human experimental endotoxemia pilot study. Brain Behav Immun Health 2023; 34:100707. [PMID: 38020479 PMCID: PMC10679487 DOI: 10.1016/j.bbih.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 11/06/2023] [Accepted: 11/12/2023] [Indexed: 12/01/2023] Open
Abstract
In this pilot study, a human intravenous injection of low-dose endotoxin (lipopolysaccharide, LPS) model was used to test if fibromyalgia is associated with altered immune responses to Toll-like receptor 4 (TLR4) activation. Eight women with moderately-severe fibromyalgia and eight healthy women were administered LPS at 0.1 ng/kg in session one and 0.4 ng/kg in session two. Blood draws were collected hourly to characterize the immune response. The primary analytes of interest, leptin and fractalkine, were assayed via commercial radioimmunoassay and enzyme-linked immunosorbent assay kits, respectively. Exploratory analyses were performed on 20 secreted cytokine assays by multiplex cytokine panels, collected hourly. Exploratory analyses were also performed on testosterone, estrogen, and cortisol levels, collected hourly. Additionally, standard clinical complete blood counts with differential (CBC-D) were collected before LPS administration and at the end of the session. The fibromyalgia group demonstrated enhanced leptin and suppressed fractalkine responses to LPS administration. In the exploratory analyses, the fibromyalgia group showed a lower release of IFN-γ, CXCL10, IL-17A, and IL-12 and higher release of IL-15, TARC, MDC, and eotaxin than the healthy group. The results of this study suggest that fibromyalgia may involve an altered immune response to TLR4 activation.
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Affiliation(s)
- Chloe Jones
- Department of Psychology, University of Alabama at Birmingham, 1300 University Blvd, Birmingham, AL, 35294, USA
| | - Luke Parkitny
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Neurological Research Institute, Texas Children's Hospital, Houston, TX, USA
| | - Larissa Strath
- Pain Research and Intervention Center of Excellence, The University of Florida, Gainesville, FL, USA
- College of Medicine, Department of Health Outcomes and Biomedical Informatics, The University of Florida, Gainesville, FL, USA
| | - Brant M. Wagener
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew Barker
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jarred Younger
- Department of Psychology, University of Alabama at Birmingham, 1300 University Blvd, Birmingham, AL, 35294, USA
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16
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Rupp A, Young E, Chadwick AL. Low-dose naltrexone's utility for non-cancer centralized pain conditions: a scoping review. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1270-1281. [PMID: 37302106 PMCID: PMC10628981 DOI: 10.1093/pm/pnad074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/24/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND At low doses, naltrexone (LDN) has been shown to modulate inflammation through the interruption of microglial cell activation within the central nervous system. One of the most likely contributors to centralized pain is changes in microglial cell processing. Therefore, it has been postulated that LDN can be used to manage patients with pain resulting from central sensitization due to this relationship. This scoping review aims to synthesize the relevant study data for LDN as a novel treatment strategy for various centralized pain conditions. METHODS A comprehensive literature search was conducted in PubMed, Embase, and Google Scholar, guided by the Scale for Assessment of Narrative Review Articles (SANRA) criteria. RESULTS Forty-seven studies related to centralized pain conditions were identified. Many of the studies were case reports/series and narrative reviews, but a few randomized control trials have been conducted. Overall, the body of evidence revealed improvement in patient-reported pain severity and in outcomes related to hyperalgesia, physical function, quality of life, and sleep. Variability in dosing paradigms and the time to patient response was present in the reviewed studies. CONCLUSIONS Evidence synthesized for this scoping review supports the ongoing use of LDN for the treatment of refractory pain in various centralized chronic pain conditions. Upon review of the currently available published studies, it is apparent that further high-quality, well-powered randomized control trials need to be conducted to establish efficacy, standardization for dosing, and response times. In summary, LDN continues to offer promising results in the management of pain and other distressing symptoms in patients with chronic centralized pain conditions.
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Affiliation(s)
- Adam Rupp
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Erin Young
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Andrea L Chadwick
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS 66160, United States
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17
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Bonilla H, Tian L, Marconi VC, Shafer R, McComsey GA, Miglis M, Yang P, Bonilla A, Eggert L, Geng LN. Low-dose naltrexone use for the management of post-acute sequelae of COVID-19. Int Immunopharmacol 2023; 124:110966. [PMID: 37804660 PMCID: PMC11028858 DOI: 10.1016/j.intimp.2023.110966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 10/09/2023]
Abstract
The global prevalence of Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) stands at approximately 43 % among individuals who have previously had acute COVID-19. In contrast, in the United States, the National Center for Health Statistics (NCHS) estimates that around 11 % of individuals who have been infected with SARS-CoV-2 go on to experience long COVID. The underlying causes of PASC remains under investigation, and there are no currently established FDA-approved therapies. One of the leading hypotheses for the cause of PASC is the persistent activation of innate immune cells with increase systemic inflammation. Naltrexone is a medication with anti-inflammatory and immunomodulatory properties that has been used in other conditions that overlap with PASC. We performed a retrospective review of a clinical cohort of 59 patients at a single academic center who received low-dose naltrexone (LDN) off-label as a potential therapeutic intervention for PASC. The use of LDN was associated with a fewer number of symptoms, improved clinical symptoms (fatigue, post-exertional malaise, unrefreshing sleep, and abnormal sleep pattern), and a better functional status. This observation warrants testing in rigorous, randomized, placebo-controlled clinical trials.
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Affiliation(s)
- Hector Bonilla
- Division of Infectious Diseases & Geographic Medicine, L-134 Stanford University, 300 Pasteur Dr., Palo Alto, CA 94305, United States.
| | - Lu Tian
- Department: Biomedical Data Science, Stanford University, Professor X347 MSOB, Palo Alto, CA 94305, United States
| | - Vincent C Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, United States; Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, United States; Atlanta Veterans Affairs Health Care System, Decatur, GA, United States; Health Sciences Research Building, 1760 Haygood Dr NE, Room W325, Atlanta, GA 30322, United States
| | - Robert Shafer
- Division of Infectious Diseases & Geographic Medicine, Stanford University, 3652 Biomedical Innovations Building, 3rd Floor, Palo Alto, CA 94305, United States
| | - Grace A McComsey
- Department of Pediatrics and Medicine, Case Western Reserve University and University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106, United States
| | - Mitchel Miglis
- Department of Neurology and Neurological Sciences, Stanford University, Stanford University, 213 Quarry Road, Palo Alto, CA 94304, United States
| | - Philip Yang
- Department: Medicine - Med/Cardiovascular Medicine, Stanford University, 300 Pasteur Dr # H2157, Palo Alto, CA 94305-2200, United States
| | - Andres Bonilla
- Department of Molecular, Cell and Developmental Biology, University of Michigan, Ann Arbor, MI, United States
| | - Lauren Eggert
- Division of Pulmonary and Critical Care Medicine, 300 Pasteur Dr Rm H3143 MC 5236, Palo Alto, CA 94305-2200, United States
| | - Linda N Geng
- Department of Medicine - Primary Care and Population Health, Stanford University, 211 Quarry Rd Ste 205 MC 5987, Palo Alto, CA 94304, United States
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Varrassi G, Rekatsina M, Perrot S, Bouajina E, Paladini A, Coaccioli S, Narvaez Tamayo MA, Sarzi Puttini P. Is Fibromyalgia a Fashionable Diagnosis or a Medical Mystery? Cureus 2023; 15:e44852. [PMID: 37809234 PMCID: PMC10560069 DOI: 10.7759/cureus.44852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Despite its prevalence, there is no clear-cut diagnostic path or treatment paradigm for fibromyalgia; this can lead to a multiplicity of symptoms and comorbid conditions that complicate care. "Overlapping symptoms" describe conditions that can occur concomitantly with fibromyalgia and include migraine, irritable bowel syndrome, obesity, and pelvic pain syndromes. A variety of pharmacologic and nonpharmacologic treatments are available for fibromyalgia, but treatment is best personalized for an individual and recognizes potential comorbidities. Opioids are not the recommended front-line treatment, cannabinoids hold promise but with limitations and nonpharmacologic options, such as aerobic or resistance exercise and cognitive behavior therapy, can play a very important but often underestimated role. Amitriptyline appears to be safe and effective in treating six of the main fibromyalgia domains: pain, disturbed sleep, fatigue, affective symptoms, functional limitations, and impaired cognition ("fibro fog"). Very low-dose naltrexone (2.5-4.5 mg) may offer analgesic and anti-inflammatory benefits to fibromyalgia patients, but further studies are needed. Fibromyalgia can be a devastating and debilitating condition for patients, and clinicians are challenged with its diagnosis and treatment as well. Further research as well as compassionate approaches to offering personalized care to those with fibromyalgia are required.
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Affiliation(s)
| | | | | | - Elyse Bouajina
- Rheumatology, Farhat Hached University Hospital Center, Sousse, TUN
| | - Antonella Paladini
- Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
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19
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Poliwoda S, Noss B, Truong GTD, Creech ZA, Koushik SS, Urits I, Viswanath O. The Utilization of Low Dose Naltrexone for Chronic Pain. CNS Drugs 2023; 37:663-670. [PMID: 37505425 DOI: 10.1007/s40263-023-01018-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Abstract
Naltrexone is a mu-opioid receptor antagonist with a long half-life compared with naloxone. Both of these drugs, along with others, were developed with the intention of reversing the effects of opioid abuse or toxicity. Evidence has also shown that naltrexone has a benefit in preventing relapse by reducing opioid cravings and reducing symptoms of opioid withdrawal. The benefits of this drug were not only shown with opioid abuse. In 1984 this drug was also approved for alcohol abuse. Naltrexone has been proven to decrease alcohol relapse by decreasing the craving. Apart from these approved indications for the use of naltrexone, with time, it has been seen that this drug has a benefit in treating chronic pain. A number of studies have shown the benefits of this drug with inflammatory bowel disease, fibromyalgia, multiple sclerosis, diabetic neuropathy, and complex regional pain syndrome, among others. More studies are needed to approve this medication for specific chronic pain conditions.
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Affiliation(s)
- Salomon Poliwoda
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, USA.
| | - Bryant Noss
- Creighton University School of Medicine Phoenix, Phoenix, AZ, USA
| | | | - Zachary A Creech
- Creighton University School of Medicine Phoenix, Phoenix, AZ, USA
| | - Sarang S Koushik
- Department of Anesthesiology and Pain Medicine, Valleywise Health Medical Center, Creighton University School of Medicine Phoenix, Phoenix, AZ, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
- Southcoast Health Physicians Group, Southcoast Health Pain Management, Wareham, MA, USA
| | - Omar Viswanath
- Innovative Pain and Wellness, Scottsdale, AZ, USA
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
- Department of Anesthesiology, Creighton University School of Medicine, Phoenix, AZ, USA
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20
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Bendiks S, Cheng DM, Blokhina E, Vetrova M, Verbitskaya E, Gnatienko N, Bryant K, Krupitsky E, Samet JH, Tsui JI. Pilot study of tolerability and safety of opioid receptor antagonists as novel therapies for chronic pain among persons living with HIV with past year heavy drinking: a randomized controlled trial. AIDS Care 2023; 35:1191-1200. [PMID: 33682527 PMCID: PMC8421451 DOI: 10.1080/09540121.2021.1896663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03278886.
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Affiliation(s)
- Sally Bendiks
- Department of Medicine, Section of General Internal Medicine,
Boston Medical Center, Clinical Addiction Research and Education (CARE)
Unit, Boston, MA, USA
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public
Health, Boston, MA,USA
| | - Elena Blokhina
- First Pavlov State Medical University of St. Petersburg, St.
Petersburg, Russian Federation
| | - Marina Vetrova
- First Pavlov State Medical University of St. Petersburg, St.
Petersburg, Russian Federation
| | - Elena Verbitskaya
- First Pavlov State Medical University of St. Petersburg, St.
Petersburg, Russian Federation
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine,
Boston Medical Center, Clinical Addiction Research and Education (CARE)
Unit, Boston, MA, USA
| | - Kendall Bryant
- HIV/AIDS Research, National Institute on Alcohol Abuse and
Alcoholism, National Institutes of Health, Bethesda, MD, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical University of St. Petersburg, St.
Petersburg, Russian Federation; Department of Addictions, V.M. Bekhterev
National Medical Research Center for Psychiatry and Neurology, St.
Petersburg, Russian Federation
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine,
Boston University School of Medicine/Boston Medical Center, Clinical
Addiction Research and Education (CARE) Unit, Boston, MA, USA; Department of
Community Health Sciences, Boston University School of Public Health,
Boston, MA, USA
| | - Judith I. Tsui
- Department of Medicine, Division of General Internal Medicine,
University of Washington/Harborview Medical Center, Seattle, WA, USA
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21
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Bested K, Jensen LM, Andresen T, Tarp G, Skovbjerg L, Johansen TS, Schmedes AV, Storgaard IK, Madsen JS, Werner MU, Bendiksen A. Low-dose naltrexone for treatment of pain in patients with fibromyalgia: a randomized, double-blind, placebo-controlled, crossover study. Pain Rep 2023; 8:e1080. [PMID: 38226027 PMCID: PMC10789452 DOI: 10.1097/pr9.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/26/2023] [Accepted: 04/15/2023] [Indexed: 01/17/2024] Open
Abstract
Introduction Fibromyalgia (FM) is a chronic fluctuating, nociplastic pain condition. Naltrexone is a µ-opioid-receptor antagonist; preliminary studies have indicated a pain-relieving effect of low-dose naltrexone (LDN) in patients with FM. The impetus for studying LDN is the assumption of analgesic efficacy and thus reduction of adverse effects seen from conventional pharmacotherapy. Objectives First, to examine if LDN is associated with analgesic efficacy compared with control in the treatment of patients with FM. Second, to ascertain the analgesic efficacy of LDN in an experimental pain model in patients with FM evaluating the competence of the descending inhibitory pathways compared with controls. Third, to examine the pharmacokinetics of LDN. Methods The study used a randomized, double-blind, placebo-controlled, crossover design and had a 3-phase setup. The first phase included baseline assessment and a treatment period (days -3 to 21), the second phase a washout period (days 22-32), and the third phase a baseline assessment followed by a treatment period (days 33-56). Treatment was with either LDN 4.5 mg or an inactive placebo given orally once daily. The primary outcomes were Fibromyalgia Impact Questionnaire revised (FIQR) scores and summed pain intensity ratings (SPIR). Results Fifty-eight patients with FM were randomized. The median difference (IQR) for FIQR scores between LDN and placebo treatment was -1.65 (18.55; effect size = 0.15; P = 0.3). The median difference for SPIR scores was -0.33 (6.33; effect size = 0.13; P = 0.4). Conclusion Outcome data did not indicate any clinically relevant analgesic efficacy of the LDN treatment in patients with FM.
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Affiliation(s)
- Kirsten Bested
- Multidisciplinary Pain Clinic, Friklinikken, Grindsted, Denmark
| | - Lotte M. Jensen
- Multidisciplinary Pain Clinic, Friklinikken, Grindsted, Denmark
| | - Trine Andresen
- Molecular Diagnostics and Clinical Research Unit, Hospital Sonderjylland, Aabendraa, Denmark
| | - Grete Tarp
- Multidisciplinary Pain Clinic, Friklinikken, Grindsted, Denmark
| | - Louise Skovbjerg
- Multidisciplinary Pain Center, Neuroscience Center, Rigshospitalet, Copenhagen University Hospitals, Copenhagen, Denmark
| | | | - Anne V. Schmedes
- Department of Clinical Biochemistry and Immunology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ida K. Storgaard
- Department of Drug Design and Pharmacology, Copenhagen University Hospitals, Copenhagen, Denmark
| | - Jonna S. Madsen
- Department of Clinical Biochemistry and Immunology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Mads U. Werner
- Multidisciplinary Pain Center, Neuroscience Center, Rigshospitalet, Copenhagen University Hospitals, Copenhagen, Denmark
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22
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Favretti M, Iannuccelli C, Di Franco M. Pain Biomarkers in Fibromyalgia Syndrome: Current Understanding and Future Directions. Int J Mol Sci 2023; 24:10443. [PMID: 37445618 DOI: 10.3390/ijms241310443] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/16/2023] [Accepted: 06/18/2023] [Indexed: 07/15/2023] Open
Abstract
Fibromyalgia is a complex and heterogeneous clinical syndrome, mainly characterized by the presence of widespread pain, possibly associated with a variety of other symptoms. Fibromyalgia can have an extremely negative impact on the psychological, physical and social lives of people affected, sometimes causing patients to experience dramatically impaired quality of life. Nowadays, the diagnosis of fibromyalgia is still clinical, thus favoring diagnostic uncertainties and making its clear identification challenging to establish, especially in primary care centers. These difficulties lead patients to undergo innumerable clinical visits, investigations and specialist consultations, thus increasing their stress, frustration and even dissatisfaction. Unfortunately, research over the last 25 years regarding a specific biomarker for the diagnosis of fibromyalgia has been fruitless. The discovery of a reliable biomarker for fibromyalgia syndrome would be a critical step towards the early identification of this condition, not only reducing patient healthcare utilization and diagnostic test execution but also providing early intervention with guideline-based treatments. This narrative article reviews different metabolite alterations proposed as possible biomarkers for fibromyalgia, focusing on their associations with clinical evidence of pain, and highlights some new, promising areas of research in this context. Nevertheless, none of the analyzed metabolites emerge as sufficiently reliable to be validated as a diagnostic biomarker. Given the complexity of this syndrome, in the future, a panel of biomarkers, including subtype-specific biomarkers, could be considered as an interesting alternative research area.
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Affiliation(s)
- Martina Favretti
- Rheumatology Unit, Department of Internal Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Cristina Iannuccelli
- Rheumatology Unit, Department of Internal Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Manuela Di Franco
- Rheumatology Unit, Department of Internal Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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23
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McKenzie-Brown AM, Boorman DW, Ibanez KR, Agwu E, Singh V. Low-Dose Naltrexone (LDN) for Chronic Pain at a Single Institution: A Case Series. J Pain Res 2023; 16:1993-1998. [PMID: 37337611 PMCID: PMC10276990 DOI: 10.2147/jpr.s389957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 06/02/2023] [Indexed: 06/21/2023] Open
Abstract
Purpose Low-dose naltrexone (LDN) has increased in popularity as a non-opioid medication that may decrease chronic pain symptoms. LDN is most commonly used to treat fibromyalgia, complex regional pain syndrome (CRPS), and painful diabetic neuropathy. Other studies suggest that LDN provides general symptom reduction in inflammatory conditions such as Crohn's disease and multiple sclerosis. We reviewed our experience with patients to whom we have prescribed LDN to see what types of painful conditions were most responsive to LDN in our patient population. Patients and Methods Charts from patients who came to the Pain Center between 2014 and 2021 were reviewed. Results Of the n = 137 patients who were prescribed LDN, 44% had no evidence of ever filling the prescription, and 4.4% of the responses were not charted. Of the remaining who took LDN (n = 70), 64% had some relief and were designated as 'Responders'. The most common pain diagnosis was neuropathic pain which, when added to the diagnosis of complex regional pain syndrome, accounted for 51% of responders to LDN. Patients who experienced greater than 50% pain relief from LDN were more likely to have the diagnosis of neuropathic pain or complex regional pain syndrome (p = 0.038, Fisher's Exact Test). There was a significant difference in the diagnosis of patients who responded to LDN. Patients with spondylosis were much less likely to respond to LDN when compared with other diagnoses (p = 0.00435, Chi-Square Test). Conclusion Patients with all types of neuropathic pain, including CRPS, were significantly more likely to have pain relief from LDN than patients with spondylosis (p=0.018). The diagnosis of spondylosis was more often associated with a lack of response to LDN than any other diagnosis. Patients may need to have a trial of several weeks before analgesic effects are seen with LDN.
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Affiliation(s)
| | - David W Boorman
- Department of Anesthesiology, School of Medicine, Emory University, Atlanta, GA, USA
| | - Kristen R Ibanez
- School of Medicine, University of Central Florida, Orlando, FL, USA
| | - Ezihe Agwu
- Department of Anesthesiology, Vassar Brothers Medical Center, Poughkeepsie, NY, USA
| | - Vinita Singh
- Department of Anesthesiology, School of Medicine, Emory University, Atlanta, GA, USA
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Partridge S, Quadt L, Bolton M, Eccles J, Thompson C, Colasanti A, Bremner S, Jones CI, Bruun KD, Van Marwijk H. A systematic literature review on the clinical efficacy of low dose naltrexone and its effect on putative pathophysiological mechanisms among patients diagnosed with fibromyalgia. Heliyon 2023; 9:e15638. [PMID: 37206027 PMCID: PMC10189400 DOI: 10.1016/j.heliyon.2023.e15638] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 02/26/2023] [Accepted: 04/18/2023] [Indexed: 05/21/2023] Open
Abstract
Background Low dose naltrexone (LDN) is used off-label by many individuals with fibromyalgia to help manage their pain. There is no current systematic literature review summarising the evidence to support this use of LDN. The objectives of this study were to evaluate if patients with fibromyalgia prescribed LDN have reduced pain scores and greater quality of life compared with those allocated to placebo in randomized controlled trials. Secondly to determine if changes in inflammatory markers and brain structure and function are observed among patients with fibromyalgia taking LDN. Methods Systematic literature searches were conducted in MEDLINE, Embase Classic + Embase, APA PsychInfo, and The Cochrane Library from inception to May 2022. Reference lists from the selected papers were cross-checked with database search results. Results Three studies met our inclusion criteria for the assessment of efficacy, and two studies on potential LDN mechanisms. Results indicated some evidence to suggest LDN reduces pain and increases quality of life. One study reported baseline erythrocyte sedimentation rate (ESR) predicted LDN response (≥30% reduction in fibromyalgia symptoms) and a second study showed plasma concentrations of inflammatory biomarkers were lower after LDN treatment. To our knowledge, there are no brain imaging studies reporting the effect of LDN in patients with fibromyalgia. All studies were based on small sample sizes, were restricted to women and the risk of bias was assessed to be high. There is also some evidence of publication bias. Conclusion The strength of evidence from randomized controlled trials to support the use of LDN among patients with fibromyalgia is low. Two small studies suggest ESR and cytokines may be involved in the mechanism by which LDN exerts its effects. Two trials (INNOVA and FINAL) are currently in progress, but further work is needed among men and different ethnic groups.
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Affiliation(s)
- Sarah Partridge
- Brighton and Sussex Medical School, University of Sussex, UK
| | - Lisa Quadt
- Brighton and Sussex Medical School, University of Sussex, UK
- Sussex Partnership NHS Foundation Trust, UK
| | - Monica Bolton
- Brighton and Sussex Medical School, University of Sussex, UK
| | - Jessica Eccles
- Brighton and Sussex Medical School, University of Sussex, UK
- Sussex Partnership NHS Foundation Trust, UK
| | | | - Alessandro Colasanti
- Brighton and Sussex Medical School, University of Sussex, UK
- Sussex Partnership NHS Foundation Trust, UK
| | - Stephen Bremner
- Brighton and Sussex Medical School, University of Sussex, UK
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Beaudette-Zlatanova B, Lew RA, Otis JD, Branch-Elliman W, Bacorro E, Dubreuil M, Eyvazzadeh C, Kaur M, Lazzari AA, Libbey C, Monach PA. Pilot Study of Low-Dose Naltrexone for the Treatment of Chronic Pain Due to Arthritis: A Randomized, Double-blind, Placebo-Controlled, Crossover Clinical Trial. Clin Ther 2023:S0149-2918(23)00113-3. [PMID: 37045708 DOI: 10.1016/j.clinthera.2023.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE Low-dose naltrexone (LDN) is commonly used to control pain and other symptoms, especially in patients with autoimmune diseases, but with limited evidence. This study tests the efficacy of LDN in reducing chronic pain in patients with osteoarthritis (OA) and inflammatory arthritis (IA), where existing approaches often fail to adequately control pain. METHODS In this randomized, double-blind, placebo-controlled, crossover clinical trial, each patient received 4.5 mg LDN for 8 weeks and placebo for 8 weeks. Outcome measures were patient reported, using validated questionnaires. The primary outcome was differences in pain interference during the LDN and placebo periods, using the Brief Pain Inventory (scale, 0-70). Secondary outcomes included changes in mean pain severity, fatigue, depression, and multiple domains of health-related quality of life. The painDETECT questionnaire classified pain as nociceptive, neuropathic, or mixed. Data were analyzed using mixed-effects models. FINDINGS Seventeen patients with OA and 6 with IA completed the pilot study. Most patients described their pain as nociceptive (n = 9) or mixed (n = 8) rather than neuropathic (n = 3). There was no difference in change in pain interference after treatment with LDN (mean [SD], -23 [19.4]) versus placebo (mean [SD], -22 [19.2]; P = 0.90). No significant differences were seen in pain severity, fatigue, depression, or health-related quality of life. IMPLICATIONS In this small pilot study, findings do not support LDN being efficacious in reducing nociceptive pain due to arthritis. Too few patients were enrolled to rule out modest benefit or to assess inflammatory or neuropathic pain. CLINICALTRIALS gov identifier: NCT03008590.
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Affiliation(s)
- Britte Beaudette-Zlatanova
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts; VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts
| | - Robert A Lew
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts
| | - John D Otis
- Research Service, VA Boston Healthcare System, Boston, Massachusetts
| | - Westyn Branch-Elliman
- VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts; Infectious Diseases Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Eugene Bacorro
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Maureen Dubreuil
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | | | - Maneet Kaur
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Antonio A Lazzari
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Caryn Libbey
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Paul A Monach
- Rheumatology Section, VA Boston Healthcare System, Boston, Massachusetts; VA Cooperative Studies Program, VA Boston Healthcare System, Boston, Massachusetts.
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Driver CN, D’Souza RS. Efficacy of Low-Dose Naltrexone and Predictors of Treatment Success or Discontinuation in Fibromyalgia and Other Chronic Pain Conditions: A Fourteen-Year, Enterprise-Wide Retrospective Analysis. Biomedicines 2023; 11:1087. [PMID: 37189705 PMCID: PMC10135963 DOI: 10.3390/biomedicines11041087] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/07/2023] Open
Abstract
Current pharmacologic treatments may provide limited analgesia in fibromyalgia and other chronic pain disorders. Low-dose naltrexone (LDN) has emerged as a potential analgesic option that has been minimally explored. This study aims to describe current real-world prescribing practices of LDN, to investigate if patients have a perceived benefit of LDN in treating pain symptoms and to identify predictors associated with a perceived benefit or discontinuation of LDN. We evaluated all outpatient prescriptions for LDN prescribed for any pain indication in the Mayo Clinic Enterprise from 1 January 2009 to 10 September 2022. A total of 115 patients were included in the final analysis. The patients were 86% female, had a mean age of 48 ± 16 years, and 61% of prescriptions were for fibromyalgia-related pain. The final daily dose of oral LDN ranged from 0.8 to 9.0 mg, while the most common dose was 4.5 mg once daily. Of patients who reported follow-up data, 65% reported benefit in their pain symptoms while taking LDN. Adverse effects were reported in 11 (11%) patients and 36% discontinued taking LDN by the most recent follow-up. Concomitant analgesic medications were used by 60% of patients and were not associated with perceived benefit nor discontinuation of LDN, including concomitant opioids. LDN is a relatively safe pharmacologic option that may benefit patients with chronic pain conditions and warrants further investigation in a prospective, controlled, and well-powered randomized clinical trial.
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Affiliation(s)
| | - Ryan S. D’Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Schmidt MG, Torres IL, Stahnke DN, Paniz VMV. [Low-dose naltrexone (LDN): consumption trend in Brazilian capitals and the Federal District, 2014-2020]. CIENCIA & SAUDE COLETIVA 2023; 28:947-955. [PMID: 36888876 DOI: 10.1590/1413-81232023283.10392022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/16/2022] [Indexed: 03/08/2023] Open
Abstract
The scope of this paper is an ecological study to determine the consumption of low-dose naltrexone (LDN) in the 26 Brazilian capitals and the Federal District and monitor the trend between the years 2014 to 2020. Data collection on the dispensation of manipulated naltrexone was done through the National Management System of Controlled Products, published in 2020, considering low-dose prescriptions of up to 5 mg. The calculation of the dispensation coefficients used the population estimates of the Brazilian Institute of Geography and Statistics. Descriptive statistical analysis and generalized Prais-Winsten regression analysis were used for the time series analysis. The trends observed were classified as increasing, stable, or decreasing, with a 95% confidence interval and 5% significance level. The results showed higher LDN consumption coefficients in the Mid-West, South and Southeast regions and lower coefficients in the North and Northeast. Increasing dispensation of LDN was observed in 55.6% of the capitals, being stationary in 44.4%, with no decreasing coefficients. Despite the limited evidence regarding LDN pharmacotherapy and its off-label prescription, the data show that prescription, dispensing, and consumption have been on the increase in Brazil, with emphasis on the central-south regions of the country.
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Affiliation(s)
- Michele Gabriela Schmidt
- Programa de Pós-Graduação em Saúde Coletiva, Universidade do Vale do Rio dos Sinos. Av. Unisinos 950, Cristo Rei. 93022-750 São Leopoldo RS Brasil.
| | - Iraci Ls Torres
- Laboratório de Farmacologia e Neuromodulação da Dor: Investigação Pré-Clínica, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul. Porto Alegre RS Brasil
| | - Douglas Nunes Stahnke
- Programa de Pós-Graduação em Saúde Coletiva, Universidade do Vale do Rio dos Sinos. Av. Unisinos 950, Cristo Rei. 93022-750 São Leopoldo RS Brasil.
| | - Vera Maria Vieira Paniz
- Programa de Pós-Graduação em Saúde Coletiva, Universidade do Vale do Rio dos Sinos. Av. Unisinos 950, Cristo Rei. 93022-750 São Leopoldo RS Brasil.
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Delaney SL, Murray LA, Fallon BA. Neuropsychiatric Symptoms and Tick-Borne Diseases. Curr Top Behav Neurosci 2023; 61:279-302. [PMID: 36512289 DOI: 10.1007/7854_2022_406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
In North America, Lyme disease (LD) is primarily caused by the spirochetal bacterium Borrelia burgdorferi, transmitted to humans by Ixodes species tick bites, at an estimated rate of 476,000 patients diagnosed per year. Acute LD often manifests with flu-like symptoms and an expanding rash known as erythema migrans (EM) and less often with neurologic, neuropsychiatric, arthritic, or cardiac features. Most acute cases of Lyme disease are effectively treated with antibiotics, but 10-20% of individuals may experience recurrent or persistent symptoms. This chapter focuses on the neuropsychiatric aspects of Lyme disease, as these are less widely recognized by physicians and often overlooked. Broader education about the potential complexity, severity, and diverse manifestations of tick-borne diseases is needed.
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Affiliation(s)
- Shannon L Delaney
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA.
| | - Lilly A Murray
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
| | - Brian A Fallon
- Lyme and Tick-Borne Diseases Research Center at Columbia University Irving Medical Center, New York, NY, USA
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Yang J, Shin KM, Do A, Bierle DM, Abu Dabrh AM, Yin Z, Bauer BA, Mohabbat AB. The Safety and Efficacy of Low-Dose Naltrexone in Patients with Fibromyalgia: A Systematic Review. J Pain Res 2023; 16:1017-1023. [PMID: 36974308 PMCID: PMC10039621 DOI: 10.2147/jpr.s395457] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
Fibromyalgia (FM) is a chronic pain sensitivity syndrome characterized by diffuse musculoskeletal pain and many other systemic manifestations. Low-dose naltrexone (LDN) has been increasingly used as an off-label treatment option in FM. However, current evidence on the safety and efficacy of LDN in patients with FM is not well known. To systematically assess the current evidence on the safety and efficacy of LDN use in the treatment of FM. A comprehensive bibliographic search was conducted on EBM Reviews - Cochrane Central Register of Controlled Trials, EBM Reviews - Cochrane Database of Systematic, Embase, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions and Scopus databases in September 2022. Inclusion criteria were articles that were published in English, focusing on clinical trials involving LDN for the treatment of FM. Two reviewers independently screened and extracted the data. A qualitative analysis was used due to the high methodological heterogeneity between studies. The electronic search produced 805 articles. After applying the inclusion criteria, 9 articles (one RCT, two case reports, two case series, and four pilot trials) were selected for evaluation. LDN intervention protocols, study designs, and follow-up periods were different among the included studies. Overall, LDN was found to be effective in the symptomatic management of FM, and of the 78% of included studies that evaluated for safety, no severe adverse events were reported. Proving the efficacy and safety of low-dose naltrexone is a future possibility based on current study data, but the level of scientific evidence is limited. Future well-designed trials with large sample sizes are required.
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Affiliation(s)
- Juan Yang
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kyung-Min Shin
- KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, 34054, South Korea
| | - Alex Do
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Dennis M Bierle
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Abd Moain Abu Dabrh
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Ziying Yin
- Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Brent A Bauer
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Arya B Mohabbat
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
- Correspondence: Arya B Mohabbat, Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, RO_GO_17_102GIM, Rochester, MN, 55905, USA, Tel +1-507-284-2511, Email
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Plank JR, Glover SC, Moloney BD, Hoeh NR, Sundram F, Sumner RL, Muthukumaraswamy S, Lin JC. A randomized, double-blind, placebo-controlled, hybrid parallel-arm study of low-dose naltrexone as an adjunctive anti-inflammatory treatment for major depressive disorder. Trials 2022; 23:822. [PMID: 36175917 PMCID: PMC9524133 DOI: 10.1186/s13063-022-06738-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is a leading cause of disability worldwide. The current treatments are ineffective in approximately one-third of patients, resulting in a large economic burden and reduced quality of life for a significant proportion of the global population. There is considerable evidence that increased inflammation may distinguish a sub-type of MDD, and there are no validated diagnostic tools or treatments for neuroinflammation in MDD patients. The current study aims to explore the potential role of low-dose naltrexone (LDN), a drug with purported anti-inflammatory properties in the central nervous system, as an adjunctive treatment in patients with MDD. METHODS/DESIGN This double-blind placebo-controlled hybrid parallel arm study enables the exploration of peripheral and central inflammatory markers with LDN as an approach to investigate inflammation as a pathophysiological contributor to MDD. Eligible participants with MDD (n = 48) will be stratified into the high and low inflammatory groups according to the levels of high-sensitivity C-reactive protein (hs-CRP) and then randomized to receive LDN or placebo for an initial 12 weeks, followed by a further 12 weeks during which all participants will receive LDN. The primary outcome measure will be the Montgomery-Åsberg Depression Rating Scale (MADRS) administered at baseline, 2 weeks, 4 weeks, 8 weeks, 12 weeks, 14 weeks, 16 weeks, 20 weeks, and 24 weeks, to assess the effectiveness of the anti-depressant response. The secondary outcomes include the use of MRI techniques including quantitative magnetization transfer (qMT), echo-planar spectroscopic imaging (EPSI), and diffusion-weighted imaging (DWI) to help to elucidate the neurobiological mechanism of LDN, and the inflammatory mechanisms in action in MDD. Electroencephalography, blood samples, cognitive tasks, and additional questionnaires will also be used to determine if there is a specific profile of symptoms in individuals with inflammatory MDD. Healthy participants (n = 24) will be recruited for baseline outcome measures only, to enable comparison with patients with MDD. DISCUSSION This trial contributes to the literature on inflammation in MDD, including the understanding of the pathophysiology and efficacy of anti-inflammatory treatments. The investigation of inflammatory mechanisms in MDD is an important first step in the development of biomarkers to classify patient sub-groups, increase the accuracy of diagnosis, and tailor the approach to patients in clinical practice. This study may provide evidence of the benefit of LDN for the groups in whom conventional anti-depressants are ineffective and lead the way for translation into clinical practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12622000881730 . Registered on 21 June 2022.
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Affiliation(s)
- Julia R Plank
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Stephanie C Glover
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Ben D Moloney
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Nicholas R Hoeh
- Department of Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 22-30 Park Avenue, Grafton, Auckland, 1023, New Zealand
| | - Frederick Sundram
- Department of Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 22-30 Park Avenue, Grafton, Auckland, 1023, New Zealand
| | - Rachael L Sumner
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Suresh Muthukumaraswamy
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Joanne C Lin
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
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Paula TMHD, Castro MS, Medeiros LF, Paludo RH, Couto FF, Costa TRD, Fortes JP, Salbego MDO, Behnck GS, Moura TAMD, Tarouco ML, Caumo W, Souza AD. Association of low-dose naltrexone and transcranial direct current stimulation in fibromyalgia: a randomized, double-blinded, parallel clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022:S0104-0014(22)00104-X. [PMID: 35988815 PMCID: PMC10362456 DOI: 10.1016/j.bjane.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Fibromyalgia is a complex, generalized, and diffuse chronic musculoskeletal pain. Pharmacological approaches are widely used to relieve pain and increase quality of life. Low-Dose Naltrexone (LDN) was shown to increase the nociceptive threshold in patients with fibromyalgia. Transcranial Direct Current Stimulation (tDCS) is effective for pain management. OBJECTIVE The purpose of this study was to evaluate the analgesic and neuromodulatory effects of a combination of LDN and tDCS in patients with fibromyalgia. METHODS This was a randomized, double-blinded, parallel, placebo/sham-controlled trial (NCT04502251; RBR-7HK8N) in which 86 women with fibromyalgia were included, and written informed consent was obtained from them. The patients were allocated into four groups: LDN + tDCS (n = 21), LDN + tDCS Sham (n = 22), placebo + tDCS (n = 22), and placebo+tDCS Sham (n = 21). The LDN or placebo (p.o.) intervention lasted 26 days; in the last five sessions, tDCS was applied (sham or active, 20 min, 2 mA). The following categories were assessed: sociodemographic, Visual Analog Pain Scale (VAS), Pain Catastrophizing Scale (PCS), State-Trait Anxiety Inventory (STAI), Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI-II), Profile of Chronic Pain Scale (PCP:S), Pain Pressure Threshold (PPT), and Conditioned Pain Modulation (CPM). Blood samples were collected to analyze BDNF serum levels. RESULTS At baseline, no significant difference was found regarding all measurements. VAS pain was significantly reduced in the LDN + tDCS (p = 0.010), LDN + tDCS Sham (p = 0.001), and placebo+tDCS Sham (p = 0.009) groups. In the PCP:S, the LDN+tDCS group showed reduced pain frequency and intensity (p = 0.001), effect of pain on activities (p = 0.014) and emotions (p = 0.008). Depressive symptoms reduced after all active interventions (p > 0.001). CONCLUSION Combined LDN+tDCS has possible benefits in reducing pain frequency and intensity; however, a placebo effect was observed in pain using VAS, and further studies should be performed to analyze the possible association.
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Affiliation(s)
| | - Mariane Schäffer Castro
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Liciane Fernandes Medeiros
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Biológicas: Farmacologia e Terapêutica, Porto Alegre, RS, Brazil
| | - Rodrigo Hernandes Paludo
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Fabricia Fritz Couto
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Tainá Ramires da Costa
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Juliana Pereira Fortes
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Maiara de Oliveira Salbego
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Gabriel Schardosim Behnck
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Thielly Amaral Mesquita de Moura
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Mariana Lenz Tarouco
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade La Salle, Canoas, RS, Brazil
| | - Wolnei Caumo
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Biológicas: Farmacologia e Terapêutica, Porto Alegre, RS, Brazil
| | - Andressa de Souza
- Universidade La Salle, Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Canoas, RS, Brazil; Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Biológicas: Farmacologia e Terapêutica, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Médicas: Medicina, Porto Alegre, RS, Brazil.
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Staud R. Advances in the management of fibromyalgia: what is the state of the art? Expert Opin Pharmacother 2022; 23:979-989. [PMID: 35509228 DOI: 10.1080/14656566.2022.2071606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Fibromyalgia (FM) is a chronic pain syndrome associated with fatigue, insomnia, dyscognition, and emotional distress. Critical illness mechanisms include central sensitization to nociceptive and non-nociceptive stimuli often resulting in hypersensitivity to all sensory input. AREAS COVERED The clinical presentation of FM can vary widely and therefore requires therapies tailored to each patient's set of symptoms. This manuscript examines currently prescribed therapeutic approaches supported by empirical evidence as well as promising novel treatments. Although pharmacological therapy until now has been only moderately effective for FM symptoms, it represents a critical component of every treatment plan. EXPERT OPINION Currently approved pharmacological therapies for FM symptoms have limited but proven effectiveness. Novel therapies with cannabinoids and naltrexone appear promising. Recent functional imaging studies of FM have discovered multiple brain network abnormalities that may provide novel targets for mechanism-based therapies. Future treatment approaches, however, need to improve more than clinical pain but also other FM domains like fatigue, insomnia, and distress.
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Affiliation(s)
- Roland Staud
- Division of Rheumatology and Clinical Immunology, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
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D'Souza RS, Langford B, Wilson RE, Her YF, Schappell J, Eller JS, Evans TC, Hagedorn JM. The State-of-the-art Pharmacotherapeutic Options for the Treatment of Chronic Non-Cancer Pain. Expert Opin Pharmacother 2022; 23:775-789. [PMID: 35354341 DOI: 10.1080/14656566.2022.2060741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Pharmacotherapeutic options continue to expand for the treatment of chronic non-cancer pain. There has been an increasing emphasis on multimodal analgesia. This strategy employs use of multiple analgesic medications each with a distinct mechanism of action, which when administered concomitantly may provide profound analgesia. AREAS COVERED The authors describe evidence from randomized controlled trials and systematic reviews on a variety of established medications including anti-inflammatory agents, opioids, anti-convulsants, anti-depressants, N-methyl-D-aspartate receptor antagonists, sodium channel blockers, cannabinoids, and alpha-2-receptor blockers. Furthermore, they provide developing evidence on more novel pharmacotherapeutics including alpha lipoic acid, acetyl-L-carnitine, low dose naltrexone, calcitonin gene-related peptide antagonists, targeted toxin therapy, Nav1.7 inhibitors, neurotensin agonists, purinoceptor antagonists, and sigma-1 receptor antagonists. Furthermore, the authors review the safety and adverse effect profile for these agents. EXPERT OPINION In this era of the opioid epidemic, clinicians should first offer non-opioid analgesics and employ a multimodal analgesic strategy. Current guidelines recommend a personalized approach to the chronic pain treatment, in each case accounting for type, location, severity, and chronicity of pain. Clinicians should also carefully consider the risk-to-benefit ratio to the patient based on the drug side effect profile, patient age, and comorbidities.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brendan Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Rachel E Wilson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Justin Schappell
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN, USA
| | - Jennifer S Eller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Timothy C Evans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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Martin SJ, McAnally HB, Okediji P, Rogosnitzky M. Low-dose naltrexone, an opioid-receptor antagonist, is a broad-spectrum analgesic: a retrospective cohort study. Pain Manag 2022; 12:699-709. [DOI: 10.2217/pmt-2021-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the use of low-dose naltrexone (LDN) as a broad-spectrum analgesic. Methods: Retrospective cohort study from a single pain management practice using data from 2014 to 2020. Thirty-six patients using LDN for ≥2 months were matched to 42 controls. Pain scores were assessed at initial visit and at most recent/final documented visit using a 10-point scale. Results: Cases reported significantly greater pain reduction (-37.8%) than controls (-4.3%; p < 0.001). Whole sample multivariate modeling predicts 33% pain reduction with LDN, with number needed to treat (for 50% pain reduction) of 3.2. Patients with neuropathic pain appeared to benefit even more than those with ‘nociceptive’/inflammatory pain. Conclusion: LDN is effective in a variety of chronic pain states, likely mediated by TLR-4 antagonism.
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Affiliation(s)
- Samuel J Martin
- Northern Anesthesia & Pain Medicine, 10928 Eagle River Rd. #240, Eagle River, AK 99577, USA
- Loma Linda University School of Medicine, 11175 Campus St., Loma Linda, CA 92350, USA
| | - Heath B McAnally
- Northern Anesthesia & Pain Medicine, 10928 Eagle River Rd. #240, Eagle River, AK 99577, USA
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Paul Okediji
- MedInsight Research Institute, Pekeris 4, Weizmann Science Park, Rehovot, 7670204, Israel
| | - Moshe Rogosnitzky
- MedInsight Research Institute, Pekeris 4, Weizmann Science Park, Rehovot, 7670204, Israel
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Wang A, Shulman M, Choo T, Pavlicova M, Langleben DD, Nunes EV, Rotrosen J. Baseline- and treatment-associated pain in the X:BOT comparative effectiveness study of extended-release naltrexone versus buprenorphine-naloxone for OUD. Addict Biol 2022; 27:e13112. [PMID: 34877769 DOI: 10.1111/adb.13112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 10/06/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022]
Abstract
Chronic pain is highly prevalent among patients with opioid use disorder (OUD). However, little is known about how pharmacological treatments for OUD, for example, extended-release naltrexone (XR-NTX) and buprenorphine-naloxone (BUP-NX), affect pain. To begin addressing this question, we performed a secondary analysis of pain data on a large prospective 24-week, open-label, randomized-controlled comparative effectiveness trial of XR-NTX versus BUP-NX (X:BOT trial). Participants' pain status was measured by the EuroQol (EQ-5D). Based on their responses to the pain question at baseline, participants were dichotomized into "Pain" versus "No Pain" categories. Participant's pain status was evaluated every 4 weeks. A mixed effects longitudinal logistic regression model was fitted to examine the differential effect of XR-NTX versus BUP-NX on pain, modelling pain at all available follow-up assessments, adjusted for age, sex, and baseline pain. A total of 474 individuals who were successfully inducted onto their assigned medications were included in this analysis. Among participants endorsing pain at baseline, substantial reductions in pain were observed over the course of the study in both treatment groups. Howecver reduction in pain was slightly greater in the group treated with XR-NTX than the one treated with BUP-NX (OR = 1.60 [95% CI: 1.07-2.40], P = 0.023). Future research using instruments and design specifically focused on pain could extend the present observations and evaluate their clinical significance.
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Affiliation(s)
- An‐Li Wang
- Addiction Institute of Mount Sinai, Department of Psychiatry Icahn School of Medicine at Mount Sinai New York New York USA
| | - Matisyahu Shulman
- Department of Psychiatry Columbia University Irving Medical Center and New York State Psychiatric Institute New York New York USA
| | - Tse‐Hwei Choo
- Department of Psychiatry Columbia University Irving Medical Center and New York State Psychiatric Institute New York New York USA
| | - Martina Pavlicova
- Department of Biostatistics Columbia University Mailman School of Public Health New York New York USA
| | - Daniel D. Langleben
- Department of Psychiatry University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Edward V. Nunes
- Department of Psychiatry Columbia University Irving Medical Center and New York State Psychiatric Institute New York New York USA
| | - John Rotrosen
- Department of Psychiatry NYU Grossman School of Medicine New York New York USA
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Siembida J, Johnson B. Depression in Fibromyalgia Patients May Require Low-Dose Naltrexone to Respond: A Case Report. Cureus 2022; 14:e22677. [PMID: 35386139 PMCID: PMC8967077 DOI: 10.7759/cureus.22677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 01/14/2023] Open
Abstract
Fibromyalgia and depression are frequently comorbid. We propose a hormonal system model in understanding the underlying endogenous opioid system dysregulation in fibromyalgia with the utilization of the cold pressor test (CPT) in clinical practice to monitor treatment response to low-dose naltrexone (LDN) and the subsequent remission of major depressive disorder by restoring opioid tone. A 60-year-old professional on permanent disability presented with refractory depression and chronic widespread pain after years of multiple failed medication trials. Rating scales confirmed severe depression, Hamilton Rating Scale for Depression (HAM-D) of 20, a short cold pressor test (CPT) time of 21 seconds, and a face pain scale (FPS) of 8/10. Physical examination assessing for fibromyalgia was diagnostic, with 18/18 positive tender points. LDN, a minor increase in trazodone, and transference-focused psychotherapy were employed. The patient’s CPT time increased modestly. The patient achieved remission of both conditions in 10 weeks when both disorders were treated at once (FPS and HAM-D of zero), restoring the quality of life, relatedness, and motivation. Some fibromyalgia patients may achieve remission of comorbid depression with concomitant low-dose naltrexone (LDN) treatment that is widely used “off label” to treat pain. LDN is a promising alternative for the treatment of chronic pain in fibromyalgia with its safety profile, high tolerability, and absence of abuse potential. Our unique finding is that without successful LDN treatment of fibromyalgia, remission of depression may be unlikely.
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Colomer-Carbonell A, Sanabria-Mazo JP, Hernández-Negrín H, Borràs X, Suso-Ribera C, García-Palacios A, Muchart J, Munuera J, D'Amico F, Maes M, Younger JW, Feliu-Soler A, Rozadilla-Sacanell A, Luciano JV. Study protocol for a randomised, double-blinded, placebo-controlled phase III trial examining the add-on efficacy, cost-utility and neurobiological effects of low-dose naltrexone (LDN) in patients with fibromyalgia (INNOVA study). BMJ Open 2022; 12:e055351. [PMID: 34992118 PMCID: PMC8739052 DOI: 10.1136/bmjopen-2021-055351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION There is evidence that low-dose naltrexone (LDN; <5.0 mg/day) reduces pain and improves the quality of life of people with fibromyalgia syndrome (FMS). However, no randomised controlled trials with long-term follow-ups have been carried out. The INNOVA study will evaluate the add-on efficacy, safety, cost-utility and neurobiological effects of LDN for reducing pain in patients with FMS, with a 1-year follow-up. METHODS AND ANALYSIS A single-site, prospective, randomised, double-blinded, placebo-controlled, parallel design phase III trial will be performed. Eligibility criteria include being adult, having a diagnosis of FMS and experiencing pain of 4 or higher on a 10-point numerical rating scale. Participants will be randomised to a LDN intervention group (4.5 mg/day) or to a placebo control group. Clinical assessments will be performed at baseline (T0), 3 months (T1), 6 months (T2) and 12 months (T3). The primary endpoint will be pain intensity. A sample size of 60 patients per study arm (120 in total), as calculated prior to recruitment for sufficient power, will be monitored between January 2022 and August 2024. Assessment will also include daily ecological momentary evaluations of FMS-related symptoms (eg, pain intensity, fatigue and sleep disturbance), and side effects via ecological momentary assessment through the Pain Monitor app during the first 3 months. Costs and quality-adjusted life years will be also calculated. Half of the participants in each arm will be scanned with MRI at T0 and T1 for changes in brain metabolites related to neuroinflammation and central sensitisation. Inflammatory biomarkers in serum will also be measured. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of the Fundació Sant Joan de Déu. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and community engagement activities. TRIAL REGISTRATION NUMBER NCT04739995.
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Affiliation(s)
- Ariadna Colomer-Carbonell
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, St. Boi de Llobregat, Spain
- Department of Basics, Developmental and Educational Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Juan P Sanabria-Mazo
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, St. Boi de Llobregat, Spain
- Department of Basics, Developmental and Educational Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Halbert Hernández-Negrín
- Department of Basics, Developmental and Educational Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
- Universidad de Ciencias Médicas de Villa Clara, Santa Clara, Cuba
| | - Xavier Borràs
- Department of Basics, Developmental and Educational Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Carlos Suso-Ribera
- Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, Castello de la Plana, Spain
- Biomedical Research Centre in Physiopathology of Obesity and Nutrition (CIBERobn), Madrid, Spain
| | - Azucena García-Palacios
- Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, Castello de la Plana, Spain
- Biomedical Research Centre in Physiopathology of Obesity and Nutrition (CIBERobn), Madrid, Spain
| | - Jordi Muchart
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Josep Munuera
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Francesco D'Amico
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Michael Maes
- Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand
| | | | - Albert Feliu-Soler
- Department of Clinical and Health Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | | | - Juan V Luciano
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, St. Boi de Llobregat, Spain
- Department of Clinical and Health Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
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Bruun KD, Amris K, Vaegter HB, Blichfeldt-Eckhardt MR, Holsgaard-Larsen A, Christensen R, Toft P. Low-dose naltrexone for the treatment of fibromyalgia: protocol for a double-blind, randomized, placebo-controlled trial. Trials 2021; 22:804. [PMID: 34781989 PMCID: PMC8591911 DOI: 10.1186/s13063-021-05776-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/29/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Low-dose naltrexone (LDN) is used widely as an off-label treatment for pain despite limited evidence for its effectiveness. A few small trials with a high risk of bias have investigated the effect of LDN on pain associated with fibromyalgia in women, but larger and more methodologically robust studies are needed. The primary aim of this randomized controlled trial is to investigate if 12 weeks of LDN treatment is superior to placebo in reducing the average pain intensity during the last 7 days in women with fibromyalgia. METHODS A single-center, permuted block randomized, double-blind, placebo-controlled, parallel-group trial will be performed in Denmark. Randomization comprises 100 women aged 18-64 years diagnosed with fibromyalgia who will be treated with either LDN or placebo for 12 weeks including a 4-week titration phase. The primary outcome is change in average pain intensity (during the last 7 days) from baseline to 12 weeks. Secondary outcomes are other fibromyalgia-related symptoms, i.e., tenderness, fatigue, sleep disturbance, stiffness, memory problems, depression, anxiety and measures of global assessment, physical function, impact of fibromyalgia, pain distribution, and health-related quality of life. Intention-to-treat analysis will be performed, and the number of responders with a more than 15%, 30%, and 50% improvement of pain after 12 weeks will be calculated for the LDN and placebo groups. Exploratory outcomes include measures of pain sensitivity, muscle performance, and biomarkers. DISCUSSION This study will contribute with high-level evidence on the efficacy of low-dose naltrexone for the treatment of pain in women with fibromyalgia. Secondary outcomes include both disease-specific and generic components investigating whether LDN influences other symptoms than pain. Explorative outcomes are included to provide greater insight into the mechanism of action of LDN and possibly a better understanding of the underlying pathology in fibromyalgia. TRIAL REGISTRATION EudraCT 2019-000702-30. Registered on 12 July 2019. ClinicalTrials.gov NCT04270877. Registered on 17 February 2020.
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Affiliation(s)
- Karin Due Bruun
- Pain Research Group, Pain Center, Odense University Hospital, Heden 7-9, Indgang 20, DK - 5000, Odense C, Denmark. .,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark. .,The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
| | - Kirstine Amris
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Department of Rheumatology, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Henrik Bjarke Vaegter
- Pain Research Group, Pain Center, Odense University Hospital, Heden 7-9, Indgang 20, DK - 5000, Odense C, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Rune Blichfeldt-Eckhardt
- Pain Research Group, Pain Center, Odense University Hospital, Heden 7-9, Indgang 20, DK - 5000, Odense C, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Anders Holsgaard-Larsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Palle Toft
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
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Gupta H, Girma B, Jenkins JS, Kaufman SE, Lee CA, Kaye AD. Milnacipran for the Treatment of Fibromyalgia. Health Psychol Res 2021; 9:25532. [PMID: 34746490 DOI: 10.52965/001c.25532] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/02/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose of review This is a comprehensive review of the literature regarding the use of milnacipran in treating fibromyalgia. A chronic pain disorder with other system disturbances, fibromyalgia is often resistant to many therapeutic approaches. This review presents the background, evidence, and indications for using milnacipran as a treatment option for this condition. Recent Findings The definition of fibromyalgia has evolved over many years as it is a relatively tricky syndrome to measure objectively. Today, it is characterized by chronic, widespread pain accompanied by alterations in sleep, mood, and other behavioral aspects. A variety of therapeutic regimens currently used to treat the syndrome as a singular approach are rarely effective.Milnacipran is one of three drugs currently approved by the FDA for the treatment of fibromyalgia. It acts as a serotonin and norepinephrine reuptake inhibitor, which results in decreased pain transmission. Milnacipran remains an effective treatment option for fibromyalgia in adults and needs to be further evaluated with existing therapeutic approaches. Summary Fibromyalgia is a broad-spectrum disorder primarily characterized by chronic pain coupled with disturbances in cognitive functioning and sleep. The progression of this syndrome is often debilitating and significantly affects the quality of life. Milnacipran is one of three FDA-approved drugs used to alleviate the symptom burden and is comparatively more therapeutic in specific domains of fibromyalgia. A more holistic approach is needed to treat fibromyalgia effectively and further research, including direct comparison studies, should be conducted to fully evaluate the usefulness of this drug.
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Srinivasan A, Dutta P, Bansal D, Chakrabarti A, Bhansali AK, Hota D. Efficacy and safety of low-dose naltrexone in painful diabetic neuropathy: A randomized, double-blind, active-control, crossover clinical trial. J Diabetes 2021; 13:770-778. [PMID: 34014028 DOI: 10.1111/1753-0407.13202] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is a need for newer therapies for chronic painful diabetic neuropathy as the existing drugs have their own limitations. Clinical trials on low-dose naltrexone (1-5 mg/d) showed efficacy and safety in certain chronic painful conditions, but not in painful diabetic neuropathy. Hence the present study was planned. METHODS Sixty-seven participants with painful diabetic neuropathy were randomized to receive either 2 mg naltrexone or 10 mg amitriptyline daily following a 2-week run-in period. The participants were followed up every 2 weeks for a total of 6 weeks. Up-titration was done (to 4 mg naltrexone or 25/50 mg amitriptyline) if the pain reduction was less than 20% on the visual analog scale (VAS) during the next follow-up visit. Efficacy was assessed using the change in VAS score at the end of 6 weeks from baseline. Safety was evaluated at each follow-up visit. After 2 weeks of washout period, the participants were crossed over to receive the comparator drug for another 6 weeks with similar evaluations. RESULTS The difference (confidence interval) in the change in VAS score between groups from baseline was 1.64 (-0.92 to 4.20) in per-protocol analysis and 1.5 (-1.11 to 4.13) in intention-to-treat analysis. Eight and fifty-two adverse events were reported in the naltrexone and amitriptyline groups, respectively (P < .001). The most common adverse events were mild diarrhea with naltrexone and somnolence with amitriptyline. CONCLUSIONS Low-dose naltrexone exhibited similar efficacy and a superior safety profile compared with amitriptyline in painful diabetic neuropathy.
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Affiliation(s)
- Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipika Bansal
- Department of Clinical Research, National Institute of Pharmaceutical Education and Research, SAS Nagar, India
| | - Amitava Chakrabarti
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Kumar Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Debasish Hota
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, India
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Dworsky-Fried Z, Chadwick CI, Kerr BJ, Taylor AMW. Multiple Sclerosis and the Endogenous Opioid System. Front Neurosci 2021; 15:741503. [PMID: 34602975 PMCID: PMC8484329 DOI: 10.3389/fnins.2021.741503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/26/2021] [Indexed: 01/10/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease characterized by chronic inflammation, neuronal degeneration and demyelinating lesions within the central nervous system. The mechanisms that underlie the pathogenesis and progression of MS are not fully known and current therapies have limited efficacy. Preclinical investigations using the murine experimental autoimmune encephalomyelitis (EAE) model of MS, as well as clinical observations in patients with MS, provide converging lines of evidence implicating the endogenous opioid system in the pathogenesis of this disease. In recent years, it has become increasingly clear that endogenous opioid peptides, binding μ- (MOR), κ- (KOR) and δ-opioid receptors (DOR), function as immunomodulatory molecules within both the immune and nervous systems. The endogenous opioid system is also well known to play a role in the development of chronic pain and negative affect, both of which are common comorbidities in MS. As such, dysregulation of the opioid system may be a mechanism that contributes to the pathogenesis of MS and associated symptoms. Here, we review the evidence for a connection between the endogenous opioid system and MS. We further explore the mechanisms by which opioidergic signaling might contribute to the pathophysiology and symptomatology of MS.
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Affiliation(s)
- Zoë Dworsky-Fried
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
| | - Caylin I. Chadwick
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Bradley J. Kerr
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Anna M. W. Taylor
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
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Mackay A. A Paradigm for Post-Covid-19 Fatigue Syndrome Analogous to ME/CFS. Front Neurol 2021; 12:701419. [PMID: 34408721 PMCID: PMC8365156 DOI: 10.3389/fneur.2021.701419] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
A significant proportion of COVID-19 patients are suffering from prolonged Post-COVID-19 Fatigue Syndrome, with characteristics typically found in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). However, no clear pathophysiological explanation, as yet, has been provided. A novel paradigm for a Post-COVID-19 Fatigue Syndrome is developed here from a recent unifying model for ME/CFS. Central to its rationale, SARS-CoV-2, in common with the triggers (viral and non-viral) of ME/CFS, is proposed to be a physiologically severe stressor, which could be targeting a stress-integrator, within the brain: the hypothalamic paraventricular nucleus (PVN). It is proposed that inflammatory mediators, released at the site of COVID-19 infection, would be transmitted as stress-signals, via humoral and neural pathways, which overwhelm this stress-center. In genetically susceptible people, an intrinsic stress-threshold is suggested to be exceeded causing ongoing dysfunction to the hypothalamic PVN's complex neurological circuitry. In this compromised state, the hypothalamic PVN might then be hyper-sensitive to a wide range of life's ongoing physiological stressors. This could result in the reported post-exertional malaise episodes and more severe relapses, in common with ME/CFS, that perpetuate an ongoing disease state. When a certain stress-tolerance-level is exceeded, the hypothalamic PVN can become an epicenter for microglia-induced activation and neuroinflammation, affecting the hypothalamus and its proximal limbic system, which would account for the range of reported ME/CFS-like symptoms. A model for Post-COVID-19 Fatigue Syndrome is provided to stimulate discussion and critical evaluation. Brain-scanning studies, incorporating increasingly sophisticated imaging technology should enable chronic neuroinflammation to be detected, even at a low level, in the finite detail required, thus helping to test this model, while advancing our understanding of Post-COVID-19 Fatigue Syndrome pathophysiology.
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Affiliation(s)
- Angus Mackay
- The Brain Health Research Centre, University of Otago, Dunedin, New Zealand
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Abstract
Fibromyalgia (FM) is a condition of chronic widespread pain (CWP) that can occur throughout the life cycle and is likely underrecognized in older patients. FM is associated with considerable suffering and reduction in quality of life and may occur as a unique condition, but in older patients is most likely to be associated with another medical illness. Understood mechanistically to be a sensitization of the nervous system, recently identified as nociplastic pain, FM is accepted as a valid medical illness that requires a positive diagnosis and directed treatments. The cornerstone of treatments for FM are nonpharmacologic interventions, with the understanding that medications provide only modest benefit for most patients, and with particular concern about adverse effects in older patients. If FM is not recognized, treatments may be misdirected to the other medical condition, with failure to address FM symptoms, leading to overall poor outcome. In contrast, new complaints in older patients should not immediately be attributed to FM, and physicians should be vigilant to ensure that onset of a new illness is not ignored. As FM is most often a lifelong condition, patients should be encouraged to identify their own personal strategies that can attenuate symptoms, especially when symptoms flare. Continued life participation should be the outcome goal.
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Affiliation(s)
- Amir Minerbi
- Institute for Pain Medicine, Rambam Health Campus, Haifa, Israel.,Ruth and Bruce Rapaport Faculty of Medicine, Technion, Haifa, Israel
| | - Mary-Ann Fitzcharles
- Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada. .,Division of Rheumatology, McGill University Health Centre, Montreal, QC, Canada.
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44
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Potru S, Tang YL. Chronic Pain, Opioid Use Disorder, and Clinical Management Among Older Adults. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:294-302. [PMID: 34690595 PMCID: PMC8475938 DOI: 10.1176/appi.focus.20210002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Because of unique factors related to physiological changes and altered metabolism in advanced age, special attention is needed concerning chronic pain, opioid use, and opioid use disorder among older adults. Clinicians need to follow the most updated clinical guidelines regarding opioid prescribing. Routine screening and awareness are the keys to identifying opioid use disorder. Comprehensive assessments often require both pain assessment (including functional status) and substance use assessment, including the use of urine toxicological testing and structured, validated screening tools and instruments. Comprehensive, interdisciplinary efforts are critical in managing the care of older adults with chronic pain and opioid use disorder. A collaborative approach that includes substance abuse treatment and pain management (including pain subspecialty care) is often recommended. Medications for opioid use disorder have been extensively studied and have the most convincing evidence to date, and psychosocial treatments may be beneficial in some circumstances.
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Affiliation(s)
- Sudheer Potru
- Department of Anesthesiology (Potru) and Department of Psychiatry and Behavioral Sciences (Tang), both at Emory University, Atlanta; Department of Anesthesiology (Potru) and Substance Abuse Treatment Program (Tang), both at Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Yi-Lang Tang
- Department of Anesthesiology (Potru) and Department of Psychiatry and Behavioral Sciences (Tang), both at Emory University, Atlanta; Department of Anesthesiology (Potru) and Substance Abuse Treatment Program (Tang), both at Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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45
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Reported Benefits of Low-Dose Naltrexone Appear to Be Independent of the Endogenous Opioid System Involving Proopiomelanocortin Neurons and β-Endorphin. eNeuro 2021; 8:ENEURO.0087-21.2021. [PMID: 34031099 PMCID: PMC8211470 DOI: 10.1523/eneuro.0087-21.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/08/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
Naltrexone is an opioid receptor antagonist approved for the treatment of alcohol and opioid use disorders at doses of 50–150 mg/d. Naltrexone has also been prescribed at much lower doses (3–6 mg/d) for the off-label treatment of inflammation and pain. Currently, a compelling mechanistic explanation for the reported efficacy of low-dose naltrexone (LDN) is lacking and none of the proposed mechanisms can explain patient reports of improved mood and sense of well-being. Here, we examined the possibility that LDN might alter the activity of the endogenous opioid system involving proopiomelanocortin (POMC) neurons in the arcuate nucleus of the hypothalamus (ARH) in male and female mice. Known actions of POMC neurons could account for changes in pain perception and mood. However, using electrophysiologic, imaging and peptide measurement approaches, we found no evidence for such a mechanism. LDN did not change the sensitivity of opioid receptors regulating POMC neurons, the production of the β-endorphin precursor Pomc mRNA, nor the release of β-endorphin into plasma. Spontaneous postsynaptic currents (sPSCs) onto POMC neurons were slightly decreased after LDN treatment and GCaMP fluorescent signal, a proxy for intracellular calcium levels, was slightly increased. However, LDN treatment did not appear to change POMC neuron firing rate, resting membrane potential, nor action potential threshold. Therefore, LDN appears to have only slight effects on POMC neurons that do not translate to changes in intrinsic excitability or baseline electrical activity and mechanisms beyond POMC neurons and altered opioid receptor sensitivity should continue to be explored.
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46
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Consideration of Fibromyalgia in the Assessment and Treatment of SLE. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00181-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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47
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Clauw D. Time to Stop the Fibromyalgia Criteria Wars and Refocus on Identifying and Treating Individuals With This Type of Pain Earlier in Their Illness. Arthritis Care Res (Hoboken) 2021; 73:613-616. [PMID: 32248650 DOI: 10.1002/acr.24198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 01/11/2023]
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48
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Glia and Orofacial Pain: Progress and Future Directions. Int J Mol Sci 2021; 22:ijms22105345. [PMID: 34069553 PMCID: PMC8160907 DOI: 10.3390/ijms22105345] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 12/14/2022] Open
Abstract
Orofacial pain is a universal predicament, afflicting millions of individuals worldwide. Research on the molecular mechanisms of orofacial pain has predominately focused on the role of neurons underlying nociception. However, aside from neural mechanisms, non-neuronal cells, such as Schwann cells and satellite ganglion cells in the peripheral nervous system, and microglia and astrocytes in the central nervous system, are important players in both peripheral and central processing of pain in the orofacial region. This review highlights recent molecular and cellular findings of the glia involvement and glia–neuron interactions in four common orofacial pain conditions such as headache, dental pulp injury, temporomandibular joint dysfunction/inflammation, and head and neck cancer. We will discuss the remaining questions and future directions on glial involvement in these four orofacial pain conditions.
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Stanculescu D, Larsson L, Bergquist J. Theory: Treatments for Prolonged ICU Patients May Provide New Therapeutic Avenues for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Front Med (Lausanne) 2021; 8:672370. [PMID: 34026797 PMCID: PMC8137963 DOI: 10.3389/fmed.2021.672370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/01/2021] [Indexed: 12/20/2022] Open
Abstract
We here provide an overview of treatment trials for prolonged intensive care unit (ICU) patients and theorize about their relevance for potential treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Specifically, these treatment trials generally target: (a) the correction of suppressed endocrine axes, notably through a "reactivation" of the pituitary gland's pulsatile secretion of tropic hormones, or (b) the interruption of the "vicious circle" between inflammation, oxidative and nitrosative stress (O&NS), and low thyroid hormone function. There are significant parallels in the treatment trials for prolonged critical illness and ME/CFS; this is consistent with the hypothesis of an overlap in the mechanisms that prevent recovery in both conditions. Early successes in the simultaneous reactivation of pulsatile pituitary secretions in ICU patients-and the resulting positive metabolic effects-could indicate an avenue for treating ME/CFS. The therapeutic effects of thyroid hormones-including in mitigating O&NS and inflammation and in stimulating the adreno-cortical axis-also merit further studies. Collaborative research projects should further investigate the lessons from treatment trials for prolonged critical illness for solving ME/CFS.
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Affiliation(s)
| | - Lars Larsson
- Basic and Clinical Muscle Biology, Department of Physiology and Pharmacology, Karolinska Institute, Solna, Sweden
| | - Jonas Bergquist
- Analytical Chemistry and Neurochemistry, Department of Chemistry–Biomedical Center, Uppsala University, Uppsala, Sweden
- The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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50
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Rahman MS, Winsvold BS, Chavez Chavez SO, Børte S, Tsepilov YA, Sharapov SZ, Aulchenko YS, Hagen K, Fors EA, Hveem K, Zwart JA, van Meurs JB, Freidin MB, Williams FM. Genome-wide association study identifies RNF123 locus as associated with chronic widespread musculoskeletal pain. Ann Rheum Dis 2021; 80:1227-1235. [PMID: 33926923 PMCID: PMC8372387 DOI: 10.1136/annrheumdis-2020-219624] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/18/2022]
Abstract
Background and objectives Chronic widespread musculoskeletal pain (CWP) is a symptom of fibromyalgia and a complex trait with poorly understood pathogenesis. CWP is heritable (48%–54%), but its genetic architecture is unknown and candidate gene studies have produced inconsistent results. We conducted a genome-wide association study to get insight into the genetic background of CWP. Methods Northern Europeans from UK Biobank comprising 6914 cases reporting pain all over the body lasting >3 months and 242 929 controls were studied. Replication of three independent genome-wide significant single nucleotide polymorphisms was attempted in six independent European cohorts (n=43 080; cases=14 177). Genetic correlations with risk factors, tissue specificity and colocalisation were examined. Results Three genome-wide significant loci were identified (rs1491985, rs10490825, rs165599) residing within the genes Ring Finger Protein 123 (RNF123), ATPase secretory pathway Ca2+transporting 1 (ATP2C1) and catechol-O-methyltransferase (COMT). The RNF123 locus was replicated (meta-analysis p=0.0002), the ATP2C1 locus showed suggestive association (p=0.0227) and the COMT locus was not replicated. Partial genetic correlation between CWP and depressive symptoms, body mass index, age of first birth and years of schooling were identified. Tissue specificity and colocalisation analysis highlight the relevance of skeletal muscle in CWP. Conclusions We report a novel association of RNF123 locus and a suggestive association of ATP2C1 locus with CWP. Both loci are consistent with a role of calcium regulation in CWP. The association with COMT, one of the most studied genes in chronic pain field, was not confirmed in the replication analysis.
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Affiliation(s)
- Md Shafiqur Rahman
- Department of Twin Research and Genetic Epidemiology, School of Life Course Sciences, King's College London, London, UK
| | - Bendik S Winsvold
- Department of Research, Innovation and Education,Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.,Department of Neurology, Oslo universitetssykehus Ullevål, Oslo, Norway.,K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sergio O Chavez Chavez
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Sigrid Børte
- K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Research and Communication Unit for Musculoskeletal Health (FORMI), Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yakov A Tsepilov
- Laboratory of Theoretical and Applied Functional Genomics, Novosibirsk State University, Novosibirsk, 630090, Novosibirskaâ, Russia.,PolyOmica, 's-Hertogenbosch, PA, The Netherlands.,Laboratory of Recombination and Segregation Analysis, Institute of Cytology and Genetics, 10 Lavrentiev Avenue, Novosibirsk, 630090, Russia
| | - Sodbo Zh Sharapov
- Laboratory of Theoretical and Applied Functional Genomics, Novosibirsk State University, Novosibirsk, 630090, Novosibirskaâ, Russia.,Laboratory of Recombination and Segregation Analysis, Institute of Cytology and Genetics, 10 Lavrentiev Avenue, Novosibirsk, 630090, Russia
| | | | - Yurii S Aulchenko
- Laboratory of Theoretical and Applied Functional Genomics, Novosibirsk State University, Novosibirsk, 630090, Novosibirskaâ, Russia.,PolyOmica, 's-Hertogenbosch, PA, The Netherlands
| | - Knut Hagen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Clinical Research Unit Central Norway, St Olavs University Hospital, Trondheim, Norway
| | - Egil A Fors
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristian Hveem
- K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,HUNT Research Center, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - John Anker Zwart
- Department of Research, Innovation and Education,Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.,K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Institute of Clinical Medicine,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Joyce B van Meurs
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Maxim B Freidin
- Department of Twin Research and Genetic Epidemiology, School of Life Course Sciences, King's College London, London, UK
| | - Frances Mk Williams
- Department of Twin Research and Genetic Epidemiology, School of Life Course Sciences, King's College London, London, UK
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