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Ma T, Qi H, Mao Y, Wang Y, Duan B, Ma K. Comparative Efficacy and Safety of Antidepressants for Patients with Chronic Back Pain: A Network Meta-Analysis. J Clin Pharmacol 2024; 64:205-214. [PMID: 37794650 DOI: 10.1002/jcph.2365] [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: 05/19/2023] [Accepted: 09/30/2023] [Indexed: 10/06/2023]
Abstract
Various antidepressants have introduced in clinical practice for pain management, but it is important to understand how to properly use them. We therefore performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of antidepressants for patients with chronic back pain. We identified eligible randomized controlled trials (RCTs) that investigated the efficacy and safety of antidepressants for chronic back pain from PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov, searching from inception to May 2023. Six categories of antidepressants for the treatment of chronic back pain were included, and the surface under the cumulative ranking probabilities was applied to rank the treatment strategies. Overall, we selected 19 RCTs recruiting 2903 patients for the meta-analysis. Tricyclic antidepressants presented the best relative effects for relief in pain score (surface under the cumulative ranking, 84.4%). The results of pairwise comparison analyses found the use of serotonin-noradrenaline reuptake inhibitors (SNRIs) significantly reduced pain score and low disability score compared with placebo, irrespective of treatment duration. Noradrenaline-dopamine reuptake inhibitors (relative risk [RR], 2.80; 95% confidence interval [CI], 1.30-6.03; P = .008) and SNRIs (RR, 1.17; 95% CI, 1.07-1.27; P < .001) significantly increased the risk of adverse events. SNRIs were associated with an increased risk of withdrawal due to adverse events (RR, 2.37; 95% CI, 1.64-3.43; P < .001). This study found that antidepressants are more efficacious than placebos for treating chronic back pain, and tricyclic antidepressants are the most likely medications that lead to pain relief.
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Affiliation(s)
- Tao Ma
- Department of Algology, Qinghai Provincial People's Hospital, Xining, China
| | - Hongyu Qi
- Department of Gastroenterology, Qinghai Provincial People's Hospital, Xining, China
| | - Yuanrong Mao
- Department of Algology, Qinghai Provincial People's Hospital, Xining, China
| | - Ya Wang
- Department of Algology, Qinghai Provincial People's Hospital, Xining, China
| | - Baolin Duan
- Department of Algology, Qinghai Provincial People's Hospital, Xining, China
| | - Ke Ma
- Department of Algology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Birkinshaw H, Friedrich CM, Cole P, Eccleston C, Serfaty M, Stewart G, White S, Moore RA, Phillippo D, Pincus T. Antidepressants for pain management in adults with chronic pain: a network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD014682. [PMID: 37160297 PMCID: PMC10169288 DOI: 10.1002/14651858.cd014682.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well-being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients' global impression of change for certain chronic pain conditions. However, there has not been a network meta-analysis (NMA) examining all antidepressants across all chronic pain conditions. OBJECTIVES To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. SELECTION CRITERIA We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double-blind. We included RCTs with active comparators that were unable to be double-blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow-up was less than two weeks and those with fewer than 10 participants in each arm. DATA COLLECTION AND ANALYSIS: Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta-analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta-Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB-MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. MAIN RESULTS This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo-controlled (83), and parallel-armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate-certainty evidence) and continuous pain intensity (standardised mean difference (SMD) -0.31, 95% CI -0.39 to -0.24; 18 studies, 4959 participants; moderate-certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD -0.22, 95% CI -0.39 to 0.06; 4 studies, 1866 participants; moderate-certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD -0.5, 95% CI -0.78 to -0.22; 1 study, 406 participants; low-certainty evidence), while duloxetine showed a small effect (SMD -0.16, 95% CI -0.22 to -0.1; 26 studies, 7952 participants; moderate-certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest-ranked antidepressants with moderate-certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low-certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. AUTHORS' CONCLUSIONS Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point.
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Affiliation(s)
- Hollie Birkinshaw
- Department of Psychology, University of Southampton, Southampton, UK
| | | | - Peter Cole
- Oxford Pain Relief Unit, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | | | | | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | | | | | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, UK
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Risk of cardiovascular events according to the tricyclic antidepressant dosage in patients with chronic pain: a retrospective cohort study. Eur J Clin Pharmacol 2023; 79:159-171. [PMID: 36443528 DOI: 10.1007/s00228-022-03421-z] [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: 05/24/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to examine the risk of cardiovascular adverse events by tricyclic antidepressant (TCA) dosage among patients with chronic pain. METHODS A retrospective cohort study was conducted using a nationwide sample cohort. Among patients aged ≥ 18 years with a chronic pain diagnosis and no history of cardiovascular events, we extracted users and non-users of TCAs through 1:1 propensity score matching. TCA users were categorized into three groups according to the mean defined daily dose (DDD): very low doses (< 0.15 DDD), low doses (0.15-0.34 DDD), and traditional doses (≥ 0.34 DDD). A 6-month follow-up was conducted with an intention-to-treat approach. We examined the hazard ratio of cardiovascular adverse events using Cox proportional hazards analysis. RESULTS In total, 16,660 matched patients were followed up (8330 TCA users and 8330 non-users). TCA use did not significantly increase cardiovascular adverse events (hazard ratio [HR] 1.12, 95% confidence interval [CI] 0.94-1.33). Low-dose (0.15-0.34 DDD) TCAs (HR 1.37, 95% CI 1.08-1.74), particularly low-dose (0.15-0.34 DDD) nortriptyline (HR 2.11, 95% CI 1.44-3.08), was associated with an increased risk of cardiovascular adverse events. Administration of TCAs at the traditional dose (≥ 0.34 DDD) increased the risk of ischemic stroke (HR 2.08, 95% CI 1.11-3.88). CONCLUSION Close monitoring of patients on long-term, low-dose use of TCAs should be conducted to avoid an increase in the cumulative dose, which increases the risk of cardiovascular adverse events.
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Modarresi S, Lukacs MJ, Ghodrati M, Salim S, MacDermid JC, Walton DM. A Systematic Review and Synthesis of Psychometric Properties of the Numeric Pain Rating Scale and the Visual Analog Scale for Use in People With Neck Pain. Clin J Pain 2021; 38:132-148. [PMID: 34699406 DOI: 10.1097/ajp.0000000000000999] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To conduct a systematic search and synthesis of evidence about the measurement properties of the Numeric Pain Rating Scale (NPRS) and the Visual Analog Scale (VAS) as patient-reported outcome measures in neck pain research. METHODS AND MATERIALS CINAHL, Embase, PsychInfo, and MedLine databases were searched to identify studies evaluating the psychometric properties of the NPRS and the VAS used in samples of which >50% of participants were people with neck pain. Quality and consistency of findings were synthesized to arrive at recommendations. RESULTS A total of 46 manuscripts were included. Syntheses indicated high-to-moderate-quality evidence of good-to-excellent (intraclass correlation coefficient 0.58 to 0.93) test-retest reliability over an interval of 7 hours to 4 weeks. Moderate evidence of a clinically important difference of 1.5 to 2.5 points was found, while minimum detectable change ranged from 2.6 to 4.1 points. Moderate evidence of a moderate association (r=0.48 to 0.54) between the NPRS or VAS and the Neck Disability Index. Findings from other patient-reported outcomes indicated stronger associations with ratings of physical function than emotional status. There is limited research addressing the extent that these measures reflect outcomes that are important to patients. DISCUSSION It is clear NPRS and the VAS ratings are feasible to implement, provide reliable scores and relate to multi-item patient-reported outcome measures. Responsiveness (meaningful change) of the scales and interpretation of change scores requires further refinement. The NPRS can be a useful single-item assessment complimenting more comprehensive multi-item patient-reported outcome measures in neck pain research and practice.
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Affiliation(s)
- Shirin Modarresi
- School of Physical Therapy
- Department of Health and Rehabilitation Sciences, Western University, London
| | - Michael J Lukacs
- Department of Health and Rehabilitation Sciences, Western University, London
| | - Maryam Ghodrati
- Department of Health and Rehabilitation Sciences, Western University, London
| | - Shahan Salim
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Joy C MacDermid
- School of Physical Therapy
- Department of Health and Rehabilitation Sciences, Western University, London
| | - David M Walton
- School of Physical Therapy
- Department of Health and Rehabilitation Sciences, Western University, London
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O'Brien JB, Roman DL. Novel treatments for chronic pain: moving beyond opioids. Transl Res 2021; 234:1-19. [PMID: 33727192 DOI: 10.1016/j.trsl.2021.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023]
Abstract
It is essential that safe and effective treatment options be available to patients suffering from chronic pain. The emergence of an opioid epidemic has shaped public opinions and created stigmas surrounding the use of opioids for the management of pain. This reality, coupled with high risk of adverse effects from chronic opioid use, has led chronic pain patients and their healthcare providers to utilize nonopioid treatment approaches. In this review, we will explore a number of cellular reorganizations that are associated with the development and progression of chronic pain. We will also discuss the safety and efficacy of opioid and nonopioid treatment options for chronic pain. Finally, we will review the evidence for adenylyl cyclase type 1 (AC1) as a novel target for the treatment of chronic pain.
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Affiliation(s)
- Joseph B O'Brien
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - David L Roman
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, Iowa; Iowa Neuroscience Institute, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa.
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Nijs J, George SZ, Clauw DJ, Fernández-de-Las-Peñas C, Kosek E, Ickmans K, Fernández-Carnero J, Polli A, Kapreli E, Huysmans E, Cuesta-Vargas AI, Mani R, Lundberg M, Leysen L, Rice D, Sterling M, Curatolo M. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. THE LANCET. RHEUMATOLOGY 2021; 3:e383-e392. [PMID: 38279393 DOI: 10.1016/s2665-9913(21)00032-1] [Citation(s) in RCA: 180] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 12/15/2022]
Abstract
Chronic pain is a leading cause of disability globally and associated with enormous health-care costs. The discrepancy between the extent of tissue damage and the magnitude of pain, disability, and associated symptoms represents a diagnostic challenge for rheumatology specialists. Central sensitisation, defined as an amplification of neural signalling within the CNS that elicits pain hypersensitivity, has been investigated as a reason for this discrepancy. Features of central sensitisation have been documented in various pain conditions common in rheumatology practice, including fibromyalgia, osteoarthritis, rheumatoid arthritis, Ehlers-Danlos syndrome, upper extremity tendinopathies, headache, and spinal pain. Within individual pain conditions, there is substantial variation among patients in terms of presence and magnitude of central sensitisation, stressing the importance of individual assessment. Central sensitisation predicts poor treatment outcomes in multiple patient populations. The available evidence supports various pharmacological and non-pharmacological strategies to reduce central sensitisation and to improve patient outcomes in several conditions commonly seen in rheumatology practice. These data open up new treatment perspectives, with the possibility for precision pain medicine treatment according to pain phenotyping as a logical next step. With this view, studies suggest the possibility of matching non-pharmacological approaches, or medications, or both to the central sensitisation pain phenotypes.
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Affiliation(s)
- Jo Nijs
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic pain rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium; Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, and Center for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham NC, USA
| | - Daniel J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kelly Ickmans
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic pain rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Josué Fernández-Carnero
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Andrea Polli
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Eleni Kapreli
- Clinical Exercise Physiology and Rehabilitation Research Laboratory, Physiotherapy Department, Faculty of Health Sciences, University of Thessaly, Lamia, Greece
| | - Eva Huysmans
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Chronic pain rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Belgium; Research Foundation - Flanders (FWO), Brussels, Belgium
| | - Antonio I Cuesta-Vargas
- Cátedra de Fisioterapia, Universidad de Malaga, Andalucia Tech, Instituto de Investigacion Biomédica de Malaga (IBIMA) Grupo de Clinimetria (F-14), Malaga, Spain
| | - Ramakrishnan Mani
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy and Pain@Otago Research Theme, University of Otago, Dunedin, New Zealand
| | - Mari Lundberg
- Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, and Center for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Laurence Leysen
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - David Rice
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand; Waitemata Pain Service, Department of Anaesthesiology and Perioperative Medicine, Waitemata District Health Board, Auckland, New Zealand
| | - Michele Sterling
- Recover Injury Research Centre and NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, University of Queensland, Brisbane, QLD, Australia
| | - Michele Curatolo
- CLEAR Center for Musculoskeletal Disorders, Harborview Injury Prevention and Research Center, and Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle WA, USA
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Comparison between Two Low Doses of Amitriptyline in the Management of Chronic Neck Pain: A Randomized, Double-Blind, Comparative Study. Pain Res Manag 2021; 2021:8810178. [PMID: 33532013 PMCID: PMC7837778 DOI: 10.1155/2021/8810178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/10/2021] [Indexed: 12/28/2022]
Abstract
Chronic neck pain (CNP) is a major concern for pain therapists. Many drugs including antidepressants such as amitriptyline have been used in the management of CNP. This study compared the efficacy and safety of 2 different doses of amitriptyline (5 mg and 10 mg at bedtime) in patients with CNP. A total of 80 patients of both sexes with idiopathic CNP, ranging in age from 18 to 75 years, were divided into 2 groups that received 5 or 10 mg oral amitriptyline at bedtime for 120 days. The primary outcome measure was neck pain disability index (NPDI). Neck pain intensity, Athens Insomnia Scale score, Hospital Anxiety and Depression Scale (HADS), side effects of the drug, and patient satisfaction were secondary outcome measures. NPDI decreased by 71.9% ± 13.4% in the 10 mg group compared to 47.3% ± 17.3% in the 5 mg group, representing a statistically significant difference (95% confidence interval: 27.3–12.6). Additionally, the 10 mg group showed greater mean reductions in pain score and HADS scores (both the anxiety and depression subscales), as well as improvement in sleep disturbance compared to the 5 mg group. A higher dose (10 mg) of amitriptyline at bedtime significantly reduced neck pain intensity, sleep disturbance, and anxiety and depression compared to a lower dose (5 mg) in patients with idiopathic and nontraumatic CNP after 120 days of treatment, with no significant difference between groups in the rate of side effects.
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Ferreira GE, McLachlan AJ, Lin CWC, Zadro JR, Abdel-Shaheed C, O'Keeffe M, Maher CG. Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. BMJ 2021; 372:m4825. [PMID: 33472813 PMCID: PMC8489297 DOI: 10.1136/bmj.m4825] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, International Pharmaceutical Abstracts, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to 15 November and updated on 12 May 2020. ELIGIBILITY CRITERIA FOR STUDY SELECTION Randomised controlled trials comparing the efficacy or safety, or both of any antidepressant drug with placebo (active or inert) in participants with low back or neck pain, sciatica, or hip or knee osteoarthritis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data. Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). A random effects model was used to calculate weighted mean differences and 95% confidence intervals. Safety (any adverse event, serious adverse events, and proportion of participants who withdrew from trials owing to adverse events) was a secondary outcome. Risk of bias was assessed with the Cochrane Collaboration's tool and certainty of evidence with the grading of recommendations assessment, development and evaluation (GRADE) framework. RESULTS 33 trials (5318 participants) were included. Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference -5.30, 95% confidence interval -7.31 to -3.30) at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain (-9.72, -12.75 to -6.69) at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less (-18.60, -31.87 to -5.33) but not at 3-13 weeks (-17.50, -42.90 to 7.89). Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less (-7.55, -18.25 to 3.15) but did at 3-13 weeks (-15.95, -31.52 to -0.39) and 3-12 months (-27.0, -36.11 to -17.89). Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks (-3.55, -5.22 to -1.88) and disability due to osteoarthritis at two weeks or less (-5.10, -7.31 to -2.89), with low certainty evidence at 3-13 weeks (-6.07, -8.13 to -4.02). TCAs and other antidepressants did not reduce pain or disability from back pain. CONCLUSION Moderate certainty evidence shows that the effect of SNRIs on pain and disability scores is small and not clinically important for back pain, but a clinically important effect cannot be excluded for osteoarthritis. TCAs and SNRIs might be effective for sciatica, but the certainty of evidence ranged from low to very low. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020158521.
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Affiliation(s)
- Giovanni E Ferreira
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
- Institute for Musculoskeletal Health, Sydney, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
| | - Chung-Wei Christine Lin
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
- Institute for Musculoskeletal Health, Sydney, Australia
| | | | - Christina Abdel-Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
- Institute for Musculoskeletal Health, Sydney, Australia
| | - Mary O'Keeffe
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
- Institute for Musculoskeletal Health, Sydney, Australia
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Republic of Ireland
| | - Chris G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
- Institute for Musculoskeletal Health, Sydney, Australia
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Ethosuximide improves chronic pain-induced anxiety- and depression-like behaviors. Eur Neuropsychopharmacol 2019; 29:1419-1432. [PMID: 31767519 DOI: 10.1016/j.euroneuro.2019.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 08/30/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023]
Abstract
Chronic pain is a heavy burden disease. Current treatments are generally weakly effective or associated with adverse effects. New therapeutic approaches are therefore needed. Recent studies have suggested T-type calcium channels as an attractive target for the treatment of chronic pain. In this perspective, it was decided to perform a preclinical evaluation of the efficacy of ethosuximide, a T-type channel blocker used clinically as an antiepileptic, as a novel pharmacological treatment for chronic pain. Assessment of the effect of ethosuximide was thus made in both nociception and pain-related comorbidities as anxiety and depression are frequently encountered in chronic pain patients. Our results show that such symptoms occurred in three animal models of chronic pain designed to reflect traumatic neuropathic, chemotherapy-induced neuropathic and inflammatory pain conditions. Administration of ethosuximide reduced both chronic pain and comorbidities with a marked intensity ranging from partial reduction to a complete suppression of symptoms. These results make ethosuximide, and more broadly the inhibition of T-type calcium channels, a new strategy for the management of uncontrolled chronic pain, likely to improve not only pain but also the accompanying anxiety and depression.
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Exposto FG, Arima T, Svensson P. Sleep Disorders and Chronic Orofacial Pain. CURRENT SLEEP MEDICINE REPORTS 2019. [DOI: 10.1007/s40675-019-00152-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Reynolds AC, Adams RJ. Treatment of sleep disturbance in older adults. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1565] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Amy C. Reynolds
- The Appleton Institute CQUniversity Australia Adelaide Australia
- School of Health Medical and Applied Sciences CQUniversity Adelaide Australia
| | - Robert J. Adams
- Adelaide Institute for Sleep Health Flinders University Adelaide Australia
- Respiratory and Sleep Service Southern Adelaide Local Health Network Adelaide Australia
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Kerckhove N, Pereira B, Soriot-Thomas S, Alchaar H, Deleens R, Hieng VS, Serra E, Lanteri-Minet M, Arcagni P, Picard P, Lefebvre-Kuntz D, Maindet C, Mick G, Balp L, Lucas C, Creach C, Letellier M, Martinez V, Navez M, Delbrouck D, Kuhn E, Piquet E, Bozzolo E, Brosse C, Lietar B, Marcaillou F, Hamdani A, Leroux-Bromberg N, Perier Y, Vergne-Salle P, Gov C, Delage N, Gillet D, Romettino S, Richard D, Mallet C, Bernard L, Lambert C, Dubray C, Duale C, Eschalier A. Efficacy and safety of a T-type calcium channel blocker in patients with neuropathic pain: A proof-of-concept, randomized, double-blind and controlled trial. Eur J Pain 2018; 22:1321-1330. [PMID: 29577519 DOI: 10.1002/ejp.1221] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND T-type calcium channels have been shown to play an important role in the initiation and maintenance of neuropathic pain and represent a promising therapeutic target for new analgesic treatments. Ethosuximide (ETX), an anticonvulsant and a T-type channel blocker has shown analgesic effect in several chronic pain models but has not yet been evaluated in patients with neuropathic pain. METHODS This proof-of-concept, multicentre, double-blind, controlled and randomized trial compared the efficacy and safety of ETX (given as add-on therapy) to an inactive control (IC) in 114 patients with non-diabetic peripheral neuropathic pain. After a 7-day run-in period, eligible patients aged over 18 years were randomly assigned (1:1) to ETX or IC for 6 weeks. The primary outcome was the difference between groups in the pain intensity (% of change from the baseline to end of treatment) assessed in the intention-to-treat population. This study is registered with EudraCT (2013-004801-26) and ClinicalTrials.gov (NCT02100046). RESULTS The study was stopped during the interim analysis due to the high number of adverse events in the active treatment group. ETX failed to reduce total pain and showed a poor tolerance in comparison to IC. In the per-protocol analysis, ETX significantly reduced pain intensity by 15.6% (95% CI -25.8; -5.4) from baseline compared to IC (-7.8%, 95% CI -14.3; -1.3; p = 0.033), but this result must be interpreted with caution because of a small subgroup of patients. CONCLUSION Ethosuximide did not reduce the severity of neuropathic pain and induces, at the doses used, many adverse events. SIGNIFICANCE This article shows that ETX is not effective to treat neuropathic pain. Nevertheless, per-protocol analysis suggests a possible analgesic effect of ETX. Thus, our work adds significant knowledge to preclinical and clinical data on the benefits of T-type calcium channel inhibition for the treatment of neuropathic pain.
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Affiliation(s)
- N Kerckhove
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France.,Analgesia Institute, Université Clermont Auvergne, Clermont-Ferrand, France
| | - B Pereira
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | | | - H Alchaar
- Université Nice Côte-d'Azur, CHU Nice - Hôpital de Cimiez, Fédération Hospitalo-Universitaire INOVPAIN, CETD, Nice, France
| | | | | | - E Serra
- CHU Amiens Picardie, CETD, CRC, Amiens, France
| | - M Lanteri-Minet
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France.,Université Nice Côte-d'Azur, CHU Nice - Hôpital de Cimiez, Fédération Hospitalo-Universitaire INOVPAIN, CETD, Nice, France
| | - P Arcagni
- CHU Saint-Etienne, CETD, Saint-Etienne, France
| | - P Picard
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | | | - C Maindet
- CHU Grenoble Alpes, CETD, Grenoble, France
| | - G Mick
- CH Voiron, UETD, Voiron, France
| | - L Balp
- CH Lons-le-Saunier, CETD, Lons-le-Saunier, France
| | - C Lucas
- Université Lille Nord de France, CHRU Lille, CETD, Lille, France
| | - C Creach
- CHU Saint-Etienne, CETD, Saint-Etienne, France
| | | | - V Martinez
- AP-HP - Hôpital Raymond Poincaré, CETD, Paris, France
| | - M Navez
- CHU Saint-Etienne, CETD, Saint-Etienne, France
| | | | - E Kuhn
- CHU Nantes, CETD, Nantes, France
| | - E Piquet
- Université Nice Côte-d'Azur, CHU Nice - Hôpital de Cimiez, Fédération Hospitalo-Universitaire INOVPAIN, CETD, Nice, France
| | - E Bozzolo
- Université Nice Côte-d'Azur, CHU Nice - Hôpital de Cimiez, Fédération Hospitalo-Universitaire INOVPAIN, CETD, Nice, France
| | - C Brosse
- CHU Saint-Etienne, CETD, Saint-Etienne, France
| | - B Lietar
- CHU Saint-Etienne, CETD, Saint-Etienne, France
| | - F Marcaillou
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | - A Hamdani
- Cancer Centre Oscar-Lambret, Lille, France
| | | | - Y Perier
- CH Avranches, CETD, Avranches, France
| | | | - C Gov
- HCL - Hôpital Neurologique, CETD, Lyon, France
| | - N Delage
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | | | - S Romettino
- Université Nice Côte-d'Azur, CHU Nice - Hôpital de Cimiez, Fédération Hospitalo-Universitaire INOVPAIN, CETD, Nice, France
| | - D Richard
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | - C Mallet
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | - L Bernard
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | - C Lambert
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France
| | - C Dubray
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France.,Analgesia Institute, Université Clermont Auvergne, Clermont-Ferrand, France
| | - C Duale
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France.,Analgesia Institute, Université Clermont Auvergne, Clermont-Ferrand, France
| | - A Eschalier
- Service de Pharmacologie Médicale, Direction de la Recherche Clinique et de l'Innovation, CETD, CIC, CNRS, SIGMA Clermont, ICCF, Service de Pharmacie, Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM - NEURO-DOL, Clermont-Ferrand, France.,Analgesia Institute, Université Clermont Auvergne, Clermont-Ferrand, France
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