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Cano A, Fonseca E, Ettcheto M, Sánchez-López E, de Rojas I, Alonso-Lana S, Morató X, Souto EB, Toledo M, Boada M, Marquié M, Ruíz A. Epilepsy in Neurodegenerative Diseases: Related Drugs and Molecular Pathways. Pharmaceuticals (Basel) 2021; 14:1057. [PMID: 34681281 PMCID: PMC8538968 DOI: 10.3390/ph14101057] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/14/2021] [Accepted: 10/14/2021] [Indexed: 12/17/2022] Open
Abstract
Epilepsy is a chronic disease of the central nervous system characterized by an electrical imbalance in neurons. It is the second most prevalent neurological disease, with 50 million people affected around the world, and 30% of all epilepsies do not respond to available treatments. Currently, the main hypothesis about the molecular processes that trigger epileptic seizures and promote the neurotoxic effects that lead to cell death focuses on the exacerbation of the glutamate pathway and the massive influx of Ca2+ into neurons by different factors. However, other mechanisms have been proposed, and most of them have also been described in other neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease, Huntington's disease, or multiple sclerosis. Interestingly, and mainly because of these common molecular links and the lack of effective treatments for these diseases, some antiseizure drugs have been investigated to evaluate their therapeutic potential in these pathologies. Therefore, in this review, we thoroughly investigate the common molecular pathways between epilepsy and the major neurodegenerative diseases, examine the incidence of epilepsy in these populations, and explore the use of current and innovative antiseizure drugs in the treatment of refractory epilepsy and other neurodegenerative diseases.
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Affiliation(s)
- Amanda Cano
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
- Department of Pharmacy, Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
- Institute of Nanoscience and Nanotechnology (IN2UB), 08028 Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (E.F.); (M.T.)
- Research Group on Status Epilepticus and Acute Seizures, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Miren Ettcheto
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
- Department of Pharmacology, Toxicology and Therapeutic Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
- Institute of Neurosciences (UBNeuro), University of Barcelona, 08007 Barcelona, Spain
| | - Elena Sánchez-López
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
- Department of Pharmacy, Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
- Institute of Nanoscience and Nanotechnology (IN2UB), 08028 Barcelona, Spain
| | - Itziar de Rojas
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
| | - Silvia Alonso-Lana
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
| | - Xavier Morató
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
| | - Eliana B. Souto
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Coimbra, 3004-531 Coimbra, Portugal;
- Centre of Biological Engineering (CEB), University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (E.F.); (M.T.)
- Research Group on Status Epilepticus and Acute Seizures, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Mercè Boada
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
| | - Marta Marquié
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
| | - Agustín Ruíz
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya (UIC), 08029 Barcelona, Spain; (I.d.R.); (S.A.-L.); (X.M.); (M.B.); (M.M.); (A.R.)
- Biomedical Research Networking Centre in Neurodegenerative Diseases (CIBERNED), 28031 Madrid, Spain; (M.E.); (E.S.-L.)
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Abstract
Pain is a major matter for patients with multiple sclerosis; treatment response is frequently inadequate, with a significant impact on quality of life. The estimated prevalence of pain in multiple sclerosis ranges widely (26-86%), and different subtypes of pain, mediated by specific pathophysiological mechanisms, are described. The aim of this narrative review, performed using a systematic search methodology, was to provide current, evidence-based, knowledge about the pharmacological treatment of the different kinds of pain in multiple sclerosis. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov), considering publications up to November 2019. Two authors independently selected studies for inclusion, data extraction, and bias assessment. A total of 27 randomized controlled trials were identified, but in only a few cases, patients with different pain qualities were stratified. Following a mechanism-based approach, treatment of paroxysmal pain and painful tonic spasms should be based on sodium-channel blockers, whereas treatment of ongoing extremity pain should be based on gabapentinoids and antidepressants.
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Villoslada P, Steinman L. New targets and therapeutics for neuroprotection, remyelination and repair in multiple sclerosis. Expert Opin Investig Drugs 2020; 29:443-459. [DOI: 10.1080/13543784.2020.1757647] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Pablo Villoslada
- Department of Psychiatry and Behavioural Sciences & Department of Neurology and Neurological Sciences, Stanford University, California, CA, USA
| | - Lawrence Steinman
- Department of Psychiatry and Behavioural Sciences & Department of Neurology and Neurological Sciences, Stanford University, California, CA, USA
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Alcántara Montero A, Sánchez Carnerero CI. Role of voltage-gated sodium channel blockers in the treatment of chronic pain: Potential uses in clinical practice based on available evidence. ACTA ACUST UNITED AC 2018; 65:275-283. [PMID: 29496230 DOI: 10.1016/j.redar.2018.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/20/2017] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
Abstract
Once patients have failed first line therapy, there is an apparent lack of knowledge on how to proceed with choosing subsequent therapy. To choose amongst alternative agents, an understanding of pharmacology, pharmacokinetics, and available evidence in targeting various pain conditions is necessary. This article focuses on the use of the carboxamide class of voltage-gated sodium channel blockers (carbamazepine, oxcarbazepine, eslicarbazepine acetate) for adjunct pain medication management; including research updates in pharmacology, pharmacokinetics, and evidence for pain along on this therapeutic group with promising future areas of research. Although evidence for voltage-gated sodium channel blockers in chronic pain management is limited, emerging research has identified this area as promising for additional clinical trials to better guide clinical practice.
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Affiliation(s)
- A Alcántara Montero
- Unidad del Dolor, Hospital Don Benito-Villanueva de la Serena, Don Benito, Badajoz, España.
| | - C I Sánchez Carnerero
- Complejo Hospitalario Universitario de Cáceres, Hospital San Pedro de Alcántara, Cáceres, España
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Thomas AM, Atkinson TJ. Old Friends With New Faces: Are Sodium Channel Blockers the Future of Adjunct Pain Medication Management? THE JOURNAL OF PAIN 2017; 19:1-9. [PMID: 28842369 DOI: 10.1016/j.jpain.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 07/20/2017] [Accepted: 08/05/2017] [Indexed: 11/30/2022]
Abstract
Providers are being asked to decrease the emphasis and overutilization of long-term opioid therapy, but many are left without proper guidance on appropriate utilization of nonopioid therapies. Furthermore, therapeutic options are quite limited and many providers lack confidence in distinguishing available alternatives. When first-line therapy has failed in a patient, there is an apparent lack of knowledge on how to proceed with choosing subsequent therapy. To choose among alternative agents, an understanding of pharmacology, pharmacokinetics, and efficacy in targeting various pain conditions is necessary. This article focuses on the use of the carboxamide class of sodium channel blockers (carbamazepine, oxcarbazepine, eslicarbazepine) for adjunct pain medication management including research updates in pharmacology, pharmacokinetics, and current evidence for pain along with promising areas of research. It is an evidence update for clinical use of sodium channel blockers, clarifies misconceptions regarding their use, and highlights emerging research for improved pain targets that justifies additional study. We performed a complete review of the literature using the search terms, "oxcarbazepine," "carbamazepine," and "eslicarbazepine" in conjunction with "pharmacokinetics," "adverse effects," "pharmacology," "voltage-gated sodium channel subtype," "neuropathic pain," "inflammatory pain," "metabolism," "epoxide metabolite formation," "drug interactions," "CYP450 interactions," "pain phenotype," and "chronic pain management." Databases searched included PubMed and Google Scholar. Package inserts were used for drug structure illustration, adverse reactions, and bioavailability. Pharmacology and pharmacokinetic data were taken from randomized controlled trials evaluating this area as well as in vitro published results. For validity, only peer-reviewed literature was included. Evidence for sodium channel blockers in chronic pain management was limited. This review focuses on highlighting the data available for the use of sodium channel blockers for certain pain syndromes as well as underutilized potential. Emerging literature on sodium channel subtypes and their connection to neuropathic, inflammatory, and mechanical pain transmission is elucidated. The authors also scrutinize literature surrounding the pharmacokinetics of oxcarbazepine and eslicarbazepine to provide clearer guidance to the significance of any drug interactions and refute assumptions made on the basis of structural similarity to carbamazepine and its known undesirable drug interactions. Side effect profiles are outlined and compared, emphasizing the differences between agents. Sodium channel blocker doses used in certain pain syndromes are outlined with a call for further research to better understand their place in chronic pain management. Identification of sodium channel subtypes with links to specific pain conditions and the ability to target them hints at the potential for truly individualized therapy. Sodium channel inhibitors are underutilized on the basis of available evidence, and emerging research has identified this area as promising for additional clinical trials to better guide clinical practice. PERSPECTIVE This article provides a review of the pharmacology, evidence for pain management, and pharmacokinetics of oxcarbazepine, carbamazepine, and eslicarbazepine. There is a disparity in evidence using sodium channel blockers for pain and this article highlights the potential that is currently underutilized. The authors believe this will catalyze interest for further studies.
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Affiliation(s)
- Ashley M Thomas
- VA Tennessee Valley Healthcare System, Murfreesboro, Tennessee.
| | - Timothy J Atkinson
- PGY-2 Pain and Palliative Care Pharmacy Residency Program, VA Tennessee Valley Healthcare System, Murfreesboro, Tennessee
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Vesterinen HM, Connick P, Irvine CMJ, Sena ES, Egan KJ, Carmichael GG, Tariq A, Pavitt S, Chataway J, Macleod MR, Chandran S. Drug repurposing: a systematic approach to evaluate candidate oral neuroprotective interventions for secondary progressive multiple sclerosis. PLoS One 2015; 10:e0117705. [PMID: 25856304 PMCID: PMC4391783 DOI: 10.1371/journal.pone.0117705] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 12/30/2014] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To develop and implement an evidence based framework to select, from drugs already licenced, candidate oral neuroprotective drugs to be tested in secondary progressive multiple sclerosis. DESIGN Systematic review of clinical studies of oral putative neuroprotective therapies in MS and four other neurodegenerative diseases with shared pathological features, followed by systematic review and meta-analyses of the in vivo experimental data for those interventions. We presented summary data to an international multi-disciplinary committee, which assessed each drug in turn using pre-specified criteria including consideration of mechanism of action. RESULTS We identified a short list of fifty-two candidate interventions. After review of all clinical and pre-clinical evidence we identified ibudilast, riluzole, amiloride, pirfenidone, fluoxetine, oxcarbazepine, and the polyunsaturated fatty-acid class (Linoleic Acid, Lipoic acid; Omega-3 fatty acid, Max EPA oil) as lead candidates for clinical evaluation. CONCLUSIONS We demonstrate a standardised and systematic approach to candidate identification for drug rescue and repurposing trials that can be applied widely to neurodegenerative disorders.
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Affiliation(s)
- Hanna M. Vesterinen
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Connick
- The Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
| | - Cadi M. J. Irvine
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Emily S. Sena
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Kieren J. Egan
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Gary G. Carmichael
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Afiyah Tariq
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Sue Pavitt
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Jeremy Chataway
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Malcolm R. Macleod
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, United Kingdom
- * E-mail: (MRM); (SC)
| | - Siddharthan Chandran
- The Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
- * E-mail: (MRM); (SC)
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Malik R, Irodenko V, Zimmermann L, Green A, Layzer R. Focal amyotrophy in multiple sclerosis. Muscle Nerve 2014; 51:137-40. [PMID: 25186124 DOI: 10.1002/mus.24439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2014] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The assumption that multiple sclerosis (MS) is purely a white matter disease has been challenged in recent years by observations of axonal damage and neuronal loss in gray matter of the cortex, subcortex, and spinal cord. METHODS We report the case of a 71-year-old man with primary progressive MS and longstanding right arm weakness who presented with intermittent right arm pain. RESULTS Neurological examination showed atrophy, weakness, and hyporeflexia, and electromyography (EMG) showed acute and chronic partial denervation in multiple segments of the right arm. Magnetic resonance imaging (MRI) demonstrated asymmetric volume loss and increased T2 signal in the right anterior spinal cord from C3 to C7, with no evidence of nerve root compression. CONCLUSIONS Lower motor neuron involvement of his right arm was caused by MS with involvement of either the anterior horn cells or the intraspinal motor nerve roots.
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Affiliation(s)
- Rabia Malik
- Department of Neurology, San Francisco VA Medical Center, University of California, 505 Parnassus Avenue, Box 0114, M-798, San Francisco, California, 94143, USA
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Use of natural compounds in the management of diabetic peripheral neuropathy. Molecules 2014; 19:2877-95. [PMID: 24603557 PMCID: PMC6271156 DOI: 10.3390/molecules19032877] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/20/2014] [Accepted: 02/26/2014] [Indexed: 11/18/2022] Open
Abstract
Nephropathy, retinopathy cardiomyopathy and peripheral neuropathy are all recognized as important complications in about 50% of diabetes mellitus (DM) patients, mostly related to a poor glycemic control or to an improper management of this pathology. In any case, amongst others, diabetic peripheral neuropathy (DPN) seems the leading and most painful complication usually affecting many DM patients. For this reason, this work was conceived to review the large variety of strategies adopted for management of DPN, starting from the most conventional therapies to arrive at alternative approaches. From this perspective, both the most popular pharmacological treatments used to respond to the poorly effect of common analgesics—non-steroidal anti-inflammatory drugs (NSAIDS) and opioids—understood as gabapentin vs. pregabalin clinical use, and the guidelines provided by Oriental Medicine as well as by a long list of natural compounds that many authors identify as possible therapeutic or alternative agents to replace or to combine with the existing therapies will be included. Moreover, in the effort to provide the widest panel of remedies, the most antique techniques of acupuncture and electrostimulation will be considered as alternative, which are useful approaches to take into account in any non-pharmacological strategy for DPN management.
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Iannitti T, Kerr BJ, Taylor BK. Mechanisms and pharmacology of neuropathic pain in multiple sclerosis. Curr Top Behav Neurosci 2014; 20:75-97. [PMID: 24590824 PMCID: PMC4464806 DOI: 10.1007/7854_2014_288] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The neuropathic pain of multiple sclerosis is quite prevalent and severely impacts quality of life. A few randomized, placebo-controlled, blinded clinical trials suggest that cannabis- and anticonvulsant-based treatments provide partial pain relief, but at the expense of adverse events. An even smaller, but emerging, number of translational studies are using rodent models of experimental autoimmune encephalomyelitis (EAE), which exhibit pain-like behaviors resembling those of Multiple sclerosis (MS) patients. These studies not only support the possible effectiveness of anticonvulsants, but also compel further clinical trials with serotonin-norepinephrine reuptake inhibitors, the immunosuppressant drug rapamycin, or drugs which interfere with glutamatergic neurotransmission. Future behavioral studies in EAE models are essential toward a new pharmacotherapy of multiple sclerosis pain.
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Affiliation(s)
- T Iannitti
- Department of Physiology, School of Medicine, University of Kentucky Medical Center, Lexington, KY, 40536-0298, USA
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Khan N, Smith MT. Multiple sclerosis-induced neuropathic pain: pharmacological management and pathophysiological insights from rodent EAE models. Inflammopharmacology 2014; 22:1-22. [PMID: 24234347 PMCID: PMC3933737 DOI: 10.1007/s10787-013-0195-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 10/22/2013] [Indexed: 01/05/2023]
Abstract
In patients with multiple sclerosis (MS), pain is a frequent and disabling symptom. The prevalence is in the range 29-86 % depending upon the assessment protocols utilised and the definition of pain applied. Neuropathic pain that develops secondary to demyelination, neuroinflammation and axonal damage in the central nervous system is the most distressing and difficult type of pain to treat. Although dysaesthetic extremity pain, L'hermitte's sign and trigeminal neuralgia are the most common neuropathic pain conditions reported by patients with MS, research directed at gaining insight into the complex mechanisms underpinning the pathobiology of MS-associated neuropathic pain is in its relative infancy. By contrast, there is a wealth of knowledge on the neurobiology of neuropathic pain induced by peripheral nerve injury. To date, the majority of research in the MS field has used rodent models of experimental autoimmune encephalomyelitis (EAE) as these models have many clinical and neuropathological features in common with those observed in patients with MS. However, it is only relatively recently that EAE-rodents have been utilised to investigate the mechanisms contributing to the development and maintenance of MS-associated central neuropathic pain. Importantly, EAE-rodent models exhibit pro-nociceptive behaviours predominantly in the lower extremities (tail and hindlimbs) as seen clinically in patients with MS-neuropathic pain. Herein, we review research to date on the pathophysiological mechanisms underpinning MS-associated neuropathic pain as well as the pharmacological management of this condition. We also identify knowledge gaps to guide future research in this important field.
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Affiliation(s)
- Nemat Khan
- Centre for Integrated Preclinical Drug Development and School of Pharmacy, The University of Queensland, Level 3, Steele Building, St. Lucia Campus, Brisbane, QLD 4072 Australia
| | - Maree T. Smith
- Centre for Integrated Preclinical Drug Development and School of Pharmacy, The University of Queensland, Level 3, Steele Building, St. Lucia Campus, Brisbane, QLD 4072 Australia
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Cummins TR, Rush AM. Voltage-gated sodium channel blockers for the treatment of neuropathic pain. Expert Rev Neurother 2014; 7:1597-612. [DOI: 10.1586/14737175.7.11.1597] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Jawahar R, Oh U, Yang S, Lapane KL. A Systematic Review of Pharmacological Pain Management in Multiple Sclerosis. Drugs 2013; 73:1711-22. [DOI: 10.1007/s40265-013-0125-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.
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