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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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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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Haddad HW, Jumonville AC, Stark KJ, Temple SN, Dike CC, Cornett EM, Kaye AD. The Role of Vitamin D in the Management of Chronic Pain in Fibromyalgia: A Narrative Review. Health Psychol Res 2021; 9:25208. [PMID: 35106398 PMCID: PMC8801481 DOI: 10.52965/001c.25208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/25/2021] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Fibromyalgia (FM) is a complex disorder characterized primarily by chronic, widespread musculoskeletal pain. Currently, the Food and Drug Administration (FDA) has approved the use of three medications to treat FM: pregabalin, duloxetine, and milnacipran. The pharmaceutical intervention has lacked consistent pain relief among all patients. Therefore, the investigation into alternative treatment options has grown in interest. This narrative review aims to evaluate the evidence regarding vitamin D for the treatment of FM. METHODS Narrative review. RESULTS Low serum vitamin D has been linked to various chronic pain states. An association between vitamin D deficiency and FM has been reported but is controversial in the literature. Some studies have documented the beneficial effects of vitamin D supplementation on reducing pain symptoms and improving the overall quality of life in those with FM. Despite these positive findings, many of the studies regarding this topic lack adequate power to make substantial conclusions about the effects of vitamin D on FM. CONCLUSION Existing studies provide promising results. However, additional high-quality data on vitamin D supplementation is needed before recommendations for pain management can be made. Vitamin D supplementation is inexpensive, has minimal side effects, and can benefit FM patients regardless of its efficacy in pain control. Additionally, high-quality studies are warranted to fully elucidate the potential of vitamin D to manage chronic pain in FM.
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Affiliation(s)
- Hannah W Haddad
- Kansas City University of Medicine and Biosciences, Kansas City, MO
| | | | | | | | - Chukwudum C Dike
- University of Medicine and Health Sciences St. Kitts, Camps, Basseterre, St. Kitts
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, LA
| | - Alan D Kaye
- Department of Anesthesology, Louisiana State University Health Shreveport, LA
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Mascarenhas RO, Souza MB, Oliveira MX, Lacerda AC, Mendonça VA, Henschke N, Oliveira VC. Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis. JAMA Intern Med 2021; 181:104-112. [PMID: 33104162 PMCID: PMC7589080 DOI: 10.1001/jamainternmed.2020.5651] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Fibromyalgia is a chronic condition that results in a significant burden to individuals and society. OBJECTIVE To investigate the effectiveness of therapies for reducing pain and improving quality of life (QOL) in people with fibromyalgia. DATA SOURCES Searches were performed in the MEDLINE, Cochrane, Embase, AMED, PsycInfo, and PEDro databases without language or date restrictions on December 11, 2018, and updated on July 15, 2020. STUDY SELECTION All published randomized or quasi-randomized clinical trials that investigated therapies for individuals with fibromyalgia were screened for inclusion. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data and assessed risk of bias using the 0 to 10 PEDro scale. Effect sizes for specific therapies were pooled using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach. MAIN OUTCOMES AND MEASURES Pain intensity measured by the visual analog scale, numerical rating scales, and other valid instruments and QOL measured by the Fibromyalgia Impact Questionnaire. RESULTS A total of 224 trials including 29 962 participants were included. High-quality evidence was found in favor of cognitive behavioral therapy (weighted mean difference [WMD], -0.9; 95% CI, -1.4 to -0.3) for pain in the short term and was found in favor of central nervous system depressants (WMD, -1.2 [95% CI, -1.6 to -0.8]) and antidepressants (WMD, -0.5 [95% CI, -0.7 to -0.4]) for pain in the medium term. There was also high-quality evidence in favor of antidepressants (WMD, -6.8 [95% CI, -8.5 to -5.2]) for QOL in the short term and in favor of central nervous system depressants (WMD, -8.7 [95% CI, -11.3 to -6.0]) and antidepressants (WMD, -3.5 [95% CI, -4.5 to -2.5]) in the medium term. However, these associations were small and did not exceed the minimum clinically important change (2 points on an 11-point scale for pain and 14 points on a 101-point scale for QOL). Evidence for long-term outcomes of interventions was lacking. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis suggests that most of the currently available therapies for the management of fibromyalgia are not supported by high-quality evidence. Some therapies may reduce pain and improve QOL in the short to medium term, although the effect size of the associations might not be clinically important to patients.
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Affiliation(s)
| | - Mateus Bastos Souza
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Murilo Xavier Oliveira
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Ana Cristina Lacerda
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Vanessa Amaral Mendonça
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Nicholas Henschke
- Institute for Musculoskeletal Health, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Vinícius Cunha Oliveira
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
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Kito S, Nakajima T, Koga Y. Milnacipran for the drastic improvement of refractory pain in a patient without depressive symptoms: a case report. Eur Psychiatry 2020; 20:355. [PMID: 16018932 DOI: 10.1016/j.eurpsy.2005.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 04/10/2005] [Indexed: 11/27/2022] Open
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Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018; 154:1140-1171.e1. [PMID: 29274869 DOI: 10.1053/j.gastro.2017.11.279] [Citation(s) in RCA: 210] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Central neuromodulators (antidepressants, antipsychotics, and other central nervous system-targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut-brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations. METHODS The working team summarized the literature on the pharmacology of central neuromodulators and their effects on gastrointestinal sensorimotor function and conducted an evidence-based review on their use for treating FGID syndromes. Because of the paucity of data for FGIDs, we included data for non-gastrointestinal painful disorders and specific symptoms of pain, nausea, and vomiting. This information was combined into a final document comprising a synthesis of available evidence and recommendations for clinical use guided by the research and clinical experience of the experts on the committee. RESULTS The evidence-based review on neuromodulators in FGID, restricted by the limited available controlled trials, was integrated with open-label studies and case series, along with the experience of experts to create recommendations using a consensus (Delphi) approach. Due to the diversity of conditions and complexity of treatment options, specific recommendations were generated for different FGIDs. However, some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship. CONCLUSIONS Based on systematic and selectively focused review and the consensus of a multidisciplinary panel, we have provided summary information and guidelines for the use of central neuromodulators in the treatment of chronic gastrointestinal symptoms and FGIDs. Further studies are needed to confirm and refine these recommendations.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, North Carolina.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans Törnblom
- Departments of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Lee WK, Au Yeung KL, Lam HB, Wong CK, Au MK, Chan HYK, Cheung YWE, Chui WH, Wong TCV, Fu CK, Sham SK, Mak KY. Consensus statements on the clinical understanding and use of milnacipran in Hong Kong. Hum Psychopharmacol 2018; 33:e2651. [PMID: 29341261 DOI: 10.1002/hup.2651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 10/31/2017] [Accepted: 12/20/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Our aim is to develop a local consensus to guide medical practitioners and psychiatrists on the use of milnacipran in different psychiatric conditions. METHODS By utilizing the modified Delphi technique, 12 statements were electronically voted on anonymously for their practicability of recommendation. RESULTS There was a very high degree of agreement among the consensus group on 10 finalized consensus statements, but 2 statements were voted down due to a poor degree of agreement. CONCLUSIONS The present consensus statements were developed as general recommendations for medical practitioners and psychiatrists to be practically referred to in clinical settings.
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Affiliation(s)
- Wing King Lee
- Department of Psychiatry, Kwai Chung Hospital, Kwai Chung, Hong Kong
| | | | - Ho Bun Lam
- Department of Psychiatry, Shatin Hospital, Shatin, Hong Kong
| | - Chi Keung Wong
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | | | | | | | - Wing Ho Chui
- Department of Psychiatry, Castle Peak Hospital, Tuen Mun, Hong Kong
| | | | - Chi Kin Fu
- Psychiatrist, Private Practice, Hong Kong and Member, Education, Prevention and Publication Subcommittee, The Mental Health Association of Hong Kong, Kwun Tong, Hong Kong
| | | | - Ki Yan Mak
- Psychiatrist, Private Practice, Hong Kong, and Vice President, The Mental Health Association of Hong Kong, Kwun Tong, Hong Kong
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Welsch P, Üçeyler N, Klose P, Walitt B, Häuser W. Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia. Cochrane Database Syst Rev 2018; 2:CD010292. [PMID: 29489029 PMCID: PMC5846183 DOI: 10.1002/14651858.cd010292.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co-exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review. OBJECTIVES To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults. SEARCH METHODS For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017. SELECTION CRITERIA We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health-related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta-analysis using a random-effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L-carnitine. The majority of studies were at unclear or high risk of bias in three to five domains.The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness.Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD -0.13, 95% CI -0.18 to -0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD -0.07; 95 % CI -0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health-related quality of life (SMD -0.20, 95% CI -0.25 to -0.15; NNTB 11, 95% CI 8 to 14).There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD -0.00, 95% CI -0.01 to 0.00).There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial.There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L-carnitine, pregabalin). AUTHORS' CONCLUSIONS The update did not change the major findings of the previous review. Based on low- to very low-quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health-related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran.We did not find placebo-controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran.
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Affiliation(s)
- Patrick Welsch
- Health Care Center for Pain Medicine and Mental Health, Saarbrücken, Germany
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Abstract
Fibromyalgia (FM) has historically been associated with several diseases in gastroenterology and hepatology. The most substantiated evidence pertains to irritable bowel syndrome (IBS). The pathogeneses of FM and IBS remain unclear, but it is likely related to dysregulation within the brain-gut axis, resulting in a hyperalgesic state. IBS and FM share other similarities, including a female predominance, fatigue, insomnia, and susceptibility to psychiatric state. These common manifestations and pathogeneses serve as a foundation for overlapping, multidisciplinary treatment modalities.
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Affiliation(s)
- Richard A Schatz
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, 114 Doughty Street, STB Suite 249, Charleston, SC 29425, USA.
| | - Baharak Moshiree
- Division of Gastroenterology, Carolinas HealthCare System, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA
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Nicol AL, Hurley RW, Benzon HT. Alternatives to Opioids in the Pharmacologic Management of Chronic Pain Syndromes: A Narrative Review of Randomized, Controlled, and Blinded Clinical Trials. Anesth Analg 2017; 125:1682-1703. [PMID: 29049114 DOI: 10.1213/ane.0000000000002426] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic pain exerts a tremendous burden on individuals and societies. If one views chronic pain as a single disease entity, then it is the most common and costly medical condition. At present, medical professionals who treat patients in chronic pain are recommended to provide comprehensive and multidisciplinary treatments, which may include pharmacotherapy. Many providers use nonopioid medications to treat chronic pain; however, for some patients, opioid analgesics are the exclusive treatment of chronic pain. However, there is currently an epidemic of opioid use in the United States, and recent guidelines from the Centers for Disease Control (CDC) have recommended that the use of opioids for nonmalignant chronic pain be used only in certain circumstances. The goal of this review was to report the current body of evidence-based medicine gained from prospective, randomized-controlled, blinded studies on the use of nonopioid analgesics for the most common noncancer chronic pain conditions. A total of 9566 studies were obtained during literature searches, and 271 of these met inclusion for this review. Overall, while many nonopioid analgesics have been found to be effective in reducing pain for many chronic pain conditions, it is evident that the number of high-quality studies is lacking, and the effect sizes noted in many studies are not considered to be clinically significant despite statistical significance. More research is needed to determine effective and mechanism-based treatments for the chronic pain syndromes discussed in this review. Utilization of rigorous and homogeneous research methodology would likely allow for better consistency and reproducibility, which is of utmost importance in guiding evidence-based care.
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Affiliation(s)
- Andrea L Nicol
- From the *Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas; †Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and ‡Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Lawson K. A Brief Review of the Pharmacology of Amitriptyline and Clinical Outcomes in Treating Fibromyalgia. Biomedicines 2017; 5:biomedicines5020024. [PMID: 28536367 PMCID: PMC5489810 DOI: 10.3390/biomedicines5020024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/10/2017] [Accepted: 05/13/2017] [Indexed: 02/07/2023] Open
Abstract
Fibromyalgia is a complex chronic condition characterized by pain, physical fatigue, sleep disorder and cognitive impairment. Evidence-based guidelines recommend antidepressants as treatments of fibromyalgia where tricyclics are often considered to have the greatest efficacy, with amitriptyline often being a first-line treatment. Amitriptyline evokes a preferential reduction in pain and fatigue of fibromyalgia, and in the Fibromyalgia Impact Questionnaire (FIQ) score, which is a quality of life assessment. The multimodal profile of the mechanisms of action of amitriptyline include monoamine reuptake inhibition, receptor modulation and ion channel modulation. Several of the actions of amitriptyline on multiple nociceptive and sensory processes at central and peripheral locations have the potential to act cumulatively to suppress the characteristic symptoms of fibromyalgia. Greater understanding of the role of these mechanisms of action of amitriptyline could provide further clues to the pathophysiology of fibromyalgia and to a preferable pharmacological profile for future drug development.
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Affiliation(s)
- Kim Lawson
- Department of Biosciences and Chemistry, Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield S1 1WB, UK.
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12
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New Insights into the Pathophysiology and Treatment of Fibromyalgia. Biomedicines 2017; 5:biomedicines5020022. [PMID: 28536365 PMCID: PMC5489808 DOI: 10.3390/biomedicines5020022] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 12/22/2022] Open
Abstract
Fibromyalgia is characterized by chronic widespread pain and several additional symptoms such as fatigue, cognitive dysfunction, depressive episodes, and anxiety. The underlying pathophysiology of fibromyalgia is still poorly understood, and treatment is often unsatisfactory. Current research provides evidence for altered pain processing in chronic pain patients, and specifically in fibromyalgia patients, possibly based on altered functional connectivity and brain chemistry in brain regions within the pain processing system. Besides discussing evidence from studies applying brain imaging (specifically resting state fMRI (Functional magnetic resonance imaging)), the current review aims at providing an overview of pharmacological and non-pharmacological treatment options. We will also summarize the most important results from recently performed brain imaging studies providing new insights into the potential mechanisms of various therapeutic approaches.
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13
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Kia S, Choy E. Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology. Biomedicines 2017; 5:E20. [PMID: 28536363 PMCID: PMC5489806 DOI: 10.3390/biomedicines5020020] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/20/2017] [Accepted: 04/26/2017] [Indexed: 11/16/2022] Open
Abstract
Fibromyalgia syndrome (FMS) is a chronic condition with unknown aetiology. The pathophysiology of the disease is incompletely understood; despite advances in our knowledge with regards to abnormal central and peripheral pain processing, and hypothalamo-pituitary-adrenal dysfunction, there is no clear specific pathophysiological therapeutic target. The management of this complex condition has thus perplexed the medical community for many years, and several national and international guidelines have aimed to address this complexity. The most recent guidelines from European League Against Rheumatism (EULAR) (2016), Canadian Pain Society (2012), and The Association of the Scientific Medical Societies in Germany (AWMF) (2012) highlight the change in attitudes regarding the overall approach to FMS, but offer varying advice with regards to the use of pharmacological agents. Amitriptyline, Pregabalin and Duloxetine are used most commonly in FMS and though modestly effective, are useful adjunctive treatment to non-pharmaceutical measures.
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Affiliation(s)
- Sanam Kia
- Abertawe Bro Morgannwg University Health Board NHS Trust, Neath Port Talbot Hospital, Port Talbot, Wales SA12 7BX, UK.
| | - Ernet Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff University, Tenovus Building, Heath Park, Cardiff CF14 4XN, UK.
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14
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Konuk N, Ortancil O, Bostanci B, Kiran S, Sapmaz P. A Comparison of Reboxetine and Amitryptilline in the Treatment of Fibromyalgia Syndrome with Co-morbid Depressive Symptoms: An Open-label Preliminary Study. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/10177833.2010.11790631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Numan Konuk
- Istanbul University, Cerrahpasa Faculty of Medicine, Department of Psychiatry, Turkey
| | - Ozgur Ortancil
- Zonguldak Karaelmas University, Faculty of Medicine, Department of Physiotherapy and Rehabilitation, Turkey
| | - Bora Bostanci
- Zonguldak Karaelmas University, Faculty of Medicine, Department of Psychiatry, Turkey
| | - Sibel Kiran
- Zonguldak Karaelmas University, Faculty of Medicine, Department of Public Health, Turkey
| | - Perihan Sapmaz
- Zonguldak Karaelmas University, Faculty of Medicine, Department of Physiotherapy and Rehabilitation, Turkey
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15
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Karshikoff B, Jensen KB, Kosek E, Kalpouzos G, Soop A, Ingvar M, Olgart Höglund C, Lekander M, Axelsson J. Why sickness hurts: A central mechanism for pain induced by peripheral inflammation. Brain Behav Immun 2016; 57:38-46. [PMID: 27058164 DOI: 10.1016/j.bbi.2016.04.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/29/2016] [Accepted: 04/02/2016] [Indexed: 11/17/2022] Open
Abstract
Low-grade systemic inflammation has been implicated in chronic pain, as well as in comorbid diseases like depression and fatigue. We have previously shown that women's pain perception and regulation is more affected by systemic inflammation than that of men. Here we investigated the neural substrates underlying these effects using an fMRI paradigm previously employed in a clinical population. Fifty-one participants (29 women) were injected with 0.6ng/kg lipopolysaccharide (LPS) or saline to induce a peripheral inflammatory response. The subjects were then tested with a pressure pain fMRI paradigm designed to capture descending pain inhibitory activity 2h after injection, and blood was sampled for cytokine analysis. The subjects injected with LPS became more pain sensitive compared to the placebo group, and the heightened pain sensitivity was paralleled by decreased activity in the ventrolateral prefrontal cortex and the rostral anterior cingulate cortex (rACC) compared to placebo; areas involved in descending pain regulation. The LPS group also had higher activity in the anterior insular cortex, an area underpinning affective and interoceptive pain processing. Women displayed overall less pain-evoked rACC activity compared to men, which may have rendered women less resilient to immune provocation, possibly explaining sex differences in LPS-induced pain sensitivity. Our findings elucidate the pain-related brain circuits affected by experimental peripheral inflammation, strengthening the theoretical link between systemic inflammation and weakened pain regulation in chronic pain disorders. The results further suggest a possible mechanism underlying the female predominance in many chronic pain disorders.
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Affiliation(s)
- B Karshikoff
- Karolinska Pain Center, Behavioral Medicine Pain Treatment Service, Karolinska University Hospital, Solna, Sweden; Stress Research Institute, Stockholm University, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - K B Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - E Kosek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - G Kalpouzos
- Aging Research Center (ARC), Department of Neurobiology, Cares Sciences and Society, Karolinska Institutet and Stockholm University, Sweden
| | - A Soop
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - M Ingvar
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - C Olgart Höglund
- Osher Center for Integrative Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Department of Medicine Solna and CMM, Karolinska Institutet and Karolinska University Hospital Solna, Stockholm, Sweden
| | - M Lekander
- Stress Research Institute, Stockholm University, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - J Axelsson
- Stress Research Institute, Stockholm University, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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16
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Okifuji A, Gao J, Bokat C, Hare BD. Management of fibromyalgia syndrome in 2016. Pain Manag 2016; 6:383-400. [PMID: 27306300 PMCID: PMC5066139 DOI: 10.2217/pmt-2016-0006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 06/02/2016] [Indexed: 12/18/2022] Open
Abstract
Fibromyalgia syndrome is a chronic pain disorder and defies definitively efficacious therapy. In this review, we summarize the results from the early treatment research as well as recent research evaluating the pharmacological, interventional and nonpharmacological therapies. We further discuss future directions of fibromyalgia syndrome management; we specifically focus on the issues that are associated with currently available treatments, such as the need for personalized approach, new technologically oriented and interventional treatments, the importance of understanding and harnessing placebo effects and enhancement of patient engagement in therapy.
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Affiliation(s)
- Akiko Okifuji
- Department of Anaesthesiology, Pain Management & Research Center, University of Utah, 615 Arapeen Drive, Suite 200, Salt Lake City, UT 84108, USA
| | - Jeff Gao
- Department of Anaesthesiology, Pain Management & Research Center, University of Utah, 615 Arapeen Drive, Suite 200, Salt Lake City, UT 84108, USA
| | - Christina Bokat
- Department of Anaesthesiology, Pain Management & Research Center, University of Utah, 615 Arapeen Drive, Suite 200, Salt Lake City, UT 84108, USA
| | - Bradford D Hare
- Department of Anaesthesiology, Pain Management & Research Center, University of Utah, 615 Arapeen Drive, Suite 200, Salt Lake City, UT 84108, USA
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17
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Ahmed M, Aamir R, Jishi Z, Scharf MB. The Effects of Milnacipran on Sleep Disturbance in Fibromyalgia: A Randomized, Double-Blind, Placebo-Controlled, Two-Way Crossover Study. J Clin Sleep Med 2016; 12:79-86. [PMID: 26414990 PMCID: PMC4702190 DOI: 10.5664/jcsm.5400] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 07/24/2015] [Indexed: 01/17/2023]
Abstract
OBJECTIVE This study examined the effects of milnacipran on polysomnographic (PSG) measures of sleep and subjective complaints in patients with fibromyalgia and disturbed sleep. METHODS This was a single-site, double-blind, placebo-controlled, two-period crossover PSG study. Eligible subjects (aged 28-72 y) were randomized (1:1) to milnacipran (100 mg/d) or placebo for crossover period 1, and vice versa for period 2. Each crossover period comprised a dose-escalation and dose-maintenance phase, with a 2-w taper/washout between periods. In-laboratory PSGs were collected at baseline, and at the end of each treatment period. The primary endpoints were the difference in PSG-recorded wake after sleep onset (WASO), number of awakenings after sleep onset (NAASO), and sleep efficiency (SE) between 4 w of maintenance treatment with milnacipran and placebo. Other PSG measures, subject-rated sleep, fatigue, physical functioning, and pain were assessed. Post hoc analysis was performed in subjects showing at least 25% reduction in pain from baseline in the Brief Pain Inventory Score (responders). RESULTS Of 19 subjects randomized, 15 completed both periods. Subjects treated with milnacipran showed no significant improvements in WASO and NAASO, but showed reduced SE (p = 0.049). Milnacipran did not show significant improvement in other PSG parameters or subjective endpoints. Two thirds of completers met responder criteria and additionally showed a significant improvement in daily effect of pain (p = 0.043) and subjective sleep quality (p = 0.040). CONCLUSION The data suggest that milnacipran is not sedating in most patients with fibromyalgia and improvements in sleep are likely a result of pain improvement. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT01234675.
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Affiliation(s)
- Mansoor Ahmed
- Cleveland Sleep Research Center, Middleburg Heights, OH
| | - Rozina Aamir
- Cleveland Sleep Research Center, Middleburg Heights, OH
| | - Zahra Jishi
- Cleveland Sleep Research Center, Middleburg Heights, OH
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18
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Lee YC, Massarotti E, Edwards RR, Lu B, Liu C, Lo Y, Wohlfahrt A, Kim ND, Clauw DJ, Solomon DH. Effect of Milnacipran on Pain in Patients with Rheumatoid Arthritis with Widespread Pain: A Randomized Blinded Crossover Trial. J Rheumatol 2015; 43:38-45. [PMID: 26628607 DOI: 10.3899/jrheum.150550] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Clinical trials have shown that serotonin norepinephrine reuptake inhibitors, such as milnacipran, decrease pain in noninflammatory pain conditions such as fibromyalgia and osteoarthritis. We examined the effect of milnacipran on self-reported pain intensity and experimental pain sensitivity among patients with rheumatoid arthritis (RA) with widespread pain and stable RA disease activity. METHODS In this double-blind, crossover study, patients with RA with widespread pain, receiving a stable treatment regimen, were randomized (by a random number generator) to receive milnacipran 50 mg twice daily or placebo for 6 weeks, followed by a 3-week washout and crossed over to the other arm for the remaining 6 weeks. The primary outcome was change in average pain intensity, assessed by the Brief Pain Inventory short form. The sample size was calculated to detect a 30% improvement in pain with power = 0.80 and α = 0.05. RESULTS Of the 43 randomized subjects, 41 received the study drug, and 32 completed the 15-week study per protocol. On a 0-10 scale, average pain intensity decreased by 0.39 (95% CI -1.27 to 0.49, p = 0.37) more points during 6 weeks of milnacipran treatment compared with placebo. In the subgroup of subjects with swollen joint count ≤ 1, average pain intensity decreased by 1.14 more points during 6 weeks of milnacipran compared with placebo (95% CI -2.26 to -0.01, p = 0.04). Common adverse events included nausea (26.8%) and loss of appetite (9.7%). CONCLUSION Compared with placebo, milnacipran did not improve overall, self-reported pain intensity among subjects with widespread pain receiving stable RA medications. TRIAL REGISTRATION ClinicalTrials.gov NCT01207453.
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Affiliation(s)
- Yvonne C Lee
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital.
| | - Elena Massarotti
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Robert R Edwards
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Bing Lu
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - ChihChin Liu
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Yuanyu Lo
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Alyssa Wohlfahrt
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Nancy D Kim
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Daniel J Clauw
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
| | - Daniel H Solomon
- From the Division of Rheumatology, Immunology and Allergy, and Department of Anesthesiology, Brigham and Women's Hospital; Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA.Y.C. Lee, MD, MMSc, Division of Rheumatology, Department of Medicine, Brigham and Women's Hospital; E. Massarotti, MD, Division of Rheumatology, Brigham and Women's Hospital; R.R. Edwards, PhD, Pain Management Center, Brigham and Women's Hospital; B. Lu, MD, DrPH, Division of Rheumatology, Brigham and Women's Hospital; C. Liu, PhD, Division of Rheumatology, Brigham and Women's Hospital; Y. Lo, MPH, Division of Rheumatology, Brigham and Women's Hospital; A. Wohlfahrt, BA, Division of Rheumatology, Brigham and Women's Hospital; N.D. Kim, MD, Division of Rheumatology, Immunology and Allergy, Massachusetts General Hospital; D.J. Clauw, MD, University of Michigan; D.H. Solomon, MD, MPH, Division of Rheumatology, Brigham and Women's Hospital
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19
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Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 3, 2012. That review considered both fibromyalgia and neuropathic pain, but the efficacy of milnacipran for neuropathic pain is now dealt with in a separate review.Milnacipran is a serotonin-norepinephrine (noradrenaline) reuptake inhibitor (SNRI) that is licensed for the treatment of fibromyalgia in some countries, including Canada, Russia, and the United States. OBJECTIVES To assess the analgesic efficacy of milnacipran for pain in fibromyalgia in adults and the adverse events associated with its use in clinical trials. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE to 18 May 2015, together with reference lists of retrieved papers and reviews, and two clinical trial registries. For the earlier review, we also contacted the manufacturer. SELECTION CRITERIA We included randomised, double-blind studies of eight weeks' duration or longer, comparing milnacipran with placebo or another active treatment in fibromyalgia in adults. DATA COLLECTION AND ANALYSIS We extracted efficacy and adverse event data, and two review authors examined issues of study quality independently. MAIN RESULTS We identified one new study with 100 participants for the pooled analysis. We identified two additional reports of a study using an enriched enrolment randomised withdrawal (EERW) design that included participants from earlier randomised controlled trials and an open-label study. Because this study used the same participants already included in our main analysis, and a different design, we dealt with it separately.The main analysis included six studies (five from the earlier review; 4238 participants in total), all of which were placebo-controlled, and used titration to a target dose of milnacipran 100 or 200 mg, with assessment after 8 to 24 weeks of stable treatment. There were no studies with active comparators. Study quality was generally good, although the imputation method used in analyses of the primary outcomes could overestimate treatment effect.Both doses of milnacipran provided moderate levels of pain relief (at least 30% pain intensity reduction) to about 40% of participants treated, compared to 30% with placebo, giving a number needed to treat for an additional beneficial outcome (NNT) of 6 to 10 (high quality evidence). Using a stricter definition for responder and a more conservative method of analysis gave lower levels of response (while maintaining a 10% difference between milnacipran and placebo) and increased the NNT to 11 (high quality evidence). One EERW study was broadly supportive.Adverse events were common in both milnacipran (86%) and placebo (78%) groups (high quality evidence), but serious adverse events did not differ between groups (less than 2%) (low quality evidence). Nausea, constipation, and headache were the most common events showing the greatest difference between groups (number needed to treat for an additional harmful outcome (NNH) of 5.7 for nausea, 13 for constipation, and 29 for headache) (moderate quality evidence).Withdrawals for any reason were more common with milnacipran than placebo, and more common with 200 mg (NNH 9) than 100 mg (NNH 23), compared with placebo. This was largely driven by adverse event withdrawals, where the NNH compared with placebo was 14 for 100 mg and 7.0 for 200 mg (high quality evidence). Withdrawals due to lack of efficacy were less common with milnacipran than placebo but did not differ between doses (number needed to treat to prevent an additional unwanted outcome (NNTp) of 41) (moderate quality evidence). AUTHORS' CONCLUSIONS The evidence available indicates that milnacipran 100 mg or 200 mg is effective for a minority in the treatment of pain due to fibromyalgia, providing moderate levels of pain relief (at least 30%) to about 40% of participants, compared with about 30% with placebo. There were insufficient data to assess substantial levels of pain relief (at least 50%), and the use of last observation carried forward imputation may overestimate drug efficacy. Using stricter criteria for 'responder' and a more conservative method of analysis gave lower response rates (about 26% with milnacipran versus 17% with placebo). Milnacipran was associated with increased adverse events and adverse event withdrawals, which were significantly greater for the higher dose.
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Affiliation(s)
| | | | - Tudor Phillips
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Churchill HospitalOxfordUKOX3 7LJ
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Perrot S, Russell IJ. More ubiquitous effects from non-pharmacologic than from pharmacologic treatments for fibromyalgia syndrome: a meta-analysis examining six core symptoms. Eur J Pain 2015; 18:1067-80. [PMID: 25139817 DOI: 10.1002/ejp.564] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2014] [Indexed: 01/08/2023]
Abstract
This study aimed to characterize and compare the efficacy profile on six fibromyalgia syndrome (FM) core symptoms associated with pharmacologic and non-pharmacologic treatments. We screened PubMed, Embase and the Cochrane Library for FM articles from 1990 to September 2012 to analyse randomized controlled trials comparing pharmacologic or non-pharmacologic treatments to placebo or sham. Papers including assessments of at least 2 of the 6 main FM symptom domains - pain, sleep disturbance, fatigue, affective symptoms (depression/anxiety), functional deficit and cognitive impairment - were selected for analysis. Studies exploring pharmacologic approaches (n = 21) were mainly dedicated to treating a small number of dimensions, mostly pain. They were of good quality but were not prospectively designed to simultaneously document efficacy for the management of multiple core FM symptom domains. Only amitriptyline demonstrated a significant effect on as many as three core FM symptoms, but it exhibited many adverse effects and was subject to early tachyphylaxis. Studies involving non-pharmacologic approaches (n = 64) were typically of poorer quality but were more often dedicated to multidimensional targets. Pool therapy demonstrated significant effects on five symptom domains, repetitive transcranial magnetic stimulation on four domains, balneotherapy on three domains and exercise, cognitive behaviour therapy and massage on two domains each. Differences between pharmacologic and non-pharmacologic approaches may be related to different modes of action, tolerability profiles and study designs. Very few drugs in well-designed clinical trials have demonstrated significant relief for multiple FM symptom domains, whereas non-pharmacologic treatments with weaker study designs have demonstrated multidimensional effects. Future therapeutic trials for FM should prospectively examine each of the core domains and should attempt to combine pharmacologic and non-pharmacologic therapies in well-designed clinical trials.
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Affiliation(s)
- S Perrot
- Service de Médecine Interne et Thérapeutique, Hôtel Dieu, Paris Descartes University, INSERM U 987, France
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Smith HS, Raffa RB, Pergolizzi JV, Taylor R, Tallarida RJ. Combining Opioid and Adrenergic Mechanisms for Chronic Pain. Postgrad Med 2015; 126:98-114. [DOI: 10.3810/pgm.2014.07.2788] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Knijnik LM, Dussán-Sarria JA, Rozisky JR, Torres ILS, Brunoni AR, Fregni F, Caumo W. Repetitive Transcranial Magnetic Stimulation for Fibromyalgia: Systematic Review and Meta-Analysis. Pain Pract 2015; 16:294-304. [DOI: 10.1111/papr.12276] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/17/2014] [Accepted: 11/02/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Leonardo M. Knijnik
- Laboratory of Pain and Neuromodulation; Hospital de Clínicas de Porto Alegre (HCPA); Porto Alegre Brazil
- School of Medicine; Rio Grande do Sul Federal University (UFRGS); Porto Alegre Brazil
| | - Jairo A. Dussán-Sarria
- Laboratory of Pain and Neuromodulation; Hospital de Clínicas de Porto Alegre (HCPA); Porto Alegre Brazil
- Post-Graduate Program in Medical Sciences; School of Medicine; UFRGS; Porto Alegre Brazil
- Pain and Palliative Care Service at HCPA; UFRGS; Porto Alegre Brazil
| | - Joanna R. Rozisky
- Laboratory of Pain and Neuromodulation; Hospital de Clínicas de Porto Alegre (HCPA); Porto Alegre Brazil
| | - Iraci L. S. Torres
- Post-Graduate Program in Medical Sciences; School of Medicine; UFRGS; Porto Alegre Brazil
- Pharmacology Department; Institute of Basic Health Sciences; UFRGS; Porto Alegre Brazil
| | - Andre R. Brunoni
- Service of Interdisciplinary Neuromodulation; Department and Institute of Psychiatry; University of São Paulo; São Paulo Brazil
| | - Felipe Fregni
- Spaulding Center of Neuromodulation; Department of Physical Medicine and Rehabilitation; Harvard Medical School; Boston Massachusetts U.S.A
| | - Wolnei Caumo
- Laboratory of Pain and Neuromodulation; Hospital de Clínicas de Porto Alegre (HCPA); Porto Alegre Brazil
- Pain and Palliative Care Service at HCPA; UFRGS; Porto Alegre Brazil
- Department of Surgery; HCPA; UFRGS; Porto Alegre Brazil
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Comparison of the effects of escitalopram and nortriptyline on painful symptoms in patients with major depression. Gen Hosp Psychiatry 2015; 37:36-9. [PMID: 25480462 DOI: 10.1016/j.genhosppsych.2014.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 10/12/2014] [Accepted: 10/14/2014] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Unexplained painful physical symptoms are commonly reported by depressed patients. The evidence suggests that dual-action antidepressants are potent in relieving pain in depression. However, a direct comparison of the effects of selective serotonergic and selective noradrenergic antidepressants on painful symptoms has not been investigated so far. METHOD Sixty patients who participated in the Genome-based Therapeutic Drugs for Depression study with a diagnosis of moderate or severe episodes of depression according to the International Classification of Diseases, 10th Revision, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria were involved. All the participants were randomly allocated to receive nortriptyline or escitalopram. The severity of depression was measured using the Montgomery-Åsberg Depression Rating Scale, the Hamilton Depression Rating Scale and the Beck Depression Inventory at weeks 0, 2, 4, 6 and 8. The intensity of pain was measured on the Visual Analog Scale at the same points of the study. RESULTS At "week 0," 83.3% of the patients later randomized to treatment with escitalopram and 86.7% of those treated with nortriptyline reported at least one painful symptom. A significant decrease of pain intensity was observed after 2 weeks of treatment. The two groups did not differ in degree of pain reduction at weeks 2, 4, 6 and 8 in comparison to baseline values. A 50% reduction in pain intensity preceded the 50% reduction of depression severity. The intensity of pain at "week 0" did not differ in remitted or nonremitted patients at week 8. CONCLUSION Both selective serotonergic and selective noradrenergic antidepressants are equally effective in alleviations of painful physical symptoms of depression. The presence of painful symptoms before the onset of treatment did not determine the final response.
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Vincent A, Benzo RP, Whipple MO, McAllister SJ, Erwin PJ, Saligan LN. Beyond pain in fibromyalgia: insights into the symptom of fatigue. Arthritis Res Ther 2014; 15:221. [PMID: 24289848 PMCID: PMC3978642 DOI: 10.1186/ar4395] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Fatigue is a disabling, multifaceted symptom that is highly prevalent and stubbornly persistent. Although fatigue is a frequent complaint among patients with fibromyalgia, it has not received the same attention as pain. Reasons for this include lack of standardized nomenclature to communicate about fatigue, lack of evidence-based guidelines for fatigue assessment, and a deficiency in effective treatment strategies. Fatigue does not occur in isolation; rather, it is present concurrently in varying severity with other fibromyalgia symptoms such as chronic widespread pain, unrefreshing sleep, anxiety, depression, cognitive difficulties, and so on. Survey-based and preliminary mechanistic studies indicate that multiple symptoms feed into fatigue and it may be associated with a variety of physiological mechanisms. Therefore, fatigue assessment in clinical and research settings must consider this multi-dimensionality. While no clinical trial to date has specifically targeted fatigue, randomized controlled trials, systematic reviews, and meta-analyses indicate that treatment modalities studied in the context of other fibromyalgia symptoms could also improve fatigue. The Outcome Measures in Rheumatology (OMERACT) Fibromyalgia Working Group and the Patient Reported Outcomes Measurement Information System (PROMIS) have been instrumental in propelling the study of fatigue in fibromyalgia to the forefront. The ongoing efforts by PROMIS to develop a brief fibromyalgia-specific fatigue measure for use in clinical and research settings will help define fatigue, allow for better assessment, and advance our understanding of fatigue.
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Jensen KB, Petzke F, Carville S, Choy E, Fransson P, Gracely RH, Vitton O, Marcus H, Williams SCR, Ingvar M, Kosek E. Segregating the cerebral mechanisms of antidepressants and placebo in fibromyalgia. THE JOURNAL OF PAIN 2014; 15:1328-37. [PMID: 25283470 DOI: 10.1016/j.jpain.2014.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 09/03/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
Abstract
UNLABELLED Antidepressant drugs are commonly used to treat fibromyalgia, but there is little knowledge about their mechanisms of action. The aim of this study was to compare the cerebral and behavioral response to positive treatment effects of antidepressants or placebo. Ninety-two fibromyalgia patients participated in a 12-week, double-blind, placebo-controlled clinical trial with milnacipran, a serotonin-norepinephrine reuptake inhibitor. Before and after treatment, measures of cerebral pain processing were obtained using functional magnetic resonance imaging. Also, there were stimulus response assessments of pressure pain, measures of weekly pain, and fibromyalgia impact. Following treatment, milnacipran responders exhibited significantly higher activity in the posterior cingulum compared with placebo responders. The mere exposure to milnacipran did not explain our findings because milnacipran responders exhibited increased activity also in comparison to milnacipran nonresponders. Stimulus response assessments revealed specific antihyperalgesic effects in milnacipran responders, which was also correlated with reduced clinical pain and with increased activation of the posterior cingulum. A short history of pain predicted positive treatment response to milnacipran. We report segregated neural mechanisms for positive responses to treatment with milnacipran and placebo, reflected in the posterior cingulum. The increase of pain-evoked activation in the posterior cingulum may reflect a normalization of altered default mode network processing, an alteration implicated in fibromyalgia pathophysiology. PERSPECTIVE This study presents neural and psychophysical correlates to positive treatment responses in patients with fibromyalgia, treated with either milnacipran or placebo. The comparison between placebo responders and milnacipran responders may shed light on the specific mechanisms involved in antidepressant treatment of chronic pain.
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Affiliation(s)
- Karin B Jensen
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Athinoula A. Martinos Center for Biomedical Imaging, Boston, Massachusetts.
| | - Frank Petzke
- Center for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital, Göttingen, Germany
| | - Serena Carville
- National Clinical Guideline Centre, Royal College of Physicians, London, United Kingdom
| | - Ernest Choy
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Peter Fransson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Richard H Gracely
- Center for Neurosensory Disorders, University of North Carolina, Chapel Hill, North Carolina
| | | | - Hanke Marcus
- Department of Anesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Germany
| | - Steven C R Williams
- Centre for Neuroimaging Science, Institute of Psychiatry, King's College, London, United Kingdom
| | - Martin Ingvar
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
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Combining cognitive-behavioral therapy and milnacipran for fibromyalgia: a feasibility randomized-controlled trial. Clin J Pain 2014; 29:747-54. [PMID: 23446065 DOI: 10.1097/ajp.0b013e31827a784e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To evaluate the feasibility of a randomized-controlled trial and to obtain estimates of the effects of combined cognitive-behavioral therapy (CBT) and milnacipran for the treatment of fibromyalgia. METHODS Fifty-eight patients with fibromyalgia were randomized to 1 of the 3 treatment arms: (1) combination therapy (n = 20); (2) milnacipran+education (n = 19); and (3) placebo+CBT (n = 19). Patients received either milnacipran (100 mg/d) or placebo. Patients also received 8 sessions of phone-delivered CBT or educational instructions, but only from baseline to week 9. Assessments were conducted at baseline, week 9, and 21. The primary endpoints were baseline to week 21 changes in weekly average pain intensity and physical function (SF-36 physical function scale). RESULTS Compared with milnacipran, combination therapy demonstrated a moderate effect on improving SF-36 physical function (SE = 9.42 [5.48], P = 0.09, effect size = 0.60) and in reducing weekly average pain intensity (mean difference [SE] = -1.18 [0.62], P = 0.07, effect size = 0.67). Compared with milnacipran, CBT had a moderate to large effect in improving SF-36 physical function (mean difference [SE] = 11.0 [5.66], P = 0.06, effect size = 0.70). Despite the presence of concomitant centrally acting therapies, dropout rate was lower than anticipated (15% at week 21). Importantly, at least 6 out of the 8 phone-based therapy sessions were successfully completed by 89% of the patients; and adherence to the treatment protocols was > 95%. CONCLUSIONS In this pilot study, a therapeutic approach that combines phone-based CBT and milnacipran was feasible and acceptable. Moreover, the preliminary data supports conducting a fully powered randomized-controlled trial.
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Giacomelli C, Talarico R, Bombardieri S, Bazzichi L. The interaction between autoimmune diseases and fibromyalgia: risk, disease course and management. Expert Rev Clin Immunol 2014; 9:1069-76. [DOI: 10.1586/1744666x.2013.849440] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Fibromyalgia syndrome (FMS) is a common chronic musculoskeletal pain disorder of unknown etiology and characterized by generalized body pain, hyperalgesia, and other functional and emotional comorbidities. Despite extensive research, no treatment modality is effective for all FMS patients. In this paper, we briefly review the history of FMS and diagnostic criteria, and potential pathophysiological mechanisms including central pain modulation, neurotransmitters, sympatho-adrenal and hypothalamic–pituitary–adrenal systems and peripheral muscle issues. The primary focus of the paper is to review treatment options for managing fibromyalgia symptoms. We will discuss FDA-approved medications and other pharmacologic agents, and non-pharmacologic treatments that have shown promising effects.
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Evren B, Evren C, Guler MH. An open clinical trial of venlafaxine in the treatment of pain, depressive and anxiety symptoms in fibromyalgia. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856906776760416] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Huskey AM, Thomas CC, Waddell JA. Occurrence of Milnacipran-Associated Morbilliform Rash and Serotonin Toxicity. Ann Pharmacother 2013; 47:e32. [DOI: 10.1345/aph.1r474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report the development of morbilliform rash and serotonin toxicity after the addition of milnacipran to a patient's medication therapy. CASE SUMMARY A 57-year-old white female presented to the emergency department because of a full-body morbilliform rash, which appeared 9 days after initiation of milnacipran 50 mg twice daily. In the emergency department the patient's vital signs were: heart rate 121 beats/min, blood pressure 180/100 mm Hg, and temperature 38.9 °C. The patient reported diarrhea, nausea, dizziness, restlessness, and increased muscle pain. Her history included recurrent breast cancer first diagnosed in 1999, hypertension, fibromyalgia, depression, osteopenia, gastroesophageal reflux disease, insomnia, and endometriosis. Her home medications included milnacipran, fluoxetine, alprazolam, zolpidem, zoledronic acid, anastrozole, doxepin, ranitidine, levocetirizine, doxazosin, tramadol, vitamin D, and ferrous gluconate. The patient's increased heart rate, blood pressure, and temperature, as well as restlessness, self-reported diarrhea and nausea, and self-reported increase in muscle pain, indicated serotonin toxicity. Milnacipran, fluoxetine, and tramadol were discontinued, while doxepin was continued. Treatment consisted of acetaminophen, diphenhydramine, methylprednisolone, promethazine, and hydralazine 10 mg intravenously. The following morning all vital signs were within normal limits and the patient's diarrhea, nausea, dizziness, restlessness, and muscle pain resolved. She was discharged the following morning. The rash had resolved after day 2 of hospital discharge, which was the fourth day after discontinuation of milnacipran. DISCUSSION Given the patient's symptoms, the timing of symptom onset, the patient's history, and findings on physical examination, as well as use of the Naranjo probability scale, milnacipran was deemed the probable cause of the morbilliform reaction and serotonin toxicity. Only 1 case report of rash and 2 case reports of serotonin syndrome associated with milnacipran have been reported. CONCLUSIONS It is important to increase awareness of the possibility of developing morbilliform rash and serotonin toxicity with milnacipran therapy, as both conditions can be associated with poor outcomes if not detected early and treated appropriately.
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Affiliation(s)
- Amanda M Huskey
- Amanda M Huskey PharmD, at time of writing, PharmD Student, College of Pharmacy, University of Tennessee, Knoxville, TN; now, PGY1 Pharmacy Practice Resident, Central Baptist Hospital, Lexington, KY
| | - Cassandra C Thomas
- Cassandra C Thomas PharmD, at time of writing, PharmD Student, College of Pharmacy, University of Tennessee; now, PGY1 Pharmacy Practice Resident, Central Arkansas Veterans Healthcare System, Little Rock, AR
| | - James Aubrey Waddell
- James Aubrey Waddell PharmD, Professor, College of Pharmacy, University of Tennessee; Oncology Pharmacist, Blount Memorial Hospital, Maryville, TN
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Ablin JN, Buskila D. Fibromyalgia syndrome--novel therapeutic targets. Maturitas 2013; 75:335-40. [PMID: 23742873 DOI: 10.1016/j.maturitas.2013.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 05/06/2013] [Indexed: 02/06/2023]
Abstract
Fibromyalgia is a syndrome characterized by the presence of chronic widespread pain, representing sensitization of the central nervous system. The pthophysiology of fibromyalgia is a complex and remains in evolution, encompassing diverse issues such as disturbed patterns of sleep, alter processing and decreased conditioned pain modulation at the spinal level, as well as increased connectivity between various pain - processing areas of the brain. This evolution is continuously uncovering potential novel therapeutic targets. Treatment of fibromyalgia is a multi - faceted endeavor, inevitably combining pharmacological as well as non - pharmacological approaches. 2δ ligands and selective nor-epinephrine - serotonin reuptake inhibitors are the current mainstays of pharmacological treatment. Novel re-uptake inhibitors targeting both nor -epinephrine and dopamine are potential additions to this armamentarium as are substance P antagonists, Opiod antagonism is another intriguing possibility. Canabinoid agonists hold promise in the treatment of fibromyalgia although current evidence is incomplete. Sodium Oxybate is a unique sleep - promoting medication while drugs those promot arousals such as modafilnil are also under investigation. In the current review, current and emerging therapeutic options for the syndrome of fibromyalgia are covered.
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Affiliation(s)
- Jacob N Ablin
- Institute of Rheumatology, Tel Aviv Sourasky Medical Center and Tel Aviv University, Faculty of Medicine, Tel Aviv, Israel.
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Arnold LM, Cappelleri JC, Clair A, Masters ET. Interpreting effect sizes and clinical relevance of pharmacological interventions for fibromyalgia. Pain Ther 2013; 2:65-71. [PMID: 25135038 PMCID: PMC4107878 DOI: 10.1007/s40122-013-0011-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Indexed: 01/14/2023] Open
Abstract
Duloxetine, milnacipran, and pregabalin are approved by the United States Food and Drug Administration for the management of fibromyalgia. A number of meta-analyses, pooled analyses, and systematic reviews have been published in recent years involving the efficacy of these three medications for pain in fibromyalgia. Despite being based on the same clinical data, some analyses found these treatments to have a clinically relevant effect on pain, while others concluded that the advantages were small or of questionable clinical relevance. This commentary discussed possible reasons behind these differing conclusions and explored ways of evaluating the clinical relevance of pharmacological treatments for fibromyalgia. In particular, we considered: (1) the importance of judicious and careful interpretation of average treatment effect size and the recognition that average treatment effect sizes do not always tell the whole story; (2) the utility of individual patient response data to assess clinical relevance; and (3) the importance of considering pain reduction within the context of other benefits due to the presence of associated symptoms in patients with fibromyalgia.
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Affiliation(s)
- Lesley M. Arnold
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 260 Stetson Street, Suite 3200, Cincinnati, OH 45219 USA
| | | | - Andrew Clair
- Pfizer Inc., 235 East 42 Street, New York, NY 10017 USA
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Bernstein CD, Albrecht KL, Marcus DA. Milnacipran for fibromyalgia: a useful addition to the treatment armamentarium. Expert Opin Pharmacother 2013; 14:905-16. [PMID: 23506481 DOI: 10.1517/14656566.2013.779670] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Antidepressants are used to treat a variety of chronic pain conditions including peripheral neuropathy, headache, and more recently, fibromyalgia. The antidepressant milnacipran blocks the reuptake of norepinephrine and serotonin and is used for the management of fibromyalgia. AREAS COVERED The article contains data primarily obtained from the MEDLINE database using a PubMed search of the keywords including milnacipran, fibromyalgia and depression. Of the available serotonin norepinephrine reuptake inhibitors, milnacipran has greater potency in inhibiting reuptake of norepinephrine relative to serotonin and is proposed to work by attenuating pain signals. Milnacipran is well tolerated and effective for fibromyalgia pain when given in divided doses of 100 - 200 mg daily. Studies show that milnacipran may be effective for fibromyalgia-associated symptoms including depression and fatigue. EXPERT OPINION Milnacipran provides modest fibromyalgia pain relief and is best used as part of a multidisciplinary treatment approach. While milnacipran was not studied in fibromyalgia patients with major depression, it may be a wise choice for fibromyalgia patients with depressive symptoms and patients for whom sedation, dizziness, edema or weight gain with gabapentin and pregabalin is a problem. Milnacipran has been found to be beneficial for treating some troublesome fibromyalgia-associated symptoms, including fatigue and cognitive dysfunction.
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Affiliation(s)
- Cheryl D Bernstein
- University of Pittsburgh, Department of Anesthesiology, Suite 400, Pain Medicine, Centre Commons Building, 5750 Centre Avenue, Pittsburgh, PA 15206, USA.
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Sun P, Peng X, Sun S, Novick D, Faries DE, Andrews JS, Wohlreich MM, Wu A. Direct medical costs and medication compliance among fibromyalgia patients: duloxetine initiators vs. pregabalin initiators. Pain Pract 2013; 14:22-31. [PMID: 23489659 DOI: 10.1111/papr.12044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/02/2013] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To assess and compare direct medical costs and medication compliance between patients with fibromyalgia who initiated duloxetine and patients with fibromyalgia who initiated pregabalin in 2008. METHODS A retrospective cohort study design was used based on a large US national commercial claims database (2006 to 2009). Patients with fibromyalgia aged 18 to 64 who initiated duloxetine or pregabalin in 2008 and who had continuous health insurance 1 year preceding and 1 year following the initiation were selected into duloxetine cohort or pregabalin cohort based on their initiated agent. Medication compliance was measured by total supply days, medication possession ratio (MPR), and proportion of patients with MPR ≥ 0.8. Direct medical costs were measured by annual costs per patient and compared between the cohorts in the year following the initiation. Propensity score stratification and bootstrapping methods were used to adjust for distribution bias, as well as cross-cohort differences in demographic, clinical and economic characteristics, and medication history prior to the initiation. RESULTS Both the duloxetine (n = 3,033) and pregabalin (n = 4,838) cohorts had a mean initiation age around 49 years, 89% were women. During the postindex year, compared to the pregabalin cohort, the duloxetine cohort had higher totally annual supply days (273.5 vs. 176.6, P < 0.05), higher MPR (0.7 vs. 0.5, P < 0.05), and more patients with MPR ≥ 0.8 (45.1% vs. 29.4%, P < 0.05). Further, relative to pregabalin cohort, duloxetine cohort had lower inpatient costs ($2,994.9 vs. $4,949.6, P < 0.05), lower outpatient costs ($8,259.6 vs. $10,312.2, P < 0.05), similar medication costs ($5,214.6 vs. $5,290.8, P > 0.05), and lower total medical costs ($16,469.1 vs. $20,552.6, P < 0.05) in the postinitiation year. CONCLUSIONS In a real-world setting, patients with fibromyalgia who initiated duloxetine in 2008 had better medication compliance and consumed less inpatient, outpatient, and total medical costs than those who initiated pregabalin.
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Affiliation(s)
- Peter Sun
- Kailo Research Group, Indianapolis, IN, U.S.A
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Häuser W, Urrútia G, Tort S, Uçeyler N, Walitt B. Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia syndrome. Cochrane Database Syst Rev 2013:CD010292. [PMID: 23440848 DOI: 10.1002/14651858.cd010292] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Fibromyalgia syndrome (FMS) is a clinically well-defined chronic condition of unknown etiology characterized by chronic widespread pain that often co-exists with sleep disturbances, cognitive dysfunction and fatigue. Patients often report high disability levels and poor quality of life (QOL). Drug therapy focuses on reducing key symptoms and improving quality of life. OBJECTIVES To assess the benefits and harms of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo for treating FMS symptoms in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library 2012, Issue 9), MEDLINE (1966 to September 2012), EMBASE (1980 to September 2012), www.clinicalstudyresults.org (U.S.-marketed pharmaceuticals) (to September 2012) and www.clinicaltrials.gov (to September 2012) for published and ongoing trials and examined the reference lists of reviewed articles. SELECTION CRITERIA We selected randomized, controlled trials of any formulation of SNRIs against placebo for the treatment of FMS in adults. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data from the included studies, and assessed the risks of bias of the studies. Discrepancies were resolved by discussion. MAIN RESULTS Ten studies were included with a total of 6038 participants. Five studies investigated duloxetine against placebo, and five investigated milnacipran against placebo. A total of 3611 participants were included into duloxetine or milnacipran groups and 2427 participants into placebo groups. The studies had a low risk of bias in general. Duloxetine and milnacipran had a small incremental effect over placebo in reducing pain (standardized mean difference (SMD) -0.23; 95% confidence interval (CI) -0.29 to -0.18; 6.1% relative improvement). One-hundred and ninety-two participants per 1000 on placebo reported an at least 50% pain reduction compared to 280 per 1000 on SNRIs (Risk ratio (RR) 1.49, 95% CI 1.35 to 1.64; number needed to treat to benefit (NNTB) 11, 95% CI 9 to 15). Duloxetine and milnacipran did not reduce fatigue substantially (SMD -0.14; 95% CI -0.19 to -0.08; 2.5% relative improvement; NNTB 17, 95% CI 12 to 29), and did not improve QOL substantially (SMD -0.20; 95% CI -0.25 to -0.14; 4.6% relative improvement; NNTB 12, 95% CI 9 to 17) compared to placebo. There were no statistically significant differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD -0.07; 95% CI -0.16 to 0.03; 2.5% relative improvement). One-hundred and seven participants per 1000 on placebo dropped out due to adverse events compared to 196 per 1000 on SNRIs. The dropout rate due to adverse events in the duloxetine and milnacipran groups was statistically significantly higher than in placebo groups (RR 1.83, 95% CI 1.53 to 2.18; number needed to treat to harm (NNTH) 11, 95% CI 9 to 13). There was no statistically significant difference in serious adverse events between either duloxetine or milnacipran and placebo (RR 0.78, 95% CI 0.55 to 1.12). AUTHORS' CONCLUSIONS The SNRIs duloxetine and milnacipran provided a small incremental benefit over placebo in reducing pain. The superiority of duloxetine and milnacipran over placebo in reducing fatigue and limitations of QOL was not substantial. Duloxetine and milnacipran were not superior to placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. The most frequently reported symptoms leading to stopping medication were nausea, dry mouth, constipation, headache, somnolence/dizziness and insomnia. Rare complications of both drugs may include suicidality, liver damage, abnormal bleeding, elevated blood pressure and urinary hesitation.
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Affiliation(s)
- Winfried Häuser
- Psychosomatic Medicine and Psychotherapy,Technische Universität München, München,
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Sommer C, Häuser W, Alten R, Petzke F, Späth M, Tölle T, Uçeyler N, Winkelmann A, Winter E, Bär KJ. [Drug therapy of fibromyalgia syndrome. Systematic review, meta-analysis and guideline]. Schmerz 2013; 26:297-310. [PMID: 22760463 DOI: 10.1007/s00482-012-1172-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION Amitriptyline and-in case of comorbid depressive disorder or generalized anxiety disorder-duloxetine are recommended. Off-label use of duloxetine and pregabalin can be considered in case of no comorbid mental disorder. Strong opioids are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").
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Affiliation(s)
- C Sommer
- Neurologische Klinik, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland.
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Abstract
Fibromyalgia remains one of the most common and enigmatic musculoskeletal disorders among patients with pain and, until recently, few effective treatments have been discovered. This review will briefly consider the rationale supporting traditional treatment options and their efficacy, including the role of exercise and pharmacotherapy. Juxtaposed with these common approaches to relieve fibromyalgia pain and fatigue are the promising new medications that are being developed, such as pregabalin, milnacipran, duloxetine, sodium oxybate, ropinirole and pramipexole. Outcomes from recent randomized trials will be reviewed and compared.
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Affiliation(s)
- Andrew J Holman
- Pacific Rheumatology Associates Inc., PS 4300, Talbot Road South, Suite 101, Renton, Washington, USA.
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Understanding fibromyalgia and its related disorders. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 10:133-44. [PMID: 18458727 DOI: 10.4088/pcc.v10n0208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Fibromyalgia (FM) is a persistent pain state commonly diagnosed and managed by nurse practitioners. This article summarizes current information regarding the etiology, pathophysiology, clinical presentation, diagnostic standards, and pharmacologic and non-pharmacologic treatments necessary to successfully manage FM.
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Current evidence on atypical odontalgia: diagnosis and clinical management. Int J Dent 2012; 2012:518548. [PMID: 22844283 PMCID: PMC3400349 DOI: 10.1155/2012/518548] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 05/29/2012] [Indexed: 12/28/2022] Open
Abstract
Patients with atypical odontalgia (AO) complain of medically unexplained toothache. No evidence-based diagnostic criteria or treatment guidelines are yet available. The present paper addresses seven clinical questions about AO based on current knowledge in the literature and discusses diagnostic criteria and guidelines for treatment and management. The questions are (i) What is the prevalence of AO in the community? (ii) What psychological problems are experienced by patients with AO? (iii) Are there any comorbidities of AO? (iv) Is local anesthesia effective for the relief of pain in AO? (v) Are there any characteristic symptoms of AO other than spontaneous pain? (vi) Are antidepressants effective for treatment of AO? (vii) Are anticonvulsants effective for treatment of AO? Our literature search provided answers for these questions; however, there is insufficient evidence-based data to establish guidelines for the diagnosis and treatment of AO. Overall, some diagnostic criteria for neuropathic pain and persistent dentoalveolar pain disorder may be applied to AO patients. The patient's psychogenic background should always be considered in the treatment and/or management of AO. The clinicians may need to treat AO patients using Patient-Oriented Evidence that Matters approach.
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Jensen KB, Kosek E, Wicksell R, Kemani M, Olsson G, Merle JV, Kadetoff D, Ingvar M. Cognitive Behavioral Therapy increases pain-evoked activation of the prefrontal cortex in patients with fibromyalgia. Pain 2012; 153:1495-1503. [PMID: 22617632 DOI: 10.1016/j.pain.2012.04.010] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 04/10/2012] [Accepted: 04/10/2012] [Indexed: 11/18/2022]
Abstract
Interventions based on Cognitive Behavioral Therapy (CBT) are widely used to treat chronic pain, but the brain mechanisms responsible for these treatment effects are poorly understood. The aim of this study was to validate the relevance of the cortical control theory in response to an exposure-based form of CBT, Acceptance and Commitment Therapy, in patients with chronic pain. Forty-three female patients diagnosed with fibromyalgia syndrome were enrolled in a randomized, 12-week, waiting-list controlled clinical trial (CBT n=25; controls n=18). CBT was administered in groups of six patients during 12 weekly sessions. Functional magnetic resonance imaging (fMRI) during pressure-evoked pain was assessed before and after treatment or the 12-week period. Self-report questionnaires of depression and anxiety were administered pre- and posttreatment as well as 3 months following end of treatment. Patients treated with CBT reported larger improvement of fibromyalgia on the Patient Global Impression of Change measure, and improved depression and anxiety symptoms, compared to the waiting-list controls. However, there were no effects on clinical pain or pain sensitivity measures. An analysis of fMRI scans revealed that CBT led to increased activations in the ventrolateral prefrontal/lateral orbitofrontal cortex; regions associated with executive cognitive control. We suggest that CBT changes the brain's processing of pain through an altered cerebral loop between pain signals, emotions, and cognitions; leading to increased access to executive regions for reappraisal of pain. Our data thereby support our hypothesis about the activation of a cortical control mechanism in response to CBT treatment in chronic pain.
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Affiliation(s)
- Karin B Jensen
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA, USA Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden Behavior Medicine Pain Treatment Services, Karolinska University Hospital, Stockholm, Sweden Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
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Kimura H, Yoshida K, Ito M, Tokura T, Nagashima W, Kurita K, Ozaki N. Plasma levels of milnacipran and its effectiveness for the treatment of chronic pain in the orofacial region. Hum Psychopharmacol 2012; 27:322-8. [PMID: 22585592 DOI: 10.1002/hup.2230] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study was performed to assess the relationship between plasma levels of milnacipran and its analgesic/antidepressive effect in patients with chronic orofacial pain treated with this drug. METHODS A total of 44 patients took milnacipran for 12 weeks. Patients were assessed for their pain and depressive symptoms using the visual analog scale (VAS) and Hamilton Depression Rating Scale, respectively. The plasma milnacipran level was also assessed at week 12. RESULTS Forty patients completed study treatment and were included in the analysis. In these patients, the VAS score at week 12 significantly decreased from the baseline score (t = 5.15, p < 0.0001). The dose of milnacipran was positively correlated in a linear manner with the plasma level of the drug (Y = 44.86 + 0.33X, r = 0.54, R(2) = 0.29, p = 0.0004). A quadratic regression curve was plotted between the percentage of decrease in the VAS score and plasma milnacipran level (Y = 27.39 + 0.76X - 0.008X(2) , p = 0.048, r = 0.40, R(2) = 0.16). On the other hand, no significant relationship was noted between the percentage of decrease in the Hamilton Depression Rating Scale score and plasma milnacipran level. CONCLUSION The analgesic effect of milnacipran was suppressed in the presence of the plasma level of the drug outside the therapeutic range, whereas its antidepressant effect was not affected by its plasma level.
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Affiliation(s)
- Hiroyuki Kimura
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Japan.
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Abstract
BACKGROUND Milnacipran is a serotonin-norepinephrine reuptake inhibitor (SNRI) that is sometimes used to treat chronic neuropathic pain and fibromyalgia. OBJECTIVES To evaluate the analgesic efficacy and adverse effects of milnacipran in the management of chronic neuropathic pain or fibromyalgia. SEARCH METHODS We searched CENTRAL, MEDLINE, and EMBASE to 4th of January 2012, together with reference lists of retrieved papers and reviews. SELECTION CRITERIA We included randomised, double-blind studies of eight weeks duration or longer, comparing milnacipran with placebo or another active treatment in chronic neuropathic pain or fibromyalgia. DATA COLLECTION AND ANALYSIS We extracted efficacy and adverse event data, and two study authors examined issues of study quality independently. MAIN RESULTS Five studies (4138 participants) were included, all of which were placebo-controlled, involved participants with fibromyalgia, and used titration to a target dose of 100 mg or 200 mg milnacipran. There were no other active comparators or studies in other neuropathic pain conditions. Study quality was generally good, although the imputation method used in analyses of the primary outcomes could overestimate treatment effect.Both doses of milnacipran provided moderate levels of pain relief to about 40% of those treated, compared to 30% with placebo, giving a number needed to treat of 8 to 10. Adverse events were common in both milnacipran (87%) and placebo (78%) groups, but serious adverse events (< 2%) did not differ between groups. Nausea and constipation were the most common events showing the greatest difference between groups (number needed to treat for an additional harmful outcome of 7 and 13 respectively, compared with placebo).Withdrawals for any reason were more common with milnacipran than placebo, and more common with 200 mg than 100 mg (NNH of 23 and 8.8 respectively, compared with placebo). This was largely driven by adverse event withdrawals, where the NNH compared with placebo was 14 for 100 mg, and 7.0 for 200 mg). Withdrawals due to lack of efficacy were more common with milnacipran than placebo but did not differ between doses (number needed to treat to prevent an additional unwanted outcome of 45 and 41 respectively). AUTHORS' CONCLUSIONS The evidence available indicates that milnacipran 100 mg or 200 mg is effective for a minority in the treatment of pain due to fibromyalgia, providing moderate levels of pain relief (at least 30%) to about 40% of participants, compared with about 30% with placebo. There were insufficient data to assess substantial levels of pain relief (at least 50%), and the use of last observation carried forward imputation may overestimate drug efficacy. Milnacipran is associated with increased adverse events and adverse event withdrawals, which were significantly greater for the higher dose. There were no data for the use of milnacipran for other chronic neuropathic pain conditions.
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Affiliation(s)
- Sheena Derry
- Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), University of Oxford, Oxford,UK.
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Depoortère R, Meleine M, Bardin L, Aliaga M, Muller E, Ardid D, Newman-Tancredi A. Milnacipran is active in models of irritable bowel syndrome and abdominal visceral pain in rodents. Eur J Pharmacol 2011; 672:83-7. [DOI: 10.1016/j.ejphar.2011.09.182] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 09/20/2011] [Accepted: 09/24/2011] [Indexed: 12/28/2022]
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Choy E, Marshall D, Gabriel ZL, Mitchell SA, Gylee E, Dakin HA. A Systematic Review and Mixed Treatment Comparison of the Efficacy of Pharmacological Treatments for Fibromyalgia. Semin Arthritis Rheum 2011; 41:335-45.e6. [DOI: 10.1016/j.semarthrit.2011.06.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 05/20/2011] [Accepted: 06/14/2011] [Indexed: 01/16/2023]
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Abstract
Fibromyalgia syndrome is a common chronic pain disorder of unknown etiology. The lack of understanding of the pathophysiology of fibromyalgia has made this condition frustrating for patients and clinicians alike. The most common symptoms of this disorder are chronic widespread pain, fatigue, sleep disturbances, difficulty with memory, and morning stiffness. Emerging evidence points towards augmented pain processing within the central nervous system (CNS) as having a primary role in the pathophysiology of this disorder. Currently the two drugs that are approved by the United States Food and Drug Administration (FDA) for the management of fibromyalgia are pregabalin and duloxetine. Newer data suggests that milnacipran, a dual norepinephrine and serotonin reuptake inhibitor, may be promising for the treatment of fibromyalgia. A double-blind, placebo-controlled trial of milnacipran in 125 fibromyalgia patients showed significant improvements relative to placebo. Milnacipran given either once or twice daily at doses up to 200 mg/day was generally well tolerated and yielded significant improvements relative to placebo on measures of pain, patient's global impression of change in their disease state, physical function, and fatigue. Future studies are needed to validate the efficacy of milnacipran in fibromyalgia.
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Affiliation(s)
- Richard E Harris
- Department of Anesthesiology, The University of Michigan, Ann, Arbor, MI, USA.
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Dysfunctional neurotransmitter systems in fibromyalgia, their role in central stress circuitry and pharmacological actions on these systems. PAIN RESEARCH AND TREATMENT 2011; 2012:741746. [PMID: 22110944 PMCID: PMC3195783 DOI: 10.1155/2012/741746] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 07/11/2011] [Indexed: 01/06/2023]
Abstract
Fibromyalgia is considered a stress-related disorder, and hypo- as well as hyperactive stress systems (sympathetic nervous system and hypothalamic-pituitary-adrenal axis) have been found. Some observations raise doubts on the view that alterations in these stress systems are solely responsible for fibromyalgia symptoms. Cumulative evidence points at dysfunctional transmitter systems that may underlie the major symptoms of the condition. In addition, all transmitter systems found to be altered in fibromyalgia influence the body's stress systems. Since both transmitter and stress systems change during chronic stress, it is conceivable that both systems change in parallel, interact, and contribute to the phenotype of fibromyalgia. As we outline in this paper, subgroups of patients might exhibit varying degrees and types of transmitter dysfunction, explaining differences in symptomatoloy and contributing to the heterogeneity of fibromyalgia. The finding that not all fibromyalgia patients respond to the same medications, targeting dysfunctional transmitter systems, further supports this hypothesis.
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