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Mestdagh F, Steyaert A, Lavand'homme P. Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques. Curr Oncol 2023; 30:6838-6858. [PMID: 37504360 PMCID: PMC10378332 DOI: 10.3390/curroncol30070500] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023] Open
Abstract
Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.
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Affiliation(s)
- François Mestdagh
- Department of Anesthesiology and Pain Clinic, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - Arnaud Steyaert
- Department of Anesthesiology and Pain Clinic, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anesthesiology and Acute Postoperative & Transitional Pain Service, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
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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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Hasvik E, Haugen AJ, Grøvle L. Symptom descriptors and patterns in lumbar radicular pain caused by disc herniation: a 1-year longitudinal cohort study. BMJ Open 2022; 12:e065500. [PMID: 36549718 PMCID: PMC9772640 DOI: 10.1136/bmjopen-2022-065500] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The objective of the present study was to explore the diversity, quality, severity and distribution of symptoms in patients with radicular pain and a lumbar disc herniation. DESIGN Longitudinal cohort study. SETTING Hospital-based back clinic. PARTICIPANTS Ninety patients referred to secondary healthcare with (a) low back-related leg pain, (b) age between 18 and 65 years and (c) MRI confirmed lumbar disc herniation at a relevant side and level. OUTCOME MEASURES Neuropathic pain symptoms were assessed using the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2) and the painDETECT Questionnaire. In a subsample classified with neuropathic pain, in-depth interviews were performed, and symptomatic areas were drawn on standardised body charts. RESULTS At baseline, the most frequently used painDETECT symptom descriptor was numbness sensation, reported by 94%, followed by sudden pain attacks and tingling or prickling. The mean (SD) SF-MPQ-2 score (0-10) for aching pain was 5.9 (2.8); numbness 4.3 (3.3); tingling 4.0 (3.4); burning 2.6 (3.1); pain caused by light touch 1.5 (2.6). Leg pain was rated as extremely bothersome by 73%, numbness and tingling by 38%, weakness by 24% and back pain by 17%. In the subsample (n=52), deep-lying pain and non-painful abnormal sensations were frequent, at 71% and 85%. Drawings demonstrated substantial overlap between symptoms from compromised L5 and the S1 nerve roots. Painful and non-painful symptoms improved at approximately the same rate. At the 1-year follow-up, 45% (14/31) of patients who had received disc surgery, and 34% (18/53) of those who had received conservative treatment reported no bothersome back pain, leg pain, numbness/tingling or weakness. CONCLUSION Patients reported several highly bothersome symptoms, but not all are described as painful. The overall symptom profile of lumbar disc-related radicular pain differs from other neuropathic pain conditions with limited allodynia and thermal hyperalgesia. Symptomatic areas for the L5 and S1 nerve roots have a large overlap.
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Affiliation(s)
- Eivind Hasvik
- Department of Physical Medicine and Rehabilitation, Sykehuset Østfold HF, Grålum, Norway
| | | | - Lars Grøvle
- Department of Rheumatology, Sykehuset Østfold HF, Grålum, Norway
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Jia Z, Yu J, Zhao C, Ren H, Luo F. Outcomes and Predictors of Response of Duloxetine for the Treatment of Persistent Idiopathic Dentoalveolar Pain: A Retrospective Multicenter Observational Study. J Pain Res 2022; 15:3031-3041. [PMID: 36193165 PMCID: PMC9526422 DOI: 10.2147/jpr.s379430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 08/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Duloxetine has been reported to significantly relieve the pain of persistent idiopathic dentoalveolar pain (PIDP); however, the number of studies available is scarce and no study has identified the predictors of response of duloxetine for the treatment of PIDP. Objective To report the efficacy, safety, and identification of positive predictors of duloxetine for PIDP patients through a retrospective multicenter observational study. Methods We retrospectively reviewed the clinical database of PIDP patients who were prescribed duloxetine at 3 hospitals between January 2018 and November 2021. Demographic and pain-related baseline data, efficacy of patients after 3 months of medication by visual analog scale (VAS) scores for pain and adverse events were extracted and analyzed. The predictors of pain-relieving effect of duloxetine were identified by logistic regression analysis. Results A total of 135 patients were included in this study. Side effects occurred immediately after taking duloxetine in 24 (17.8%) patients, and the treatment with duloxetine was discontinued on 13 of them because they could not tolerate the side effects. Other 11 (8.1%) patients gradually tolerated the side effects within 2 weeks. Ninety-four out of 122 (77.0%) patients obtained pain relief with VAS significantly decreased (p < 0.01) and the other 28 (23.0%) patients stopped taking the drug because of weak efficacy. Binary logistic regression analysis showed that short disease duration (OR = 1.017, 95% CI = 1.004–1.030, P = 0.012) was an independent predictor of the positive response of duloxetine. Conclusion This study confirmed that duloxetine can significantly improve chronic pain of PIDP patients, and the safety was tolerable. Patients with shorter disease duration had more benefit from duloxetine. Limitations This is a retrospective observational study. Long-term efficacy and safety of duloxetine in the treatment of PIDP patients were not evaluated.
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Affiliation(s)
- Zipu Jia
- Department of Day Surgery Center; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jinyong Yu
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chunmei Zhao
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hao Ren
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fang Luo
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Fang Luo, Department of Anesthesiology and Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, People’s Republic of China, Tel +86 13611326978, Email
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Pirvulescu I, Biskis A, Candido KD, Knezevic NN. Overcoming clinical challenges of refractory neuropathic pain. Expert Rev Neurother 2022; 22:595-622. [PMID: 35866187 DOI: 10.1080/14737175.2022.2105206] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Refractory neuropathic pain (ReNP), and its definition, is widely disputed amongst clinicians due in part to unclear categorical diagnosing guidelines, overall time duration of neuropathic pain, and the exhaustiveness of treatment options. Usually ReNP is defined as chronic, intractable, and unresponsive neuropathic pain that have otherwise been untreatable. AREAS COVERED : In this narrative review, we discuss and summarize the effectiveness of prospective ReNP research conducted over the past 10 years. This research looks at pharmacological and interventional therapies in clinical trial settings. The pharmacological therapies discussed include the use of adjuvant treatments to improve the safety and efficacy of conventional approaches. Different modalities of administration, such as injection therapy and intrathecal drug delivery systems, provide targeted drug delivery. Interventional therapies such as neuromodulation, pulse radiofrequency, and nerve lesioning are more invasive, however, they are increasingly utilized in the field, as reflected in ongoing clinical trials. EXPERT OPINION : Based on the current data from RCTs and systematic reviews, it is clear that single drug therapy cannot be effective and has significant limitations. Transitioning to interventional modalities that showed more promising results sooner rather than later may be even more cost-efficient than attempting different conservative treatments with a high failure rate.
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Affiliation(s)
- Iulia Pirvulescu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Alexandras Biskis
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Advocate Aurora Research Institute, Chicago, IL, USA.,College of Aviation, Science and Technology, Lewis University, Romeoville, IL, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
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6
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Bibi R, Maneewat K, Sangchan H, Sae-sia W. Persistent post-surgical pain and its relationship to health-related quality of life in Pakistani women after breast cancer surgery. BELITUNG NURSING JOURNAL 2022; 8:258-265. [PMID: 37547108 PMCID: PMC10401365 DOI: 10.33546/bnj.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/10/2022] [Accepted: 05/18/2022] [Indexed: 08/08/2023] Open
Abstract
Background Breast cancer is the most commonly diagnosed cancer in women; it is also the second-leading cause of death from cancer. Persistent pain after breast cancer surgery is a serious clinical problem that negatively impacts the health-related quality of life of breast cancer survivors. Although persistent post-surgical pain following breast cancer surgery has long been under-reported; however, it is less explored in Pakistan's geographical background. Objective The study aimed to examine the persistent post-surgical pain after breast cancer surgery and its relationship to health-related quality of life among Pakistani women. Methods A descriptive correlational research design was employed in this study. The Brief Pain Inventory Short Form (BPI-SF) was used to assess the persistent post-surgical pain. The Functional Assessment of Cancer Therapy-Breast (FACT-B) was used to measure the health-related quality of life. Data were collected between February and May 2019 from Pakistani women who have undergone breast cancer surgery for at least three months and attended follow-up visits at two tertiary care hospitals in Pakistan. A Spearman's correlation coefficient was used for data analysis. Results The study included 91 Pakistani women. The participants were all females, with an average age of 45.6 years (SD = 6.53). The majority received radical mastectomy (n = 84, 92.3%) with adjuvant therapy (n = 91, 100%). The prevalence of breast surgery-related persistent pain was 100%, with 63 (69.2%) rating the pain as moderate to severe and reported neuropathic pain. The data analysis revealed a statistically significant negative correlation between BPI-SF items and FACT-B dimensions (r = -.43, p < 0.01). The participants appeared to show the highest score of the FACT-B in the social/family well-being (M = 16.58, SD = 3.44). The lowest score of the FACT-B was physical well-being (M = 6.98, SD = 6.38). Conclusion Persistent post-surgical pain has a negative impact on the health-related quality of life of Pakistani women breast cancer survivors, particularly on their physical well-being. Therefore, follow-up care of breast cancer survivors after treatment completion requires proper persistent pain-relief treatments and interventions to control pain and maintain health-related quality of life in oncology and research in this sphere. This basic knowledge from this study will enlighten the nurses and health care professionals to pay more attention to pain management and regular evaluation of persistent post-surgical pain after breast cancer surgery in order to improve their health-related quality of life.
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Affiliation(s)
- Rukhsana Bibi
- Master of Nursing Science in Adult and Gerontological Nursing, Faculty of Nursing, Prince of Songkla University, Songkhla, Thailand
| | - Khomapak Maneewat
- Surgical Nursing Department, Faculty of Nursing, Prince of Songkla University, Songkhla, Thailand
| | - Hathairat Sangchan
- Surgical Nursing Department, Faculty of Nursing, Prince of Songkla University, Songkhla, Thailand
| | - Wipa Sae-sia
- Surgical Nursing Department, Faculty of Nursing, Prince of Songkla University, Songkhla, Thailand
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Robinson C, Dalal S, Chitneni A, Patil A, Berger AA, Mahmood S, Orhurhu V, Kaye AD, Hasoon J. A Look at Commonly Utilized Serotonin Noradrenaline Reuptake Inhibitors (SNRIs) in Chronic Pain. Health Psychol Res 2022; 10:32309. [DOI: 10.52965/001c.32309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose of Review Chronic pain continues to be one of the leading healthcare cost burdens in the United States and is typically defined as ongoing pain, lasting longer than six months. Various treatment options exist for chronic pain, including physical therapy, medical management, pain psychology, and interventional therapies. Pain medications have been the mainstay of treatment for chronic pain conditions with an increasing use of membrane stabilizers and antidepressants to treat neuropathic pain conditions. Specifically, serotonin noradrenaline reuptake inhibitors (SNRIs) have been used to treat a range of pain conditions expanding from everyday use for depressive disorders. Recent Findings SNRIs, including duloxetine, venlafaxine, and milnacipran, have demonstrated efficacy in reducing pain in musculoskeletal pain (chronic low back pain and osteoarthritis), fibromyalgia, and neuropathic pain conditions (peripheral diabetic neuropathy). Summary The article describes the function, role, and use of SNRIs to treat chronic and neuropathic pain by altering the noradrenergic descending inhibitory pathways.
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Affiliation(s)
| | | | | | - Anand Patil
- Touro University California College of Medicine
| | - Amnon A. Berger
- Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Syed Mahmood
- Beth Israel Deaconess Medical Center and Harvard Medical School
| | | | - Alan D. Kaye
- Louisiana State University Health Sciences Center
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Matsuoka H, Clark K, Fazekas B, Oyamada S, Brown L, Ishiki H, Matsuda Y, Hasuo H, Ariyoshi K, Lee J, Le B, Allcroft P, Kochovska S, Fujiwara N, Miyaji T, Lovell M, Agar M, Yamaguchi T, Satomi E, Iwase S, Phillips J, Koyama A, Currow DC. Phase III, international, multicentre, double-blind, dose increment, parallel-arm, randomised controlled trial of duloxetine versus pregabalin for opioid-unresponsive neuropathic cancer pain: a JORTC-PAL16 trial protocol. BMJ Open 2022; 12:e050182. [PMID: 35131817 PMCID: PMC8823224 DOI: 10.1136/bmjopen-2021-050182] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Management of neuropathic cancer pain (NCP) refractory to regular opioids remains an important challenge. The efficacy of pregabalin for NCP except chemotherapy-induced peripheral neuropathy (CIPN) has already been confirmed in two randomised controlled trials (RCTs) compared with placebo. Duloxetine offers the potential of analgesia in opioid refractory NCP. However, there are no RCT of duloxetine for the management of opioid-refractory NCP as a first line treatment. Both classes of drugs have the potential to reduce NCP, but there has been no head-to-head comparison for the efficacy and safety, especially given differing side effect profiles. METHODS AND ANALYSIS An international, multicentre, double-blind, dose increment, parallel-arm, RCT is planned. Inclusion criteria include: adults with cancer experiencing NCP refractory to opioids; Brief Pain Inventory (BPI)-item 3 (worst pain) of ≥4; Neuropathic Pain on the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale of ≥12 despite of an adequate trial of regular opioid medication (≥60 mg/day oral morphine equivalent dose). Patients with CIPN are excluded.The study will recruit from palliative care teams (both inpatients and outpatients) in Japan and Australia. Participants will be randomised (1:1 allocation ratio) to duloxetine or pregabalin arm. Dose escalation is until day 14 and from day 14 to 21 is a dose de-escalation period to avoid withdrawal effects. The primary endpoint is defined as the mean difference in BPI item 3 for worst pain intensity over the previous 24 hours at day 14 between groups. A sample size of 160 patients will be enrolled between February 2020 and March 2023. ETHICS AND DISSEMINATION Ethics approval was obtained at Osaka City University Hospital Certified Review Board and South Western Sydney Local Health District Human Research Ethics Committee. The results of this study will be submitted for publication in international journals and the key findings presented at international conferences. TRIAL REGISTRATION NUMBERS: jRCTs051190097, ACTRN12620000656932.
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Affiliation(s)
- Hiromichi Matsuoka
- Department of Psycho-Oncology, Supportive and Palliative Care Development Center, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katherine Clark
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Shunsuke Oyamada
- Department of Biostatistics, Japanese Organisation for Research and Treatment of Cancer (JORTC) Data Center, Arakawa-ku, Tokyo, Japan
| | - Linda Brown
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Chuoh-ku, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Hideaki Hasuo
- Department of Psychosomatic Medicine, Kansai Medical University Hospital, Hirakata, Osaka, Japan
| | - Keisuke Ariyoshi
- Department of Data Management, Japanese Organisation for Research and Treatment of Cancer (JORTC) Data Center, Arakawa-ku, Tokyo, Japan
| | - Jessica Lee
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Brian Le
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Allcroft
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Slavica Kochovska
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Noriko Fujiwara
- Department of Palliative Medicine and Advanced Clinical Oncology, IMSUT Hospital of the Institute of Medical Science,The University of Tokyo, Japan, Tokyo, Japan
| | - Tempei Miyaji
- Department of Clinical Trial Data Management, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Melanie Lovell
- Palliative Care, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Eriko Satomi
- Department of Palliative Medicine, National Cancer Center Hospital, Chuoh-ku, Tokyo, Japan
| | - Satoru Iwase
- Department of Palliative Medicine, Saitama Medical University, Moroyama, Japan
| | - Jane Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Atsuko Koyama
- Department of Psychosomatic Medicine, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - David C Currow
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Cancer Institute New South Wales, Eveleigh, New South Wales, Australia
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Abstract
Managing chronic pain remains a major unmet clinical challenge. Patients can be treated with a range of interventions, but pharmacotherapy is the most common. These include opioids, antidepressants, calcium channel modulators, sodium channel blockers, and nonsteroidal anti-inflammatory drugs. Many of these drugs target a particular mechanism; however, chronic pain in many diseases is multifactorial and induces plasticity throughout the sensory neuroaxis. Furthermore, comorbidities such as depression, anxiety, and sleep disturbances worsen quality of life. Given the complexity of mechanisms and symptoms in patients, it is unsurprising that many fail to achieve adequate pain relief from a single agent. The efforts to develop novel drug classes with better efficacy have not always proved successful; a multimodal or combination approach to analgesia is an important strategy in pain control. Many patients frequently take more than one medication, but high-quality evidence to support various combinations is often sparse. Ideally, combining drugs would produce synergistic action to maximize analgesia and reduce side effects, although sub-additive and additive analgesia is still advantageous if additive side-effects can be avoided. In this review, we discuss pain mechanisms, drug actions, and the rationale for mechanism-led treatment selection.Abbreviations: COX - cyclooxygenase, CGRP - calcitonin gene-related peptide, CPM - conditioned pain modulation, NGF - nerve growth factor, NNT - number needed to treat, NMDA - N-methyl-d-aspartate, NSAID - nonsteroidal anti-inflammatory drugs, TCA - tricyclic antidepressant, SNRI - serotonin-noradrenaline reuptake inhibitor, QST - quantitative sensory testing.
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Affiliation(s)
- Ryan Patel
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, UK
| | - Anthony H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, UK
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