1
|
Albrecht PJ, Liu Y, Houk G, Ruggiero B, Banov D, Dockum M, Day A, Rice FL, Bassani G. Cutaneous targets for topical pain medications in patients with neuropathic pain: individual differential expression of biomarkers supports the need for personalized medicine. Pain Rep 2024; 9:e1119. [PMID: 38375092 PMCID: PMC10876238 DOI: 10.1097/pr9.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/30/2023] [Accepted: 11/07/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction Numerous potential cutaneous targets exist for treating chronic pain with topically applied active pharmaceutical ingredients. This preliminary human skin tissue investigation was undertaken to characterize several key biomarkers in keratinocytes and provide proof-of-principle data to support clinical development of topical compounded formulations for peripheral neuropathic pain syndromes, such as postherpetic neuralgia (PHN). Objectives The study intended to identify objective biomarkers in PHN skin on a patient-by-patient personalized medicine platform. The totality of biopsy biomarker data can provide a tissue basis for directing individualized compounded topical preparations to optimize treatment efficacy. Methods Referencing 5 of the most common actives used in topical pain relief formulations (ketamine, gabapentin, clonidine, baclofen, and lidocaine), and 3 well-established cutaneous mediators (ie, neuropeptides, cannabinoids, and vanilloids), comprehensive immunolabeling was used to quantify receptor biomarkers in skin biopsy samples taken from ipsilateral (pain) and contralateral (nonpain) dermatomes of patients with PHN. Results Epidermal keratinocyte labeling patterns were significantly different among the cohort for each biomarker, consistent with potential mechanisms of action among keratinocytes. Importantly, the total biomarker panel indicates that the enriched PHN cohort contains distinct subgroups. Conclusion The heterogeneity of the cohort differences may explain studies that have not shown statistical group benefit from topically administered compounded therapies. Rather, the essential need for individual tissue biomarker evaluations is evident, particularly as a means to direct a more accurately targeted topical personalized medicine approach and generate positive clinical results.
Collapse
Affiliation(s)
| | - Yi Liu
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - George Houk
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Beth Ruggiero
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Daniel Banov
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - Marilyn Dockum
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - A.J. Day
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| | - Frank L. Rice
- Integrated Tissue Dynamics, LLC (INTiDYN), Rensselaer, NY, USA
| | - Gus Bassani
- Professional Compounding Centers of America (PCCA), Houston, TX, USA
| |
Collapse
|
2
|
Verdiner R, Khurmi N, Choukalas C, Erickson C, Poterack K. Does adding muscle relaxant make post-operative pain better? a narrative review of the literature from US and European studies. Anesth Pain Med (Seoul) 2023; 18:340-348. [PMID: 37919918 PMCID: PMC10635846 DOI: 10.17085/apm.23055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 11/04/2023] Open
Abstract
Centrally acting skeletal muscle relaxants (CASMR) are widely prescribed as adjuncts for acute and chronic pain. Given the recent interest in multimodal analgesia and reducing opioid consumption, there has been an increase in its use for perioperative/postoperative pain control. The mechanism of action, pharmacodynamics, and pharmacokinetics of these drugs vary. Their use has been studied in a wide range of operative and non-operative settings. The best evidence for the efficacy of CASMRs is in acute, nonoperative musculoskeletal pain and, in the operative setting, in patients undergoing total knee arthroplasty and abdominal surgery, including inguinal herniorrhaphy and hemorrhoidectomy. The risk of complications and side effects, coupled with the limited evidence of efficacy, should prompt careful consideration of individual patient circumstances when prescribing CASMRs as part of perioperative pain management strategies.
Collapse
Affiliation(s)
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Christopher Choukalas
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Colby Erickson
- Midwestern Osteopathic Medical School, Glendale, CA, USA
| | - Karl Poterack
- Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
3
|
Mwaura AN, Marshall N, Anglesio MS, Yong PJ. Neuroproliferative dyspareunia in endometriosis and vestibulodynia. Sex Med Rev 2023; 11:323-332. [PMID: 37544766 DOI: 10.1093/sxmrev/qead033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Endometriosis is a common cause of deep dyspareunia, while provoked vestibulodynia is a common cause of superficial dyspareunia. The etiology of dyspareunia in both conditions is multifactorial and may include the role of local nerve growth (neurogenesis or neuroproliferation) that sensitizes pelvic structures and leads to pain with contact. OBJECTIVES To review the evidence for neuroproliferative dyspareunia in endometriosis and provoked vestibulodynia. METHODS Narrative review. RESULTS The pelvic peritoneum and vulvar vestibule receive somatic and autonomic innervation. Various markers have been utilized for nerve subtypes, including pan-neuronal markers and those specific for sensory and autonomic nerve fibers. The nerve growth factor family includes neurotrophic factors, such as nerve growth factor and brain-derived neurotrophic factor, and their receptors. Studies of endometriosis and provoked vestibulodynia have demonstrated the presence of nerve fibers around endometriosis epithelium/stroma in the pelvic peritoneum and within the vulvar vestibule. The number of nerve fibers is higher in these pain conditions as compared with control tissue. Nerve growth factor expression by endometriosis stroma and by immune cells in the vulvar vestibule may be involved in local neuroproliferation. Local inflammation is implicated in this neuroproliferation, with potential roles of interleukin 1β and mast cells in both conditions. Several studies have shown a correlation between nerve fibers around endometriosis and dyspareunia severity, but studies are lacking in provoked vestibulodynia. There are several possible clinical ramifications of neuroproliferative dyspareunia in endometriosis and provoked vestibulodynia, in terms of history, examination, biopsy, and surgical and medical treatment. CONCLUSIONS A neuroproliferative subtype of dyspareunia may be implicated in endometriosis and provoked vestibulodynia. Additional research is needed to validate this concept and to integrate it into clinical studies. Neuroproliferative pathways could serve as novel therapeutic targets for the treatment of dyspareunia in endometriosis and provoked vestibulodynia.
Collapse
Affiliation(s)
- Agnes N Mwaura
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, V6H 3N1, Canada
| | - Nisha Marshall
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, V6H 3N1, Canada
| | - Michael S Anglesio
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, V6H 3N1, Canada
| | - Paul J Yong
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, V6H 3N1, Canada
| |
Collapse
|
4
|
De Seta F, Stabile G, Antoci G, Zito G, Nappi RE. Provoked Vestibulodynia and Topical Treatment: A New Option. Healthcare (Basel) 2022; 10:healthcare10050830. [PMID: 35627968 PMCID: PMC9142053 DOI: 10.3390/healthcare10050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Provoked vestibulodynia is commonly associated with dyspareunia and affects 7% to 15% of women. This pathology has major implications on sexual function and quality of life, and several types of treatments are available for its management. However, a consensus has not been reached concerning the best treatment of vulvar pain. The aim of this study was to assess the efficacy and safety of a brand-new product, the vulvar emulgel Meclon® Lenex, for the management of provoked vestibulodynia and non-infective vulvitis. Methods: This was a monocentric, prospective, randomized, double-blind and placebo-controlled study. We enrolled 40 women with provoked vestibulodynia; 20 patients received Meclon® Lenex, whereas the remaining received a placebo. Each woman was assessed subjectively (through questionnaires) and objectively by evaluating vaginal and vulvar symptoms (Friedrichs criteria and Marinoff dyspareunia grade). We evaluated efficacy, safety, compliance and tolerability of the brand-new product vulvar gel Meclon® Lenex in provoked vestibulodynia. Results: After administration of Meclon® Lenex, we evaluated all parameters of the Friedrichs criteria (burning, dyspareunia, erythema, vulvar pain at the 5 o’clock position and 7 o’clock position), as well as the levels of Marinoff dyspareunia. The active treatment showed to be statistically significantly effective (p value ≤ 0.05) in reducing all symptoms of Friedrichs criteria, vulvar pain and Marinoff dyspareunia. Conclusion: This prospective study showed that Meclon® Lenex vulvar emulgel revealed an excellent tolerability and compliance, demonstrating to be a safe and effective option in the treatment of provoked vestibulodynia and non-infective vulvitis.
Collapse
Affiliation(s)
- Francesco De Seta
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34100 Trieste, Italy; (F.D.S.); (G.Z.)
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Guglielmo Stabile
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34100 Trieste, Italy; (F.D.S.); (G.Z.)
- Correspondence:
| | - Graziana Antoci
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Gabriella Zito
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34100 Trieste, Italy; (F.D.S.); (G.Z.)
| | - Rossella E. Nappi
- Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, 27100 Pavia, Italy;
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, School of Medicine, University of Pavia, 27100 Pavia, Italy
| |
Collapse
|
5
|
Topical Treatments and Their Molecular/Cellular Mechanisms in Patients with Peripheral Neuropathic Pain-Narrative Review. Pharmaceutics 2021; 13:pharmaceutics13040450. [PMID: 33810493 PMCID: PMC8067282 DOI: 10.3390/pharmaceutics13040450] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 12/25/2022] Open
Abstract
Neuropathic pain in humans results from an injury or disease of the somatosensory nervous system at the peripheral or central level. Despite the considerable progress in pain management methods made to date, peripheral neuropathic pain significantly impacts patients' quality of life, as pharmacological and non-pharmacological methods often fail or induce side effects. Topical treatments are gaining popularity in the management of peripheral neuropathic pain, due to excellent safety profiles and preferences. Moreover, topical treatments applied locally may target the underlying mechanisms of peripheral sensitization and pain. Recent studies showed that peripheral sensitization results from interactions between neuronal and non-neuronal cells, with numerous signaling molecules and molecular/cellular targets involved. This narrative review discusses the molecular/cellular mechanisms of drugs available in topical formulations utilized in clinical practice and their effectiveness in clinical studies in patients with peripheral neuropathic pain. We searched PubMed for papers published from 1 January 1995 to 30 November 2020. The key search phrases for identifying potentially relevant articles were "topical AND pain", "topical AND neuropathic", "topical AND treatment", "topical AND mechanism", "peripheral neuropathic", and "mechanism". The result of our search was 23 randomized controlled trials (RCT), 9 open-label studies, 16 retrospective studies, 20 case (series) reports, 8 systematic reviews, 66 narrative reviews, and 140 experimental studies. The data from preclinical studies revealed that active compounds of topical treatments exert multiple mechanisms of action, directly or indirectly modulating ion channels, receptors, proteins, and enzymes expressed by neuronal and non-neuronal cells, and thus contributing to antinociception. However, which mechanisms and the extent to which the mechanisms contribute to pain relief observed in humans remain unclear. The evidence from RCTs and reviews supports 5% lidocaine patches, 8% capsaicin patches, and botulinum toxin A injections as effective treatments in patients with peripheral neuropathic pain. In turn, single RCTs support evidence of doxepin, funapide, diclofenac, baclofen, clonidine, loperamide, and cannabidiol in neuropathic pain states. Topical administration of phenytoin, ambroxol, and prazosin is supported by observational clinical studies. For topical amitriptyline, menthol, and gabapentin, evidence comes from case reports and case series. For topical ketamine and baclofen, data supporting their effectiveness are provided by both single RCTs and case series. The discussed data from clinical studies and observations support the usefulness of topical treatments in neuropathic pain management. This review may help clinicians in making decisions regarding whether and which topical treatment may be a beneficial option, particularly in frail patients not tolerating systemic pharmacotherapy.
Collapse
|
6
|
Ala S, Alvandipour M, Saeedi M, Mansourifar M, Monajati M, Shiva A. Effect of Topical Baclofen 5% on Post-Hemorrhoidectomy Pain: Randomized Double Blind Placebo-Controlled Clinical Trial. J Gastrointest Surg 2020; 24:405-410. [PMID: 30783957 DOI: 10.1007/s11605-019-04147-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/01/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Baclofen is an agonist for a subtype of gamma-amino butyric acid (GABA-B) receptors and traditionally been used for the systemic treatment of spasticity. Topical application of baclofen has been shown to reduce pain in patients with localized neuropathic pain. OBJECTIVES In this study, we investigate the efficacy of baclofen cream (5%) in reducing postoperative pain and analgesic requirement after open hemorrhoidectomy. DESIGN The patients were randomly assigned to either baclofen (5%) cream or placebo immediately after surgery and then every 12 h for 14 days. PATIENTS A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were randomly assigned to this trial. SETTING This study was conducted at a single educational hospital. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were intensity of pain, measured with a visual analog scale, and the analgesic requirement, measured by the amount of the acetaminophen consumption. RESULTS No significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the baclofen group was significantly lower on week 1 (P = 0.01) and week 2 (P = 0.02) than the placebo group. Similarly, patients in the baclofen group consumed significantly less analgesic medication on week 1 (P = 0.025) and week 2 (P = 0.024) than the control group. CONCLUSION Topical application of baclofen effectively relieves pain after hemorrhoidectomy with minimal side effects.
Collapse
Affiliation(s)
- Shahram Ala
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Mina Alvandipour
- Department of Surgery, Imam Khomeini General Hospital Affiliated to Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
| | - Majid Saeedi
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Mohaddeseh Mansourifar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Mahila Monajati
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran
| | - Afshin Shiva
- Department of Clinical Pharmacy, Nephrology and Kidney Transplant Research Center, Faculty of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
| |
Collapse
|
7
|
Abstract
Objective: To evaluate the literature and educate the pharmacy community about the different treatment options for vulvodynia. Data Sources: Searches were performed through MEDLINE (1946-May 2018) using OVID and EBSCOhost, and Excerpta Medica (1974-May 2018) using EMBASE. Search terms included vulvar vestibulitis syndrome, vestibulodynia, vulvodynia, vulvar pain, provoked vulvar vestibulitis, and vulvodynia treatment. References of all relevant articles were then used to find additional applicable articles. Study Selection and Data Extraction: This review includes articles in the English language and human trial literature. Twenty-five trials explored the use of oral and topical medications in the treatment of vulvodynia. Data Synthesis: Vulvodynia is a poorly understood disease with an unknown etiology. Oral tricyclic antidepressants and gabapentin continue to be the most commonly used treatments for vulvodynia pain. This is due to their ease of use and patient preference. Topical treatments that have efficacy data are amitriptyline, gabapentin, lidocaine, baclofen, and hormones. This route of administration avoids systemic adverse effects and interpatient variability that accompanies oral administration. Alternative therapies more commonly used include physiotherapy, psychotherapy, and surgery. Treatment length may vary due to dose titrations and potential changes in medication therapy. Conclusions: Several medication and alternative therapies may be effective in treating vulvodynia. Current studies used wide dosing ranges, making it difficult to standardize therapy. No consistent method of assessing pain was used between studies, as well as a limited number being randomized and placebo controlled. Additional research is needed to increase knowledge and further develop vulvodynia treatments.
Collapse
Affiliation(s)
- Bobbi Jo Loflin
- Southwestern Oklahoma State University,
Weatherford, OK, USA
| | | | | |
Collapse
|
8
|
Guerrero-Alba R, Barragán-Iglesias P, González-Hernández A, Valdez-Moráles EE, Granados-Soto V, Condés-Lara M, Rodríguez MG, Marichal-Cancino BA. Some Prospective Alternatives for Treating Pain: The Endocannabinoid System and Its Putative Receptors GPR18 and GPR55. Front Pharmacol 2019; 9:1496. [PMID: 30670965 PMCID: PMC6331465 DOI: 10.3389/fphar.2018.01496] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/07/2018] [Indexed: 12/12/2022] Open
Abstract
Background: Marijuana extracts (cannabinoids) have been used for several millennia for pain treatment. Regarding the site of action, cannabinoids are highly promiscuous molecules, but only two cannabinoid receptors (CB1 and CB2) have been deeply studied and classified. Thus, therapeutic actions, side effects and pharmacological targets for cannabinoids have been explained based on the pharmacology of cannabinoid CB1/CB2 receptors. However, the accumulation of confusing and sometimes contradictory results suggests the existence of other cannabinoid receptors. Different orphan proteins (e.g., GPR18, GPR55, GPR119, etc.) have been proposed as putative cannabinoid receptors. According to their expression, GPR18 and GPR55 could be involved in sensory transmission and pain integration. Methods: This article reviews select relevant information about the potential role of GPR18 and GPR55 in the pathophysiology of pain. Results: This work summarized novel data supporting that, besides cannabinoid CB1 and CB2 receptors, GPR18 and GPR55 may be useful for pain treatment. Conclusion: There is evidence to support an antinociceptive role for GPR18 and GPR55.
Collapse
Affiliation(s)
- Raquel Guerrero-Alba
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Paulino Barragán-Iglesias
- School of Behavioral and Brain Sciences and Center for Advanced Pain Studies, University of Texas at Dallas, Richardson, TX, United States
| | - Abimael González-Hernández
- Departamento de Neurobiología del Desarrollo y Neurofisiología, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Santiago de Querétaro, Mexico
| | - Eduardo E Valdez-Moráles
- Cátedras CONACYT, Departamento de Cirugía, Centro de Ciencias Biomédicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Vinicio Granados-Soto
- Neurobiology of Pain Laboratory, Departamento de Farmacobiología, Cinvestav, Mexico City, Mexico
| | - Miguel Condés-Lara
- Departamento de Neurobiología del Desarrollo y Neurofisiología, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Santiago de Querétaro, Mexico
| | - Martín G Rodríguez
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| |
Collapse
|
9
|
Kopsky DJ, Keppel Hesselink JM. Phenytoin Cream for the Treatment for Neuropathic Pain: Case Series. Pharmaceuticals (Basel) 2018; 11:ph11020053. [PMID: 29843362 PMCID: PMC6027409 DOI: 10.3390/ph11020053] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND: Neuropathic pain can be disabling, and is often difficult to treat. Within a year, over half of all patients stop taking their prescribed neuropathic pain medication, which is most probably due to side effects or disappointing analgesic results. Therefore, new therapies are needed to alleviate neuropathic pain. As such, topical analgesics could be a new inroad in the treatment of neuropathic pain. In 2014, we developed a new topical formulation containing either phenytoin or sodium phenytoin. After optimization of the formulation, we were able to reach a 10% concentration and combine phenytoin with other co-analgesics in the same base cream. OBJECTIVE: To describe a series of 70 neuropathic pain patients who were treated with phenytoin cream. MATERIAL AND METHODS: Cases treated with phenytoin 5% or 10% creams were gathered. The mean onset of pain relief, the duration of effect, and reduction in pain intensity measured on the 11-point numerical rating scale (NRS) were all studied. A single-blind response test with phenytoin 10% and placebo creams was conducted on 12 patients in order to select responders prior to prescribing the active cream. Plasma phenytoin concentrations were measured in 16 patients. RESULTS: Nine patients applied phenytoin 5% cream, and 61 patients used phenytoin 10% cream. After grouping the effects of all of the patients, the mean onset of pain relief was 16.3 min (SD: 14.8), the mean duration of analgesia was 8.1 h (SD: 9.1), and the mean pain reduction on the NRS was 61.2% (SD: 25.0). The mean pain reduction on the NRS while using phenytoin cream was statistically significant compared with the baseline, with a reduction of 4.5 (CI: 4.0 to 5.0, p < 0.01). The 12 patients on whom a single-blind response test was performed experienced a statistically significant reduction in pain in the area where the phenytoin 10% cream was applied in comparison to the area where the placebo cream was applied (p < 0.01). Thirty minutes after the test application, the mean pain reduction on the NRS in the areas where the phenytoin 10% cream and the placebo cream were applied was 3.3 (CI: 2.3 to 4.4, p < 0.01) and 1.1 (CI: 0.4 to 1.9, p < 0.05), respectively. In all 16 patients, the phenytoin plasma levels were below the limit of detection. So far, no systemic side effects were reported. Two patients only reported local side effects: a transient burning aggravation and skin rash. CONCLUSION: In this case series, the phenytoin cream had reduced neuropathic pain considerably, with a fast onset of analgesic effect.
Collapse
Affiliation(s)
- David J Kopsky
- Institute for Neuropathic Pain, Vespuccistraat 64-III, 1056 SN Amsterdam, The Netherlands.
| | | |
Collapse
|
10
|
Kim R, Kelly KL, Olson M, Nickel JC. Early experience with topical meloxicam and lidocaine combination for the treatment of vulvodynia. Can Urol Assoc J 2018; 12:252-255. [PMID: 29629863 DOI: 10.5489/cuaj.4976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION We report our early clinical observations on the use of topical meloxicam and lidocaine gel for patients with vulvodynia. METHODS This is an early experience in participants with a history of vulvodynia evaluated and treated at the Queen's University Pelvic and Bladder Pain Clinic. Combination meloxicam 0.3% and lidocaine 5% were provided to the participants and they were instructed to apply 5 cc to the vulvar area twice daily. Standardized assessment was conducted for each participant before the start of the topical therapy and again at one week, and included Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), and pain scoring (Likert) for vulvar pain, in addition to a subjective global assessment after a week of treatment. RESULTS Of the eight participants, six had a subjective improvement in their symptoms with the use of the combination gel. They reported between one- and four-point reductions on the Likert pain scale and mild to moderate improvement of symptoms. Common side effects reported were burning and stinging. CONCLUSIONS The results from this early experience are promising for a potentially effective topical treatment for vulvodynia.
Collapse
Affiliation(s)
- Rufina Kim
- Department of Urology, Queen's University, Kingston, ON, Canada
| | | | - Merle Olson
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,VP Research, Chief Medical, Calgary, AB, Canada
| | - J Curtis Nickel
- Department of Urology, Queen's University, Kingston, ON, Canada
| |
Collapse
|
11
|
Abstract
Purpose of Review Topical therapeutic approaches in localized neuropathic pain (LNP) syndromes are increasingly used by both specialists and general practitioners, with a potentially promising effect on pain reduction. In this narrative review, we describe the available compounds for topical use in LNP syndromes and address their potential efficacy according to the literature. Recent Findings Local anaesthetics (e.g., lidocaine, bupivacaine and mepivacaine), as well as general anaesthetic agents (e.g., ketamine), muscle relaxants (e.g., baclofen), capsaicin, anti-inflammatory drugs (e.g., diclofenac), salicylates, antidepressants (e.g., amitriptyline and doxepin), α2 adrenergic agents (e.g., clonidine), or even a combination of them have been tested in various applications for the treatment of LNP. Few of them have reached a sufficient level of evidence to support systematic use as treatment options. Summary Relatively few systemic side effects or drug–drug interactions and satisfactory efficacy seem to be the benefits of topical treatments. More well-organized and tailored studies are necessary for the further conceptualization of topical treatments for LNP.
Collapse
Affiliation(s)
- Roberto Casale
- Department of High Technology Rehabilitation & Pain Rehabilitation Unit, Habilita Care and Research Hospitals, Via Bologna 1-24040, Zingonia di Ciserano (BG), Italy.
| | - Z Symeonidou
- Department of High Technology Rehabilitation & Pain Rehabilitation Unit, Habilita Care and Research Hospitals, Via Bologna 1-24040, Zingonia di Ciserano (BG), Italy.,Department of Physical and Rehabilitation Medicine, General Hospital of Attica "KAT", Athens, Greece
| | - M Bartolo
- Department of Rehabilitation, Neurorehabilitation Unit, Habilita, Zingonia di Ciserano (BG), Italy
| |
Collapse
|
12
|
Abstract
We developed and tested a new putative analgesic cream, based on the anticonvulsant phenytoin in patients suffering from treatment refractory neuropathic pain. The use of commercial topical analgesics is not widespread due to the facts that capsaicin creams or patches can give rise to side effects, such as burning, and analgesic patches (e.g., lidocaine 5% patches) have complex handling, especially for geriatric patients. Only in a few countries, compounded creams based on tricyclic antidepressants or other (co-)analgesics are available. Such topical analgesic creams, however, are easy to administer and have a low propensity for inducing side effects. We, therefore, developed a new topical cream based on 5% and 10% phenytoin and described three successfully treated patients suffering from neuropathic pain. All patients were refractory to a number of other analgesics. In all patients, phenytoin cream was effective in reducing pain completely, without any side effects, and the tolerability was excellent. The onset of action of the phenytoin creams was within 30 minutes. Phenytoin cream might become a new treatment modality of the treatment of neuropathic pain.
Collapse
|
13
|
Keppel Hesselink JM, Kopsky DJ, Bhaskar AK. Skin matters! The role of keratinocytes in nociception: a rational argument for the development of topical analgesics. J Pain Res 2016; 10:1-8. [PMID: 28031725 PMCID: PMC5179230 DOI: 10.2147/jpr.s122765] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Treatment of neuropathic pain using topical formulations is still in its infancy. Only few topical analgesic formulations have become available for clinical use, and among these, analgesic creams are still rare. This is unfortunate because analgesic creams offer a number of advantages over patches, such as convenience, ease of adapting the frequency of application, and dose, and “rubbing cream where it hurts” involves the patient much more in the therapeutic process compared to patches and other localized treatment modalities. Although the literature supporting the efficacy and safety of analgesic creams (mostly compounded) is growing since the last decade, most pain physicians have not yet noticed and appreciated the therapeutic potential and clinical value of these creams. This is most probably due to a prejudice that topical application should need to act transdermally, more or less as a slow-release formulation, such as in patches delivering opioids. We will discuss this prejudice and show that there are multiple important targets in the skin to be reached by topical analgesic or anti-inflammatory compounds, and that the keratinocyte is one of those targets. By specifically targeting the keratinocyte, analgesia seems possible, effective, and safe, and thus topical analgesic creams may hold promise as a novel treatment modality for neuropathic pain.
Collapse
Affiliation(s)
| | - David J Kopsky
- Institute for Neuropathic Pain, Vespuccistraat 64-III, Amsterdam, the Netherlands
| | - Arun K Bhaskar
- Pain management Centre, Charing Cross Hospital Imperial Healthcare NHS Trust, London, United Kingdom
| |
Collapse
|
14
|
Keppel Hesselink JM, Kopsky DJ, Sajben N. New topical treatment of vulvodynia based on the pathogenetic role of cross talk between nociceptors, immunocompetent cells, and epithelial cells. J Pain Res 2016; 9:757-762. [PMID: 27757050 PMCID: PMC5055105 DOI: 10.2147/jpr.s115407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Topical treatments of localized neuropathic pain syndromes in general are mostly neglected, mainly due to the fact that most pain physicians expect that a topical formulation needs to result in a transdermal delivery of the active compounds. On the basis of the practical experience, this study brings forth a new, somewhat neglected element of the vulvodynia pathogenesis: the cross talk between the nerve endings of nociceptors, the adjacent immunocompetent cells, and vaginal epithelial cells. Insight into this cross talk during a pathogenic condition supports the treatment of vulvodynia with topical (compounded) creams. Vulvodynia was successfully treated with an analgesic cream consisting of baclofen 5% together with the autacoid palmitoylethanolamide 1%, an endogenous anti-inflammatory compound. In this review, data is presented to substantiate the rationale behind developing and prescribing topical products for localized pain states such as vulvodynia. Most chronic inflammatory disorders are based on a network pathogenesis, and monotherapeutic inroads into the treatment of such disorders are obsolete.
Collapse
Affiliation(s)
| | - D J Kopsky
- Institute for Neuropathic Pain, Amsterdam, The Netherlands
| | - N Sajben
- Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| |
Collapse
|
15
|
Falsetta ML, Foster DC, Bonham AD, Phipps RP. A review of the available clinical therapies for vulvodynia management and new data implicating proinflammatory mediators in pain elicitation. BJOG 2016; 124:210-218. [PMID: 27312009 DOI: 10.1111/1471-0528.14157] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2016] [Indexed: 12/19/2022]
Abstract
Localised provoked vulvodynia (LPV) is a common, chronic, and disabling condition: patients experience profound pain and a diminished quality of life. The aetiologic origins of vulvodynia are poorly understood, yet recent evidence suggests a link to site-specific inflammatory responses. Fibroblasts isolated from the vestibule of LPV patients are sensitive to proinflammatory stimuli and copiously produce pain-associated proinflammatory mediators (IL-6 and PGE2 ). Although LPV is a multifactorial disorder, understanding vulvar inflammation and targeting the inflammatory response should lead to treatment advances, especially for patients exhibiting signs of inflammation. NFκB (already targeted clinically) or other inflammatory components may be suitable therapeutic targets. TWEETABLE ABSTRACT Vulvodynia is a poorly understood, prevalent, and serious women's health issue requiring better understanding to improve therapy.
Collapse
Affiliation(s)
- M L Falsetta
- Department of Environmental Medicine, University of Rochester, Rochester, NY, USA
| | - D C Foster
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USA
| | - A D Bonham
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USA
| | - R P Phipps
- Department of Environmental Medicine, University of Rochester, Rochester, NY, USA.,Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USA.,Department of Microbiology and Immunology, University of Rochester, Rochester, NY, USA
| |
Collapse
|
16
|
Safaeian P, Mattie R, Hahn M, Plastaras CT, McCormick ZL. Novel Treatment of Radicular Pain With a Multi-Mechanistic Combination Topical Agent: A Case Series and Literature Review. Anesth Pain Med 2016; 6:e33322. [PMID: 27252902 PMCID: PMC4886452 DOI: 10.5812/aapm.33322] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 11/30/2015] [Accepted: 12/20/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction Pharmacologic treatment of radicular pain with oral medications is limited by adverse effects and concern for dependence. While topical formulations have been explored in pain research, there is no published literature evaluating the efficacy in radicular pain. We present the first three cases of radicular pain successfully treated with a topical formulation of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline (T7). Case Presentation Case series evaluating T7 for treatment of radicular pain in a single, outpatient pain center. Pain was rated on the numeric rating scale (NRS) on initial evaluation and follow up after a trial of T7. One to two grams of T7 was applied to the affected area 3 - 4 times daily in addition to the patient’s baseline pharmacologic management. Three patients with median age of 50 (range, 39 to 65) and diagnosis of cervical and/or lumbosacral radicular pain participated. Two of the three had chronic radicular pain despite use of analgesic agents, spinal injections and failed spinal surgery syndrome. Each reported subjective improvement in radicular pain, function and sleep. There was an average decrease in NRS score consistent with 30% - 40% global improvement in symptoms, clinically significant based on the minimal clinically important difference for radicular pain. T7 was well tolerated without adverse reactions. Surgery was prevented or delayed in all cases. Conclusions This is the first report of the successful treatment of radicular pain with a topical agent. This highlights the need for randomized, prospective study of both single and compounded topical agents for treatment of radicular pain.
Collapse
Affiliation(s)
- Pegah Safaeian
- Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago, Northwestern Feinberg School of Medicine, Chicago, USA
- Corresponding author: Pegah Safaeian, Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, USA. Tel: +1-3126951000, E-mail:
| | - Ryan Mattie
- Department of Orthopaedics, Stanford University, Palo Alto, USA
| | - Matthew Hahn
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Christopher T. Plastaras
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Zachary L. McCormick
- Department of Physical Medicine and Rehabilitation, The Rehabilitation Institute of Chicago, Northwestern Feinberg School of Medicine, Chicago, USA
- Department of Anesthesiology, Northwestern Feinberg School of Medicine, Chicago, USA
| |
Collapse
|
17
|
|
18
|
Maccarrone M. Endocannabinoid signaling in female reproductive events: a potential therapeutic target? Expert Opin Ther Targets 2015; 19:1423-7. [PMID: 26126134 DOI: 10.1517/14728222.2015.1062878] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nearly 30 years after the discovery in 1964 of the psychoactive ingredient of cannabis (Cannabis sativa), Δ(9)-tetrahydrocannabinol, its endogenous counterparts were discovered and collectively termed endocannabinoids (eCBs): N-arachidonoylethanolamine (anandamide) in 1992 and 2-arachidonoylglycerol in 1995. Since then, intense research has identified additional eCBs and an ensemble of proteins that bind, synthesize and degrade them, the so-called eCB system. Altogether, these new compounds have been recognized as key mediators of several aspects of human pathophysiology, and in particular of female fertility. Here, the main features of the eCB system are presented, in order to put in a better perspective the relevance of eCB signaling in virtually all steps of human reproduction and to highlight emerging hopes that elements of this system might indeed become novel targets to combat fertility problems.
Collapse
Affiliation(s)
- Mauro Maccarrone
- a 1 Campus Bio-Medico University of Rome, Center of Integrated Research , Via Álvaro del Portillo 21, 00128 Rome, Italy +39 06 2254 19169 ; +39 06 2254 1456 ; .,b 2 European Center for Brain Research, Santa Lucia Foundation , Rome, Italy
| |
Collapse
|
19
|
Tavares C. Alternative methods of pain management for the older adult population: Review of topical pain medications. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.05.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AbstractThe older adult population is one of the fastest growing age groups in the United States. As this population continues to expand, determining the safest way to provide pain management has become increasingly important. More than 50% of community-dwelling older adults experience pain on a daily basis, and up to 83% of those in assisted living facilities experience persistent pain. Pain is exceedingly challenging to treat safely and effectively in the elderly because of the physiologic changes that occur as people age. In addition, many nonnarcotic medications with analgesic properties are listed in both the 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults and the Pharmacy Quality Alliance high-risk medications lists. An approach to the growing challenge of managing pain in the elderly that is gaining popularity among community-dwelling patients is the use of topical pain medications. The goal of this article is to review some of the available literature regarding the use of various topical analgesics alone or in combination, and to discuss their known or theoretical mechanisms of peripheral pain modulation. Commercially available or compounded topical pain medications may be used to replace or augment doses of oral medications in an effort to decrease the risk of adverse drug events for older adult patients. When prescribing topical pain medications physicians should consider the nature of the pain targeted, the type of analgesia expected from each ingredient, the potential for systemic absorption, and related side effects.
Collapse
|
20
|
Maccarrone M, Bab I, Bíró T, Cabral GA, Dey SK, Di Marzo V, Konje JC, Kunos G, Mechoulam R, Pacher P, Sharkey KA, Zimmer A. Endocannabinoid signaling at the periphery: 50 years after THC. Trends Pharmacol Sci 2015; 36:277-96. [PMID: 25796370 DOI: 10.1016/j.tips.2015.02.008] [Citation(s) in RCA: 434] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/10/2015] [Accepted: 02/19/2015] [Indexed: 12/19/2022]
Abstract
In 1964, the psychoactive ingredient of Cannabis sativa, Δ(9)-tetrahydrocannabinol (THC), was isolated. Nearly 30 years later the endogenous counterparts of THC, collectively termed endocannabinoids (eCBs), were discovered: N-arachidonoylethanolamine (anandamide) (AEA) in 1992 and 2-arachidonoylglycerol (2-AG) in 1995. Since then, considerable research has shed light on the impact of eCBs on human health and disease, identifying an ensemble of proteins that bind, synthesize, and degrade them and that together form the eCB system (ECS). eCBs control basic biological processes including cell choice between survival and death and progenitor/stem cell proliferation and differentiation. Unsurprisingly, in the past two decades eCBs have been recognized as key mediators of several aspects of human pathophysiology and thus have emerged to be among the most widespread and versatile signaling molecules ever discovered. Here some of the pioneers of this research field review the state of the art of critical eCB functions in peripheral organs. Our community effort is aimed at establishing consensus views on the relevance of the peripheral ECS for human health and disease pathogenesis, as well as highlighting emerging challenges and therapeutic hopes.
Collapse
Affiliation(s)
- Mauro Maccarrone
- Center of Integrated Research, Campus Bio-Medico University, Rome, Italy; Center for Brain Research, Santa Lucia Foundation IRCCS, Rome, Italy.
| | - Itai Bab
- Bone Laboratory, Hebrew University Medical Faculty, Jerusalem, Israel; Institute for Drug Research, Hebrew University Medical Faculty, Jerusalem, Israel
| | - Tamás Bíró
- DE-MTA 'Lendület' Cellular Physiology Research Group, Department of Physiology, Medical Faculty, University of Debrecen, Debrecen, Hungary
| | - Guy A Cabral
- Department of Microbiology and Immunology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sudhansu K Dey
- Division of Reproductive Sciences, Cincinnati Children's Research Foundation, Cincinnati, OH, USA
| | - Vincenzo Di Marzo
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, National Council of Research, Pozzuoli, Italy
| | - Justin C Konje
- Department of Obstetrics and Gynaecology, Sidra Medical and Research Center, Doha, Qatar
| | - George Kunos
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Raphael Mechoulam
- Institute for Drug Research, Hebrew University Medical Faculty, Jerusalem, Israel
| | - Pal Pacher
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Keith A Sharkey
- Hotchkiss Brain Institute, Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Andreas Zimmer
- Institute of Molecular Psychiatry, University of Bonn, Bonn, Germany
| |
Collapse
|
21
|
Abstract
The lasting research on the endocannabinoid system (ECS) has now provided solid and convincing evidence that proves the detrimental effects of recreational drug abuse (a growing habit among teenagers) on fertility. Endocannabinoids (eCBs) affect reproductive events from gametogenesis to fertilization, from embryo implantation to the final outcome of pregnancy and, thus, they have been proposed as suitable biomarkers to predict the reproductive potential of male and female gametes in clinical practice. Novel tools for reproductive medicine are highly sought after, and here we report the latest findings on the impact of the ECS on fertility, demonstrating how basic research can be translated into new medical strategies.
Collapse
Affiliation(s)
- Natalia Battista
- Faculty of Bioscience and Technology for Food, Agriculture and Environment, University of Teramo, Teramo, Italy
| | - Monica Bari
- European Center for Brain Research/IRCCS Santa Lucia Foundation, Rome, Italy
- Department of Experimental Medicine and Surgery, Tor Vergata University of Rome, Rome, Italy
| | - Mauro Maccarrone
- European Center for Brain Research/IRCCS Santa Lucia Foundation, Rome, Italy.
- School of Medicine and Center of Integrated Research, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 21, 00128, Rome, Italy.
| |
Collapse
|