Targeted Use of Placebo Effects Decreases Experimental Itch in Atopic Dermatitis Patients: A Randomized Controlled Trial

Shaping Treatment Expectation to Optimize Efficacy of Interleukin 17A Antagonist Secukinumab in Psoriasis Patients

Purpose

Patients' treatment expectations significantly influence the effectiveness of medical and pharmacological treatments. This clinical proof-of-concept study aimed to enhance treatment outcomes by targeting positive treatment expectations of psoriasis patients beginning systemic anti-psoriatic therapy with secukinumab, an interleukin (IL)-17A antagonist.

Patients and Methods

We randomly assigned patients to three groups: a treatment as usual (TAU) group receiving the standard 300mg dose of secukinumab, a dose-control (DC) group with 75% dose reduction and an experimental (EXP) group receiving the same reduced dose along with a "cover story" designed to positively influence treatment expectations. We evaluated skin symptoms using the Psoriasis Area and Severity Index (PASI), the Dermatology Life Quality Index (DLQI), perceived itch, mood and plasma IL-17A levels at baseline and at 1, 2, 3, 4, 8, 12, and 16 weeks post intervention.

Results

The study included N = 120 patients (average age = 45.78 years, 34% female). A high baseline expectation level (8.1 of 10 points) was observed across all groups which could not be further increased by the EXP-group's "cover story". The EXP and DC groups did not differ with regard to reaching 75% improvement in PASI scores (PASI75), a DLQI score of 0 or 1 or at least 4 points improvement in itch. Over time, the EXP-group showed a faster decline in PASI scores and anxiety symptoms compared to the DC-group, but less improvement in quality of life. IL-17A levels significantly increased throughout the treatment, with no significant differences between groups despite the 75% dose reduction.

Conclusion

This study demonstrates an attempt to modify patients' treatment expectations to enhance the effectiveness of pharmacological therapy with secukinumab in psoriasis patients. However, verbal suggestion alone did not significantly improve clinical outcomes, suggesting that future studies should explore alternative approaches to leverage placebo effects to the benefit of patients with psoriasis.

Placebo and nocebo effects and mechanisms associated with pharmacological interventions: an umbrella review

OBJECTIVES

This review aimed to summarise the existing knowledge about placebo and nocebo effects associated with pharmacological interventions and their mechanisms.

DESIGN

Umbrella review, adopting the Assessment of Multiple Systematic Reviews 2 tool for critical appraisal.

DATA SOURCES

MEDLINE/PubMed, Scopus, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trial were searched in September 2022, without any time restriction, for systematic reviews, narrative reviews, original articles. Results were summarised through narrative synthesis, tables, 95% CI.

OUTCOME MEASURES

Mechanisms underlying placebo/nocebo effects and/or their effect sizes.

RESULTS

The databases search identified 372 studies, for a total of 158 312 participants, comprising 41 systematic reviews, 312 narrative reviews and 19 original articles. Seventy-three per cent of the examined systematic reviews were of high quality.Our findings revealed that mechanisms underlying placebo and/or nocebo effects have been characterised, at least in part, for: pain, non-noxious somatic sensation, Parkinson's disease, migraine, sleep disorders, intellectual disability, depression, anxiety, dementia, addiction, gynaecological disorders, attention-deficit hyperactivity disorder, immune and endocrine systems, cardiovascular and respiratory systems, gastrointestinal disorders, skin diseases, influenza and related vaccines, oncology, obesity, physical and cognitive performance. Their magnitude ranged from 0.08 to 2.01 (95% CI 0.37 to 0.89) for placebo effects and from 0.32 to 0.90 (95% CI 0.24 to 1.00) for nocebo effects.

CONCLUSIONS

This study provides a valuable tool for clinicians and researchers, identifying both results ready for clinical practice and gaps to address in the near future.

FUNDING

Università Cattolica del Sacro Cuore, Milan, Italy with the 'Finanziamento Ponte 2022' grant.

PROSPERO REGISTRATION NUMBER

CRD42023392281.

How familiar are German dermatologists with placebo and nocebo effects and to what extent are these targeted in clinical practice: A survey within the dermatological community

BACKGROUND

Every medical treatment inevitably comprises not only physiological, but also psychological components, reflected by placebo and nocebo effects, which significantly affect treatment outcome. However, the extent of knowledge on the mechanisms steering placebo and nocebo effects in the dermatological community in Germany is currently unclear.

OBJECTIVES

To assess the state of knowledge about placebo and nocebo effects in the German dermatological community, to evaluate whether this knowledge is already being used in clinical practice, and to investigate whether German dermatologists are interested in learning more about the topic.

METHODS

German Dermatologists, the majority working in their own practice, were asked to fill in an online survey addressing the knowledge about placebo and nocebo effects and the feasibility of special techniques to enhance placebo and minimize nocebo effects within the clinical routine.

RESULTS

N = 154 complete (79%) or partial (21%) responses to the survey were recorded in the online database and included in the analysis. All participants reported to know what the placebo effect is and 59.7% (74/124) indicated that they already had experience with prescribing or recommending a treatment without active substances. In contrast, only 62.0% (80/129) stated to know what the nocebo effect is. Participants showed a rather superficial knowledge regarding placebo and nocebo mechanisms. The majority of participants (76.7%, 99/129) expressed their willingness to be further educated about the underlying mechanisms mediating placebo and nocebo effects and the possible application in clinical practice.

CONCLUSIONS

The current survey offers a so far unique insight into the state of knowledge of German dermatologists on placebo and nocebo effects. The results indicate a need for education about this topic. Encouragingly, however, German dermatologists considered communication strategies to maximize placebo and reduce nocebo effects and expressed motivation to be trained to implement these strategies in everyday clinical practice.

Placebo: a brief updated review

Our aims were to provide updated information on placebo/nocebo effect and the potential use of placebo in clinical practice. This article can only provide a rough overview on the placebo and nocebo effect and is intended to serve as a starting point for the reader to go deeper into the corresponding literature. The placebo effect has been observed in multiple medical conditions, after oral administration, with manual therapies as well as with surgery and invasive procedures. The use of placebo in clinical trials is fundamental, although the ethics of its use is under discussion. The placebo may behave like a drug from the pharmacokinetic and pharmacodynamic point of view and can also be associated with adverse events (nocebo effect). Placebo can modify treatment by increasing or decreasing the effects of drugs. The factors associated with the occurrence of placebo effect are multiple, but in addition to those that depend on the placebo itself, the doctor-patient relationship would be the most important. As a result of findings that were published in the last two decades, the psycho-neurobiological basis of placebo is becoming better understood, although further studies are needed. In conclusion, the placebo effect in the clinic exhibits weak to moderate intensity. Placebo, in addition to its use in the clinical trial, should be considered another therapeutic remedy either as stand alone or in association with treatment, and could be useful in certain circumstances. The use of placebo should be regulated by the European health authorities through a guide in clinical practice that will improve patient care.

[Relevance of demographic and psychological factors in pruritus]

BACKGROUND

Pruritus is a frequent phenomenon in patients in dermatology. The severity of pruritus often cannot be explained by the severity of the underlying disease or chronification processes alone. Especially then, demographic and psychological variables should also be considered as moderators of the intensity of pruritus.

PURPOSE

Are there associations between sex, age, emotional and cognitive factors and pruritus intensity in patients with chronic pruritus (CP) and skin-healthy control subjects?

MATERIAL AND METHODS

Recently published studies on the abovenamed moderators of pruritus were searched for in PubMed, collated and the results are summarized.

RESULTS

It was found that women reported a higher intensity of pruritus than men. In addition, negative emotions such as fear, disgust, and anger are positively associated with pruritus in patients with CP. There are also associations between cognitive factors, such as attention, catastrophizing, and pruritus.

CONCLUSION

The associations between both demographic and psychological factors and pruritus should be considered in the diagnostics and treatment of pruritus. A psychological intervention as a complementary treatment should be considered whenever patients report associations between psychological experiences and pruritus and/or automatic or extensive scratching.

Observing treatment outcomes in other patients can elicit augmented placebo effects on pain treatment: a double-blinded randomized clinical trial with patients with chronic low back pain

ABSTRACT

Clinical research on social observational learning (SoL) as an underlying mechanism for inducing expectancy and eliciting analgesic placebo effects is lacking. This double-blinded randomized controlled clinical trial investigated the influence of SoL on medication-augmenting placebo effects in 44 patients with chronic low back pain. Our hypothesis was that observing positive drug effects on pain and mobility in another patient could increase pain reduction and functional capacity. To test this, we compared the effects of observing positive treatment outcomes in a sham patient (the social learning group [SoLG]) vs hearing the same sham patient report neutral effects (the control group). In the SoLG, the sham patient told peers about pain reduction due to amitriptyline and demonstrated his improved mobility by bending forwards and sideways while he told the control group only that he was taking amitriptyline. The primary outcome was a reduction in clinical low back pain self-ratings. The secondary outcome was perceptions of pain-related disability. The exploratory outcome was mood and coping statements. Data collection occurred before and after the intervention and 2 weeks later. After the intervention, pain decreased in both groups (F [1, 41] = 7.16, P < 0.05, d = 0.83), with no difference between groups. However, the SoLG showed a significantly larger decrease in perceived disability (F [1, 41] = 5, P < 0.05, d = 0.63). The direct observation of patient with chronic low back pain of positive treatment outcomes in the sham patient seems to have enhanced the treatment effects while indirect verbal reports of reduced pain did not.

[Seeing others is believing-analgesic placebo effects through observational learning?]

Hintergrund

Es gibt viele Studien zur Placeboanalgesie und deren zugrundliegenden Wirkmechanismen, die eine Behandlung von Patient:innen mit chronischen Schmerzen signifikant verbessern können. Beobachtungslernen als ein Wirkmechanismus wurde hingegen noch wenig untersucht.

Fragestellung

Das Ziel der Arbeit ist es, einen Überblick über die aktuelle Forschungslage zu Placeboanalgesie durch Beobachtungslernen zu geben. Dabei soll geklärt werden, ob Beobachtungslernen überhaupt einen signifikanten Placeboeffekt auslösen kann und durch welche Faktoren dieses Lernen beeinflusst wird.

Material und Methoden

Dafür wurden die Forschungsdatenbanken nach Studien zur Placeboanalgesie durch Beobachtungslernen durchsucht.

Ergebnisse

Nach der Anwendung der Ein- und Ausschlusskriterien verblieben 12 Studien. Es gab nur eine Studie, die an Patient:innen mit chronischen Schmerzen durchgeführt wurde. Die geringe Anzahl an Studien lässt noch keine allgemeingültigen Aussagen zu, aber es gibt erste Hinweise für die folgenden Aussagen: Beobachtungslernen von Placeboeffekten ist unter Laborbedingungen möglich und eine Aufmerksamkeitslenkung ist wichtig. Die Effektstärken reichen von klein bis groß. Die Effekte von klassischer Konditionierung und Beobachtungslernen sind vergleichbar. Live-Modelle, Videoaufnahmen und Bilder lösen ähnliche Effekte aus. Beobachtungslernen führt zu einer Erwartungsänderung.

Diskussion

Die vorliegende Evidenz liefert die Grundlage dafür, dass theoretisch und auch praktisch klinisch signifikante Effekte möglich sind. Weitere Studien sind nötig, um diese Aussagen verlässlich auch auf chronische Schmerzpatient:innen zu beziehen.

[Systemic inflammation, "sickness behavior" and expectations : What role do expectations play in inflammation-associated symptoms?]

Hintergrund

Systemische Entzündungsprozesse gehen mit unspezifischen körperlichen und psychischen Krankheitssymptomen einher, darunter Schmerz und affektbezogene Symptome. Diese immunvermittelten Symptome („Sickness Behavior“) beruhen auf der zentralnervösen Wirkung von Immunbotenstoffen wie proinflammatorischen Zytokinen und vermitteln bei akuten Entzündungsreaktionen, etwa nach einer Impfung oder Verletzung, ein adaptives Schonverhalten. Bei chronischen Entzündungsprozessen können die Symptome des Sickness Behavior jedoch zu Einschränkungen der Lebensqualität führen und zur Komorbidität bei chronischen Schmerzerkrankungen beitragen. Trotz der hohen klinischen Relevanz des Sickness Behavior wurden bisher psychologische Ansätze zur Modulation der immunvermittelten Sickness-Symptome kaum untersucht. Einen Ansatz könnte die Nutzung von Erwartungseffekten bieten, da positive und negative Erwartungen (Placebo- bzw. Nocebo-Effekte) nachweislich einen Einfluss auf Schmerz und affektbezogene Symptome haben.

Ziel der Arbeit

In dieser Übersichtsarbeit werden die immunologischen und psychobiologischen Faktoren, die zu Schmerz im Kontext des Sickness Behavior beitragen, zusammengefasst. Aufbauend wird diskutiert, wie durch positive und negative Erwartungen Sickness-Symptome beeinflusst werden können und welche biologischen und psychologischen Mechanismen dabei involviert sind. Ziel ist es, potenzielle Ansatzpunkte zur Optimierung von Erwartungen im Kontext immunvermittelter Sickness-Symptome zu identifizieren. Perspektivisch lassen sich darauf aufbauend Interventionen entwickeln, um diese Symptome zu reduzieren sowie die Wirkungen und Nebenwirkungen von immunassoziierten Therapien durch gezielte Erwartungsinduktionen im Rahmen der Kommunikation mit Patient:innen positiv zu beeinflussen.

[The effect of treatment expectations on pruritus and skin pain]

Hintergrund

Patientenerwartungen in Bezug auf den Nutzen einer medizinischen Behandlung stellen eine wichtige Determinante für die Placeboantwort dar. Sie können Entwicklung und Verlauf von Erkrankungen sowie Wirksamkeit und Verträglichkeit von Therapien maßgeblich beeinflussen. Die Mechanismen, die diese Placebo- und Noceboeffekte vermitteln, wurden bislang am besten auf dem Gebiet der Placeboanalgesie beschrieben. Aber auch in der Dermatologie findet sich eine zunehmende Evidenz dafür, dass verschiedene Symptome wie Schmerzen an der Haut und Pruritus (Jucken) sowie verschiedene dermatologische Erkrankungen durch die Behandlungserwartungen von Patienten moduliert werden können.

Ziel der Arbeit

Das Ziel dieser Arbeit ist die Darstellung der aktuellen Datenlage in Bezug auf den Einfluss von Erwartungseffekten auf dermatologische Symptome wie Pruritus und Hautschmerzen sowie auf verschiedene dermatologische Erkrankungen. Schließlich soll die Bedeutung dieses Themas für Ärzte, die Patienten mit Hautsymptomen behandeln, vermittelt werden.

Material und Methoden

Es handelt sich um eine narrative Übersichtsarbeit.

Ergebnisse und Diskussion

Eine zunehmende Anzahl von Studien an gesunden Probanden und dermatologischen Patienten zeigt, dass Hautsymptome wie Pruritus und Schmerzen durch die Induktion positiver Erwartungen verringert und durch die Induktion negativer Erwartungen verstärkt werden können. Vorherige Behandlungserfahrungen der Patienten sowie die Qualität und Quantität der Arzt-Patienten-Kommunikation spielen für die Induktion der Behandlungserwartung eine zentrale Rolle.

Schlussfolgerung

Techniken, die darauf abzielen, positive Erwartungseffekte von Patienten mit Hautsymptomen zu maximieren und negative zu minimieren, sollten in die klinische Routine implementiert werden.