Future treatment strategies for neuropathic pain

IL-6/JAK2/STAT3 axis mediates neuropathic pain by regulating astrocyte and microglia activation after spinal cord injury

After spinal cord injury (SCI), the control of activated glial cells such as microglia and astrocytes has emerged as a promising strategy for neuropathic pain management. However, signaling mechanism involved in glial activation in the process of neuropathic pain development and maintenance after SCI is not well elucidated. In this study, we investigated the potential role and mechanism of the JAK2/STAT3 pathway associated with glial cell activation in chronic neuropathic pain development and maintenance after SCI. One month after contusive SCI, the activation of JAK2/STAT3 pathway was markedly upregulated in both microglia and astrocyte in nociceptive processing regions of the lumbar spinal cord. In addition, both mechanical allodynia and thermal hyperalgesia was significantly inhibited by a JAK2 inhibitor, AG490. In particular, AG490 treatment inhibited both microglial and astrocyte activation in the lumbar (L) 4-5 dorsal horn and significantly decreased levels of p-p38MAPK, p-ERK and p-JNK, which are known to be activated in microglia (p-p38MAPK and p-ERK) and astrocyte (p-JNK). Experiments using primary cell cultures also revealed that the JAK2/STAT3 pathway promoted microglia and astrocyte activation after lipopolysaccharide stimulation. Furthermore, JAK2/STAT3 signaling and pain behaviors were significantly attenuated when the rats were treated with anti-IL-6 antibody. Finally, minocycline, a tetracycline antibiotic, inhibited IL-6/JAK2/STAT3 signaling pathway in activated glial cells and restored nociceptive thresholds and the hyperresponsiveness of dorsal neurons. These results suggest an important role of the IL-6/JAK2/STAT3 pathway in the activation of microglia and astrocytes and in the maintenance of chronic below-level pain after SCI.

The possibility of alleviating chronic neuropathic pain and related behaviors by the direct suppression of the parabrachial nucleus

OBJECTIVE

This study aims to observe the effects of direct suppression of the parabrachial nucleus (PBN) on chronic neuropathic pain (CNP) and CNP-related behaviors in mice.

METHODS

A CNP model was established using partial sciatic nerve ligation (PSNL) in mice. Two groups were established: the experimental (PSNL) group and the control (sham) group. An assessment of PBN-region c-Fos expression was conducted following von Frey hair stimulation in the PSNL group and the sham group, and the effects of pain induction were detected using behavioral experiments. The PBN activity of the mice with CNP was manipulated using the designer receptors exclusively activated by designer drugs method. Effective and empty virus groups were used to study the effects of PBN activity inhibition on the pain threshold and pain-related behavior in mice with CNP.

RESULTS

The mechanical pain threshold (MPT) of the mice in the PSNL group was significantly lower than in the sham group. After von Frey stimulation, the c-Fos-positive, PBN-region neurons in the PSNL group were increased compared with the sham group. The central distance in the open field test and the time spent in the central area were lower in the PSNL group than in the sham group. The mice in the PSNL group had a lower duration and fewer entries in the open arm of the elevated plus-maze than the mice in the sham group. There was no difference in immobility time between the PSNL group and the sham group. PBN activity inhibition in mice with CNP did not affect their MPT or anxiety-like behavior.

CONCLUSION

CNP can induce anxiety-like behavior and increase PBN-induced pain in mice. However, direct inhibition of the PBN neuron activity alone cannot improve CNP or CNP-related behavior.

Downregulation of microRNA‑29c reduces pain after child delivery by activating the oxytocin‑GABA pathway

A significant decrease in the expression of spinal microRNA-29c (miR-29c), which is responsible for the regulation of oxytocin receptor (OXTR) expression, was observed in nerve injury pain during childbirth. The present study investigates whether spinal miR-29c could be a potential target for the treatment of pain, via the oxytocin (OT)-γ-aminobutyric acid (GABA) pathway. A spared nerve injury (SNI) rat model was established to induce neuropathic pain, simulating hyperalgesia. Spinal neurons were treated with OT to mimic the hormonal changes in the central nervous system after delivery. A change in the neuronal miniature inhibitory postsynaptic currents (mIPSCs) was observed in neurons, following the silencing of miR-29c or OT treatment with or without OXTR antagonist. The Von-Frey apparatus was used to measure the animal behaviors. Molecular biological experiments and electrophysical recordings in vivo and in vitro were performed to reveal the potential analgesic mechanisms. miR-29c was significantly downregulated (more than 8-fold) in the spinal dorsal horn of delivery+SNI rats compared with the SNI rats. The silencing of miR-29c resulted in increased pain threshold in SNI rats. Bioinformatics analysis indicated that OXTR was a potential target gene of miR-29c. The delivery+SNI rats presented with higher levels of OT in the cerebrospinal fluid compared with SNI rats, which indicated that the OT signaling pathway may participate in pain relief response. The increased expression of OXTR and GABA in delivery+SNI rats were observed in the miR-29c-silenced SNI rat model, suggesting that the silencing of miR-29c can mediate pain relief by enhancing the OT-GABA pathway. In addition, an electrophysiology assay was performed to assess the mIPSCs in neurons. The silencing of miR-29c in neurons increased the frequency and amplitude of mIPSCs but there was no influence on the decay time, which suggested that the spinal inhibitory neurons became more active, subsequently reducing the feeling of pain. The inhibition of OXTR reversed the enhanced inhibitory postsynaptic currents, indicating a crucial role for OXTR in the miR-29c-associated pain regulation. Taken together, the results of the present study suggested that spinal oxytocinergic inhibitory control plays an important role in pain relief in the neuropathic pain rat model undergoing vaginal delivery. Silencing spinal miR-29c may be a potential target for pain relief through the OT-GABA pathway.

Nerve growth factor concentrations in the synovial fluid from healthy dogs and dogs with secondary osteoarthritis

Objective: To measure the concentrations of nerve growth factor (NGF) in the synovial fluid from normal dogs and dogs with osteoarthritis (OA) secondary to common joint disorders.

Methods: Nerve growth factor synovial concentrations were measured by ELISA assay in 50 dogs divided into three groups: 12 healthy, 16 affected by acute lameness within seven days before enrolment, and 22 with chronic lameness persisting by more than one month before enrolment and accompanied by radiological signs of OA. Both acute and chronic lameness were secondary to orthopaedic diseases involving the shoulder, elbow and stifle joints. Nerve growth factor synovial concentrations were compared between means for healthy and acute groups and between the three groups using an F-test. Significance level was set at p ±0.05.

Results: Nerve growth factor was detected in all canine synovial fluid samples. However, the mean synovial NGF concentration of healthy dogs (3.65 ± 2.18 pg/ml) was not significantly different from the mean value in dogs with acute lameness (6.45 ± 2.45 pg/ml) (p ± 0.79). Conversely, the mean synovial NGF concentration in dogs with chronic lameness (20.19 ± 17.51 pg/ml) was found to be significantly higher than that found in healthy dogs (p ±0.01).

Clinical significance: This study demonstrates for the first time the presence of NGF in canine synovial fluid and its increased concentrations in dogs with chronic lameness compared to healthy dogs and dogs with acute lameness. The association between chronic lameness and raised synovial concentrations may suggest an involvement of NGF in OA inflammation and chronic pain.

Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of l-4-chlorokynurenine in healthy volunteers

BACKGROUND AND AIMS

Neuropathic pain is a significant medical problem needing more effective treatments with fewer side effects. Overactive glutamatergic transmission via N-methyl-d-aspartate receptors (NMDARs) are known to play a role in central sensitization and neuropathic pain. Although ketamine, a NMDAR channel-blocking antagonist, is often used for neuropathic pain, its side-effect profile and abusive potential has prompted the search for a safer effective oral analgesic. A novel oral prodrug, AV-101 (l-4 chlorokynurenine), which, in the brain, is converted into one of the most potent and selective GlyB site antagonists of the NMDAR, has been demonstrated to be active in animal models of neuropathic pain. The two Phase 1 studies reported herein were designed to assess the safety and pharmacokinetics of AV-101, over a wide dose range, after daily dosing for 14-days. As secondary endpoints, AV-101 was evaluated in the capsaicin-induced pain model.

METHODS

The Phase 1A study was a single-site, randomized, double-blind, placebo-controlled, single oral ascending dose (30-1800mg) study involving 36 normal healthy volunteers. The Phase 1B study was a single-site randomized, double-blind, placebo-controlled, study of multiple ascending doses (360, 1080, and 1440mg/day) of AV-101 involving 50 normal healthy volunteers, to whom AV-101 or placebo were administered orally daily for 14 consecutive days. Subjects underwent PK blood analyses, laboratory assessments, physical examination, 12-lead ECG, ophthalmological examination, and various neurocognitive assessments. The effect of AV-101 was evaluated in the intradermally capsaicin-induced pain model (ClinicalTrials.gov Identifier: NCT01483846).

RESULTS

Two Phase 1, with an aggregate of 86 subjects, demonstrated that up to 14 days of oral AV-101, up to 1440mg per day, was safe and very well tolerated with AEs quantitively and qualitatively like those observed with placebo. Mean half-life values of AV-101 were consistent across doses, ranging with an average of 1.73h, with the highest C_max (64.4μg/mL) and AUC_0-t (196μgh/mL) values for AV-101 occurring in the 1440-mg dose group. In the capsaicin induce-pain model, there was no significant change in the area under the pain time curve (AUPC) for the spontaneous pain assessment between the treatment and the placebo groups on Day 1 or 14 (the primary endpoint). In contrast, there were consistent reductions at 60-180min on Day 1 after dosing for allodynia, mechanical hyperalgesia, heat hyperalgesia, and spontaneous pain, and on Day 14 after dosing for heat hyperalgesia.

CONCLUSIONS

Although, AV-101 did not reach statistical significance in reducing pain, there were consistent reductions, for allodynia pain and mechanical and heat hyperalgesia. Given the excellent safety profile and PK characteristics demonstrated by this study, future clinical trials of AV-101 in neuropathic pain are justified.

IMPLICATIONS

This article presents the safety and PK of AV-101, a novel oral prodrug producing a potent and selective GlyB site antagonist of the NMDA receptor. These data indicate that AV-101 has excellent safety and PK characteristics providing support for advancing AV-101 into Phase 2 studies in neuropathic pain, and even provides data suggesting that AV-101 may have a role in treating depression.

Therapeutic Strategies for Neuropathic Pain: Potential Application of Pharmacosynthetics and Optogenetics

Chronic pain originating from neuronal damage remains an incurable symptom debilitating patients. Proposed molecular modalities in neuropathic pain include ion channel expressions, immune reactions, and inflammatory substrate diffusions. Recent advances in RNA sequence analysis have discovered specific ion channel expressions in nociceptors such as transient receptor potential (TRP) channels, voltage-gated potassium, and sodium channels. G protein-coupled receptors (GPCRs) also play an important role in triggering surrounding immune cells. The multiple protein expressions complicate therapeutic development for neuropathic pain. Recent progress in optogenetics and pharmacogenetics may herald the development of novel therapeutics for the incurable pain. Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) facilitate the artificial manipulation of intracellular signaling through excitatory or inhibitory G protein subunits activated by biologically inert synthetic ligands. Expression of excitatory channelrhodopsins and inhibitory halorhodopsins on injured neurons or surrounding cells can attenuate neuropathic pain precisely controlled by light stimulation. To achieve the discrete treatment of injured neurons, we can exploit the transcriptome database obtained by RNA sequence analysis in specific neuropathies. This can recommend the suitable promoter information to target the injury sites circumventing intact neurons. Therefore, novel strategies benefiting from pharmacogenetics, optogenetics, and RNA sequencing might be promising for neuropathic pain treatment in future.

Criticality and degeneracy in injury-induced changes in primary afferent excitability and the implications for neuropathic pain

Neuropathic pain remains notoriously difficult to treat despite numerous drug targets. Here, we offer a novel explanation for this intractability. Computer simulations predicted that qualitative changes in primary afferent excitability linked to neuropathic pain arise through a switch in spike initiation dynamics when molecular pathologies reach a tipping point (criticality), and that this tipping point can be reached via several different molecular pathologies (degeneracy). We experimentally tested these predictions by pharmacologically blocking native conductances and/or electrophysiologically inserting virtual conductances. Multiple different manipulations successfully reproduced or reversed neuropathic changes in primary afferents from naïve or nerve-injured rats, respectively, thus confirming the predicted criticality and its degenerate basis. Degeneracy means that several different molecular pathologies are individually sufficient to cause hyperexcitability, and because several such pathologies co-occur after nerve injury, that no single pathology is uniquely necessary. Consequently, single-target-drugs can be circumvented by maladaptive plasticity in any one of several ion channels.

DOI:http://dx.doi.org/10.7554/eLife.02370.001

Although the pain associated with an injury is unpleasant, it normally serves an important purpose: to make you avoid its source. However, some pain appears to arise from nowhere. Frustratingly, this type of pain, known as neuropathic pain, does not respond to common painkillers and is thus very difficult to treat.

The neurons that transmit pain and other sensory information do so using electrical signals. In response to a stimulus, ions travel through channels in the membrane of a neuron, which leads to a change in the electrical potential of the membrane. When this change is large enough, a voltage spike is produced: this signal is ultimately transmitted to the brain.

When certain neurons fire too easily or too often, neuropathic pain can arise. This hyperexcitability can make something painful feel even worse, or it can make things hurt that shouldn’t. To prevent this, extensive research has been devoted to identify drugs that target particular types of ion channels and block them. However, despite the discovery of many promising drugs, those drugs have been frustratingly ineffective in clinical trials.

Using simulations and experiments, Ratté et al. have examined the behavior of a type of neuron that normally conducts information about touch, but the brain sometimes misinterprets this information as pain. Increasing the flow of ions through the cell membrane in these simulations eventually causes a ‘tipping point’ to be crossed, which triggers a dramatic, discontinuous change in spiking pattern. However, as several different types of ion channels contribute to the current, there are several different ways in which the tipping point can be crossed.

This ability to produce the same result by multiple means is a common feature of complex systems. Known as degeneracy, it makes systems more robust, as a given result can still be achieved if one particular attempt to achieve this result fails. The work of Ratté et al. helps to explain why drugs that target just one type of ion channel may fail to relieve neuropathic pain: maladaptive changes in any one of several other ion channels may circumvent the therapeutic effect.

DOI:http://dx.doi.org/10.7554/eLife.02370.002

Pharmacogenetics of new analgesics

Patient phenotypes in pharmacological pain treatment varies between individuals, which could be partly assigned to their genotypes regarding the targets of classical analgesics (OPRM1, PTGS2) or associated signalling pathways (KCNJ6). Translational and genetic research have identified new targets, for which new analgesics are being developed. This addresses voltage-gated sodium, calcium and potassium channels, for which SCN9A, CACNA1B, KCNQ2 and KCNQ3, respectively, are primary gene candidates because they code for the subunits of the respective channels targeted by analgesics currently in clinical development. Mutations in voltage gated transient receptor potential (TRPV) channels are known from genetic pain research and may modulate the effects of analgesics under development targeting TRPV1 or TRPV3. To this add ligand-gated ion channels including nicotinic acetylcholine receptors, ionotropic glutamate-gated receptors and ATP-gated purinergic P2X receptors with most important subunits coded by CHRNA4, GRIN2B and P2RX7. Among G protein coupled receptors, δ-opioid receptors (coded by OPRD1), cannabinoid receptors (CNR1 and CNR2), metabotropic glutamate receptors (mGluR5 coded by GRM5), bradykinin B(1) (BDKRB1) and 5-HT(1A) (HTR1A) receptors are targeted by new analgesic substances. Finally, nerve growth factor (NGFB), its tyrosine kinase receptor (NTRK1) and the fatty acid amide hydrolase (FAAH) have become targets of interest. For most of these genes, functional variants have been associated with neuro-psychiatric disorders and not yet with analgesia. However, research on the genetic modulation of pain has already identified variants in these genes, relative to pain, which may facilitate the pharmacogenetic assessments of new analgesics. The increased number of candidate pharmacogenetic modulators of analgesic actions may open opportunities for the broader clinical implementation of genotyping information.

Microglial GRK2: a novel regulator of transition from acute to chronic pain

Pain is a hallmark of tissue damage and inflammation promoting tissue protection and thereby contributing to repair. Therefore, transient acute pain is an important feature of the adaptive response to damage. However, in a significant number of cases, pain persists for months to years after the problem that originally caused the pain has resolved. Such chronic pain is maladaptive as it no longer serves a protective aim. Chronic pain is debilitating, both physiologically and psychologically, and treatments to provide relief from chronic pain are often ineffective. The neurobiological mechanisms underlying the transition from adaptive acute pain to maladaptive chronic pain are only partially understood. In this review, we will summarize recent evidence that a kinase known as G protein-coupled receptor kinase (GRK2) is a key regulator of the transition from acute to chronic inflammatory pain. Our recent studies have shown that mice with a reduction in the cellular level of GRK2 develop chronic hyperalgesia in response to inflammatory mediators that induce only transient hyperalgesia in WT mice. This finding is clinically relevant because rodent models of chronic pain are associated with reduced cellular levels of GRK2. We propose that GRK2 is a newly discovered major player in the regulation of chronic pain. The pathways regulated by this kinase may open up new avenues for development of treatment strategies that target the cause, and not the symptoms of chronic pain.