1
|
Caliskan EB, Bingel U, Kunkel A. Translating knowledge on placebo and nocebo effects into clinical practice. Pain Rep 2024; 9:e1142. [PMID: 38533458 PMCID: PMC10965200 DOI: 10.1097/pr9.0000000000001142] [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: 04/19/2023] [Accepted: 12/18/2023] [Indexed: 03/28/2024] Open
Abstract
Introduction Positive and negative treatment expectations are powerful modulators of health and treatment outcomes. A substantial part of treatment success is due to contextual factors modulating patient's expectations towards a treatment. Consequently, treatment expectations should be a target of therapeutic interventions themselves. Objectives This article highlights the neurobiological underpinnings of treatment expectations as well as strategies to modulate contextual factors to optimize treatment outcomes in daily clinical settings. Methods This clinical update aligns with the 2022 IASP Global Year Translating Pain Knowledge into Practice and selectively reviews the best available evidence and practice. Results The effects of treatment expectations, also known as placebo and nocebo effects, are observed in various clinical conditions and physiological systems. However, most of our knowledge comes from the field of pain, where expectation effects substantially contribute to overall analgesic treatment outcomes. Experimental placebo analgesia paradigms provide the best illustration of how analgesic effects can be attributed not only to a pharmacological or specific treatment, but instead are the result of the expectation towards the treatment. The impact of expectations on treatment outcome is highly variable between individuals, and the identification of factors predicting an individual's response has proven to be challenging. Further research is required to provide personalized treatment strategies for the daily clinical practice. Conclusion Patient's previous experiences and expectations are powerful modulators of treatment efficacy, tolerability, and adherence. By providing a comprehensive overview of recent advances in this field, this review offers valuable insights for clinicians and researchers seeking to improve patient-clinician interaction.
Collapse
Affiliation(s)
- Elif Buse Caliskan
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Angelika Kunkel
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
2
|
Abstract
Adverse nocebo responses can cause harm to patients and interfere with treatment adherence and effects in both clinic practice and clinical trials. Nocebo responses refer to negative outcomes to active medical treatments in clinical trials or practice that cannot be explained by the treatment's pharmacologic effects. Negative expectancies and nocebo effects are less known than placebo responses. Nocebo effects can be triggered by verbal suggestions, prior negative experiences, observation of others experiencing negative outcomes, and other contextual and environmental factors. As research advances over the years, mechanistic knowledge is accumulating on the neurobiological mechanisms of nocebo effects. This review summarizes studies on different facets of nocebo effects and responses and discusses clinical implications, ethical considerations, and future directions.
Collapse
Affiliation(s)
- Luana Colloca
- Department of Pain and Translational Symptom Science and Placebo Beyond Opinions Center, School of Nursing, University of Maryland, Baltimore, Maryland, USA;
| |
Collapse
|
3
|
Basedau H, Ornello R, Matteis ED, Davaasuren B, Kadyrova B, Vuralli D, Bozhenko M, Azizova I, Bitsadze N, Eralieva E, Ashina M, Mitsikostas D, Puledda F. Placebo and nocebo in the treatment of migraine: How much does real world effectiveness depend on contextual effects? Cephalalgia 2023; 43:3331024231218392. [PMID: 38041833 DOI: 10.1177/03331024231218392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
PURPOSE Treatments in medicine impact individuals beyond their intended effects, due to phenomena such as the placebo and nocebo effects. The placebo effect arises from the positive expectation of a treatment being beneficial, while the nocebo effect stems from the negative expectation of a treatment causing harm. Both in real-world practice and clinical trials, treatments can lead to outcomes unrelated to their intended mechanism of action, which we categorize as placebo and nocebo responses. These responses, combined with the inherent fluctuation in a condition's natural progression, regression to the mean, and random comorbidities, make up a significant part of the therapeutic experience. Particularly in pain management, placebo and nocebo effects play a substantial role. By addressing modifiable contextual factors such as patient expectations, lifestyle choices, and the therapeutic relationship, healthcare providers can enhance the effectiveness of migraine treatments, paving the way for a more comprehensive, individualized approach to patient care. We must also consider non-modifiable factors like personal experiences, beliefs, and information from social media and the internet. CONCLUSION This review offers a summary of our current understanding of the placebo and nocebo effects in migraine management.
Collapse
Affiliation(s)
- Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Eleonora De Matteis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Begimai Kadyrova
- Department of Special Clinical Disciplines, International School of Medicine of International University of Kyrgyzstan, Bishkek, Kyrgyzstan
| | - Doga Vuralli
- Department of Neurology and Algology, Neuropsychiatry Center, Neuroscience and Neurotechnology Center of Excellence (NÖROM), Gazi University, Ankara, Turkey
| | - Myroslav Bozhenko
- Department of Neurology, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Ilaha Azizova
- Neurological Clinic "New Medical Technologies", Baku, Azerbaijan
| | | | | | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Dimos Mitsikostas
- Department of Neurology Α, Aegintion Hospital, National and Kapidistrian University of Athens, Athens, Greece
| | - Francesca Puledda
- Headache Group, Wolfson SPaRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
4
|
Patient Perspectives and Experiences of Preventive Treatments and Self-Injectable Devices for Migraine: A Focus Group Study. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 15:93-108. [PMID: 34131880 PMCID: PMC8739468 DOI: 10.1007/s40271-021-00525-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although several self-injectable preventive treatments for migraine have become available, they are not yet widely used. Thus, understanding patients' perceptions towards them is limited. OBJECTIVE This study aimed to inform the design of a preference-elicitation instrument, which is being developed to quantify preventive treatment preferences of people with migraine. METHODS We conducted a qualitative study involving nine in-person focus groups (three per country) in the United States, the United Kingdom, and Germany. Participants were adults (n = 47) with episodic or chronic migraine who were currently using or had used a prescription preventive treatment for migraine within the previous 5 years. During the focus groups, participants described their experiences of migraine and preventive treatments; handled and simulated self-injection using five different unbranded, fired demonstration auto-injectors and prefilled syringes; and ranked different aspects of preventive treatments by importance. Focus groups were analyzed with a focus on themes that would be feasible or meaningful to include in a subsequent preference-elicitation instrument. RESULTS Reducing the frequency and severity of migraine attacks was consistently ranked as the most important aspect of preventive treatment. Participants expressed dissatisfaction with available daily oral preventive treatments for migraine they had previously used because they were ineffective or caused intolerable adverse events. Many participants were willing to self-inject a treatment that was effective and tolerable. When presented with devices for self-injecting a preventive treatment for migraine, participants generally preferred autoinjectors over prefilled syringes. Participants especially valued safety features such as the unlocking step and automated needle insertion, and audible and visual dose confirmation increased confidence in autoinjector use. Autoinjector needle protection mechanisms were also appreciated, especially by participants averse to needles, as the needles are not visible. CONCLUSIONS This study highlights the fact that many people with migraine still lack access to a preventive treatment that is effective and tolerable. In addition to efficacy and safety considerations, treatment decisions may be guided by the mode of administration. In the case of self-injectable preventive treatments, key device characteristics affecting these decisions may be ease of use, comfort, and confidence in self-injection. Insights gained from this study were used to help develop a preliminary set of attributes and levels for a preference-elicitation instrument.
Collapse
|
5
|
Thomaidou MA, Veldhuijzen DS, Peerdeman KJ, Wiebing NZS, Blythe JS, Evers AWM. Learning mechanisms in nocebo hyperalgesia: the role of conditioning and extinction processes. Pain 2021; 161:1597-1608. [PMID: 32149863 PMCID: PMC7302337 DOI: 10.1097/j.pain.0000000000001861] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Nocebo hyperalgesia is a clinically relevant phenomenon and may be formed as a result of associative learning, implemented by classical conditioning. This study explored for the first time distinct nocebo conditioning methods and their consequences for nocebo attenuation methods. Healthy participants (N = 140) were recruited and randomized to the following nocebo hyperalgesia induction groups: conditioning with continuous reinforcement (CRF), conditioning with partial reinforcement (PRF), and a sham-conditioning control group. In the attenuation phase, counterconditioning was compared with extinction. During induction, participants experienced increased thermal pain in 100% of nocebo trials in the CRF groups, while in only 70% of nocebo trials in the PRF groups. During evocation, pain stimulation was equivalent across all trials. During attenuation, pain stimulation was decreased on nocebo trials relative to control trials for the counterconditioning groups, while pain remained equivalent across all trials for the extinction groups. Results showed that both PRF and CRF significantly induced nocebo hyperalgesia, but CRF was a more potent nocebo induction method, as compared to PRF. Counterconditioning was more effective than extinction in attenuating nocebo hyperalgesia. Neither CRF nor PRF resulted in resistance to extinction. However, compared with CRF, conditioning with PRF resulted in more resistance to counterconditioning. These findings demonstrate that the more ambiguous learning method of PRF can induce nocebo hyperalgesia and may potentially explain the treatment resistance and chronification seen in clinical practice. Further research is required to establish whether attenuation with counterconditioning is generalizable to clinical settings.
Collapse
Affiliation(s)
- Mia Athina Thomaidou
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Leiden Institute for Brain & Cognition, Leiden, the Netherlands
| | - Dieuwke Swaantje Veldhuijzen
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Leiden Institute for Brain & Cognition, Leiden, the Netherlands
| | - Kaya Joanne Peerdeman
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Leiden Institute for Brain & Cognition, Leiden, the Netherlands
| | | | - Joseph Sullivan Blythe
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Leiden Institute for Brain & Cognition, Leiden, the Netherlands
| | - Andrea Walbruga Maria Evers
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, the Netherlands.,Leiden Institute for Brain & Cognition, Leiden, the Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
6
|
Kleine-Borgmann J, Bingel U. Der Placeboeffekt in der Schmerztherapie – für den
klinischen Alltag nutzbar? Ja, unbedingt! AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1165-6689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungAls Placeboeffekte bezeichnet man positive physiologische oder psychologische
Veränderungen, die nach einer Einnahme von Medikamenten ohne
spezifischen Wirkstoff oder Scheineingriffen auftreten und durch Erwartungs- und
Konditionierungsprozesse induziert werden. Die mit Placeboeffekten
einhergehenden neurobiologischen und peripher-physiologischen Vorgänge
können auch bei der Vergabe von wirkstoffhaltigen Medikamenten eine
wichtige Rolle spielen und sind somit nicht zwingend an die Gabe eines
Scheinmedikamentes gebunden. Die Darreichung von
„traditionellen“ Placebos ist im klinischen Alltag aus
juristischen und ethischen Gründen höchst problematisch. Dieser
Beitrag zeigt neben neuen Erkenntnissen zu offenen Placebo-Anwendungen
(Open-Label Placebos) Wege auf, wie die zugrundeliegenden Mechanismen von
Placeboantworten dennoch gezielt im schmerztherapeutischen Alltag genutzt werden
können, um die Wirksamkeit, Verträglichkeit und Compliance
bestehender pharmakologischer und anderer Therapien zum Wohle des Patienten zu
optimieren.
Collapse
Affiliation(s)
| | - Ulrike Bingel
- Klinik für Neurologie, Universitätsmedizin Essen,
Essen
| |
Collapse
|
7
|
Vase L. Can insights from placebo and nocebo mechanisms studies improve the randomized controlled trial? Scand J Pain 2020; 20:451-467. [PMID: 32609651 DOI: 10.1515/sjpain-2019-0183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Indexed: 11/15/2022]
Abstract
Background and aims The randomized controlled trial (RCT) is currently facing several challenges, one of these being that the placebo response appears to be increasing in RCTs, thereby making it difficult to demonstrate an effect of potentially new treatments over placebo. This problem has primarily been approached by predicting the magnitude of the placebo response via stable factors, such as demographic variables, and/or by developing complex designs aimed at reducing the placebo response in the hope that it will improve the test of the active treatment. Yet, the success of this approach has so far been limited. Methods A new approach toward improving the RCT is put forward based on placebo and nocebo mechanism studies, i.e. studies that investigate the mechanisms underlying placebo analgesia and nocebo hyperalgesia. In a series of meta-analyses the magnitude of placebo and nocebo effects were determined. Experimental studies across nociplastic and neuropathic pain conditions and across pharmacological and acupuncture treatments investigated psychological and neurobiological mechanisms underlying these effects. The obtained results were used to make approximations of expectations to see if that could predict the placebo response in RCTs and function as a new way of tapping into the placebo component of treatment effects. Results The magnitude of placebo and nocebo effects is large and highly variable. Placebo effects exist across chronic pain conditions with varying degrees of known etiology as well as across pharmacological and non-pharmacological treatments. Patients' perception of the treatment, the verbal suggestions given for pain relief, and the patients' expectations toward pain relief contribute to the magnitude of the placebo effect and to pain relief following placebo interventions. Also, unintentional unblinding and patients' perception of a treatment markedly influence the treatment outcome. By making approximations of expectations toward treatment effects it was possible to predict the magnitude of the placebo response in RCTs. Conclusions and implications The new approach of tapping into or directly asking patients about their perception and expectations toward a treatment, along with the account of the natural history of pain, has the potential to improve the information that can be obtained from RCTs. Thus, by interfacing insights from placebo and nocebo mechanism studies, it may be possible to enhance the information that can be obtained from RCTs and to account for a large part of the variability in the placebo component of the overall treatment effect. This approach has the potential to improve the scientific evaluation of treatments, as well as to illustrate how the effect of treatments can be optimized in clinical practice, which is the crux of evidence-based medicine.
Collapse
Affiliation(s)
- Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Bartholins Allé 11, Building 1350, DK-8000 Aarhus C, Denmark
| |
Collapse
|
8
|
Sacco S, Braschinsky M, Ducros A, Lampl C, Little P, van den Brink AM, Pozo-Rosich P, Reuter U, de la Torre ER, Sanchez Del Rio M, Sinclair AJ, Katsarava Z, Martelletti P. European headache federation consensus on the definition of resistant and refractory migraine : Developed with the endorsement of the European Migraine & Headache Alliance (EMHA). J Headache Pain 2020; 21:76. [PMID: 32546227 PMCID: PMC7296705 DOI: 10.1186/s10194-020-01130-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/25/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Despite advances in the management of headache disorders, some patients with migraine do not experience adequate pain relief with acute and preventive treatments. It is the aim of the present document to provide a definition of those migraines which are difficult-to-treat, to create awareness of existence of this group of patients, to help Healthcare Authorities in understanding the implications, and to create a basis to develop a better pathophysiological understanding and to support further therapeutic advances. MAIN BODY Definitions were established with a consensus process using the Delphi method. Patients with migraine with or without aura or with chronic migraine can be defined as having resistant migraine and refractory migraine according to previous preventative failures. Resistant migraine is defined by having failed at least 3 classes of migraine preventatives and suffer from at least 8 debilitating headache days per month for at least 3 consecutive months without improvement; definition can be based on review of medical charts. Refractory migraine is defined by having failed all of the available preventatives and suffer from at least 8 debilitating headache days per month for at least 6 consecutive months. Drug failure may include lack of efficacy or lack of tolerability. Debilitating headache is defined as headache causing serious impairment to conduct activities of daily living despite the use of pain-relief drugs with established efficacy at the recommended dose and taken early during the attack; failure of at least two different triptans is required. CONCLUSIONS We hope, that the updated EHF definition will be able to solve the conflicts that have limited the use of definitions which have been put forward in the past. Only with a widely accepted definition, progresses in difficult-to-treat migraine can be achieved. This new definition has also the aim to increase the understanding of the impact of the migraine as a disease with all of its social, legal and healthcare implications. It is the hope of the EHF Expert Consensus Group that the proposed criteria will stimulate further clinical, scientific and social attention to patients who suffer from migraine which is difficult-to-treat.
Collapse
Affiliation(s)
- Simona Sacco
- Neuroscience section - Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy. .,Regional Referral Headache Center of the Abruzzo region, ASL Avezzano-Sulmona-L'Aquila, L'Aquila, Italy.
| | - Mark Braschinsky
- Headache Clinic, Department of Neurology, Tartu University Clinics, Tartu, Estonia
| | - Anne Ducros
- Headache Unit, Neurology Department, Montpellier University Hospital and Montpellier University, Montpellier, France
| | - Christian Lampl
- Department of Neurology, Headache Medical Centre Linz, Hospital Barmherzige Brüder, Centre of Integrative Medicine (ZiAM) Ordensklinikum Linz, Linz, Austria
| | - Patrick Little
- European Migraine & Headache Alliance (EMHA), Hendrik Ido Ambacht, The Netherlands
| | - Antoinette Maassen van den Brink
- Division of Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Uwe Reuter
- Charité Universitätsmedizin Berlin, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Alexandra J Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Zaza Katsarava
- Evangelical Hospital Unna, Unna, Germany.,Departmentof Neurology, University of Duisburg-Essen, Essen, Germany.,EVEX Medical Corporation, Tbilisi, Georgia.,IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.,Regional Referral Headache Center of the Lazio region, Sant'Andrea Hospital, Rome, Italy
| |
Collapse
|
9
|
Kravvariti E, Kitas GD, Sfikakis PP. The role of the Nocebo effect in the use of biosimilars in routine rheumatology clinical practice. Mediterr J Rheumatol 2020; 30:63-68. [PMID: 32524080 PMCID: PMC7280873 DOI: 10.31138/mjr.30.1.63] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 12/05/2022] Open
Affiliation(s)
- Evrydiki Kravvariti
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - George D Kitas
- Clinical Research Unit, Dudley Group NHS Foundation Trust, Dudley, UK.,Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National & Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
10
|
Kokoti L, Drellia K, Papadopoulos D, Mitsikostas DD. Placebo and nocebo phenomena in anti- CGRP monoclonal antibody trials for migraine prevention: a meta-analysis. J Neurol 2020; 267:1158-1170. [PMID: 31919565 DOI: 10.1007/s00415-019-09673-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/17/2022]
Abstract
High placebo and low nocebo phenomena mirror high positive expectations for a novel treatment, among other reasons. In a meta-analysis aimed to identify placebo and nocebo phenomena in the placebo-controlled randomized trials (RCTs) with the monoclonal antibodies targeting the calcitonin gene-related peptide pathway (anti-CGRP mAbs) all the placebo-treated patients were pooled and compared with the placebo-treated patients in RCTs with topiramate and onabotulinum toxin A (OBTA). In episodic migraine (EM), the proportion of placebo-treated patients who achieved the 50% responder rate (placebo) was 32.7% (95% CI 28.6%-37.0%) in anti-CGRP mAbs vs. 24.4% (95% CI 20.5%-28.5%) in topiramate trials. The proportion of dropouts due to adverse events in placebo-treated patients (nocebo) was 1.9% (95% CI 1.4%-2.6%) in anti-CGRP mAbs vs. 9.9% (95% CI 7.7%-12.3%) in topiramate RCTs. In chronic migraine (CM), the placebo 50% responder rate was 23.6% (95% CI 11.2%-38.8%) in anti-CGRP mAbs RCTs vs. 36.4% (95% CI 32.6%-39.3%) in RCTs with OBTA. The nocebo dropout in anti-CGRP mAbs and OBTA RCTs was 1.4% (95% CI 0.8%-2.1%) and 0.9 (95% CI 0.3%-1.7%), respectively. The stronger placebo and weaker nocebo phenomena in RCTs with anti-CGRP mAbs vs. those with topiramate in the prophylaxis of EM, may decisively determine anti-CGRP mAbs treatment success. No differences were detected between the anti-CGRP mAbs and OBTA in the treatment of CM.
Collapse
Affiliation(s)
- Lili Kokoti
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, 72-74 V. Sofia's Avenue, 11528, Athens, Greece
| | - Konstantina Drellia
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, 72-74 V. Sofia's Avenue, 11528, Athens, Greece
| | | | - Dimos D Mitsikostas
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, 72-74 V. Sofia's Avenue, 11528, Athens, Greece.
| |
Collapse
|
11
|
Kravvariti E, Kitas GD, Mitsikostas DD, Sfikakis PP. Nocebos in rheumatology: emerging concepts and their implications for clinical practice. Nat Rev Rheumatol 2019; 14:727-740. [PMID: 30361674 DOI: 10.1038/s41584-018-0110-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nocebo effects are noxious reactions to therapeutic interventions that occur because of negative expectations of the patient. In the past decade, neurobiological data have revealed specific neural pathways induced by nocebos (that is, interventions that cause nocebo effects), as well as the associated mechanisms and predisposing factors of nocebo effects. Epidemiological data suggest that nocebos can have a notable effect on medication adherence, clinical outcomes and health-care policy. Meta-analyses of randomized controlled trials (RCTs) of patients with rheumatic and musculoskeletal diseases (RMDs) indicate that withdrawal of treatment by placebo-arm participants owing to adverse events is common; a proportion of these events could be nocebo effects. Moreover, in large-scale, open-label studies of patients with RMDs who transition from bio-originator to biosimilar therapeutics, biosimilar retention rates were much lower than in previous double-blind switch RCTs. This discrepancy suggests that in addition to the lack of response in some patients because of intrinsic differences between the drugs, nocebos might have an important role in low biosimilar retention, thus increasing the need for awareness and early identification of nocebo effects by rheumatologists and allied health-care professionals.
Collapse
Affiliation(s)
- Evrydiki Kravvariti
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - George D Kitas
- Clinical Research Unit, Dudley Group NHS Foundation Trust, Dudley, UK.,Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Dimos D Mitsikostas
- First Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece.
| |
Collapse
|
12
|
Leal Rato M, Duarte GS, Ferreira AN, Alves M, Mainoli B, Teodoro T, Mestre TA, Costa J, Ferreira JJ. Nocebo response in Parkinson's disease: A systematic review and meta-analysis. Parkinsonism Relat Disord 2019; 65:13-19. [DOI: 10.1016/j.parkreldis.2019.04.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/23/2019] [Accepted: 04/19/2019] [Indexed: 12/19/2022]
|
13
|
Spanou I, Mavridis T, Mitsikostas DD. Nocebo in Biosimilars and Generics in Neurology: A Systematic Review. Front Pharmacol 2019; 10:809. [PMID: 31396084 PMCID: PMC6667943 DOI: 10.3389/fphar.2019.00809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Nocebo refers to adverse events related to patients’ negative expectations and previous experiences, mediated by several neurobiological pathways within the brain. It is common among neurological patients and affects adherence and treatment outcomes, representing a real clinical challenge. Methods: We conducted a systematic search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in MEDLINE database, using several keywords for studies that can be processed to investigate the magnitude of nocebo in generics and biosimilars used in the most common neurological diseases. The aim was to estimate its size and suggest strategies to minimize its prevalence in clinical trials and practice. Results: Of a total of 2,606 identified articles, after criteria-based selection, 35 studies were included for analysis. Overall, there was vast heterogeneity across the studies concerning population, study design, and outcomes. Nocebo response could be estimated only in one double-blind randomized trial of generic glatiramer acetate in relapsing remitting multiple sclerosis that included a placebo arm. In this trial, no significant differences observed between the three arms (innovator, bioequivalent, and placebo) in favorable and unfavorable outcomes. In the open-label phase of the trial, an increased withdrawal rate was recorded in patients switched from placebo to bioequivalent (8.4%) that may be related to nocebo. In other open-label and real-world studies evaluating biosimilars or generics for brain disorders, a similar indirect nocebo effect is assuming by several investigators. Also, knowledge gaps between health-care providers and patients exist towards generics and biosimilars. Conclusions: Despite its presence, the true burden of the nocebo response and effect cannot be accurately estimated in existing studies with generics and biosimilars in neurological diseases. Targeted strategies for clinical trials’ design are needed in order to measure the exact nocebo’s size.
Collapse
Affiliation(s)
- Ioanna Spanou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Mavridis
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimos D Mitsikostas
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
14
|
Varma A, Zis P. Nocebo effect in myasthenia gravis: systematic review and meta-analysis of placebo-controlled clinical trials. Acta Neurol Belg 2019; 119:257-264. [PMID: 31004288 DOI: 10.1007/s13760-019-01143-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/11/2019] [Indexed: 12/17/2022]
Abstract
Nocebo refers to the adverse events (AEs) experienced when taking a placebo drug and is believed to be a centrally mediated process. We sought to examine the AEs following placebo administration in Randomised Controlled Trials (RCTs) for Myasthenia Gravis (MG) patients. A systematic literature search was performed on Medline and Web of Science for RCTs for MG pharmacological treatments. We assessed the number of placebo-treated patients reporting at least one AE and the number of dropouts because of AEs. Data were extracted from six RCTs fulfilling the search criteria. Four out of five placebo-treated participants (80.1%) reported at least one AE and one in 40 (2.4%) discontinued placebo treatment because of AE. All patients participating in the MG trials reported similar AEs independent of the study arm to which they belonged (placebo or active treatment). This meta-analysis demonstrates a low nocebo dropout rate in MG compared to central nervous system disorders.
Collapse
|
15
|
Nocebo in cerebellar ataxia: A systematic review and meta-analysis of placebo-controlled clinical trials. J Neurol Sci 2019; 401:112-117. [PMID: 31075682 DOI: 10.1016/j.jns.2019.04.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/08/2019] [Accepted: 04/29/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Nocebo, the negative counterpart of the placebo phenomenon results in the induction of adverse events (AEs) following the administration of an inert substance. Nocebo has been demonstrated to be associated with low treatment compliance in clinical trials, thus affecting treatment outcomes. This study sought to determine the prevalence of nocebo in cerebellar ataxia. METHODS A systematic literature search was conducted on Pubmed for randomized controlled trials (RCTs) for cerebellar ataxia treatments. The number of drug-related AEs and the number of withdrawals due to drug intolerance in the placebo group were statistically analysed. RESULTS The literature search identified 214 studies, of which 6 studies fulfilled the inclusion criteria. Approximately 1 in 20 (4.8%) placebo-treated patients withdrew treatment due to AEs and approximately 1 in 7 (13.8%) placebo-treated participants reported at least one AE. Participants in cerebellar ataxia trials reported similar AEs across both treatment groups (active and placebo). CONCLUSION Our results demonstrate that the nocebo effect in cerebellar ataxia is amongst the lowest in neurological diseases.
Collapse
|
16
|
Chacón MR, Enrico DH, Burton J, Waisberg FD, Videla VM. Incidence of Placebo Adverse Events in Randomized Clinical Trials of Targeted and Immunotherapy Cancer Drugs in the Adjuvant Setting: A Systematic Review and Meta-analysis. JAMA Netw Open 2018; 1:e185617. [PMID: 30646278 PMCID: PMC6324542 DOI: 10.1001/jamanetworkopen.2018.5617] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Several reports have associated the placebo effect with objective response and improvement of a clinical condition in oncology, but only a few studies have analyzed the adverse events (AEs) in the placebo groups of the clinical trials. OBJECTIVE To determine the incidence of placebo AEs reported in randomized clinical trials of modern cancer drugs in the adjuvant setting. DATA SOURCES Based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, a systematic literature search of English-language publications from January 1, 2000, through April 15, 2018, was performed using MEDLINE (PubMed). The following search terms were used to retrieve all trials from the PubMed library: adjuvant, maintenance, consolidation, and placebo, in addition to specific cancer type-related keywords. STUDY SELECTION A double-blind, randomized, placebo-controlled, phase 3 design was mandatory for study inclusion. Only studies enrolling patients who had undergone macroscopically complete resections were included. No other anticancer treatments in addition to placebo were allowed in the control group. Only trials involving a targeted therapy (tyrosine kinase, BRAF, or MEK inhibitors) or immunotherapy-related drugs were included. Trials using chemotherapy, interferon, and endocrine therapy were excluded. Two authors (D.H.E. and F.D.W.) independently reviewed the studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted by investigators, and random-effects meta-analysis was performed to estimate the proportion of grade 3 to 4 placebo AEs in the included studies. MAIN OUTCOMES AND MEASURES Incidence of grade 3 to 4 placebo AEs in the placebo groups. RESULTS Of 731 studies screened, 10 eligible trials were found including 4 tumor types (melanoma, non-small cell lung cancer, gastrointestinal stromal tumor, and renal cell carcinoma). Overall, 11 143 patients (6270 [56.3%] in the treatment group with mean [SD] age of 55.6 [4.2] years and 4873 patients [43.7%] in the placebo group with mean [SD] age of 55.9 [4.3] years) were included. The mean incidence of any-grade placebo AEs was 85.1% (95% CI, 79.2%-91.0%). The most frequent (mean [SD]) grade 3 to 4 placebo AEs in patients were hypertension (2.8% [2.2%]), fatigue (1.0% [0.9%]), and diarrhea (0.8% [0.6%]). The overall, random-effects pooled incidence of grade 3 to 4 placebo AEs was 18% (95% CI, 15%-21%), with a high level of heterogeneity (I2 = 86%). Frequency of grade 3 to 4 placebo AEs was found to be correlated in the treatment and placebo groups (ρ = 0.7; P = .03). Mean study drug discontinuation owing to placebo AEs was 3.9% (95% CI, 2.7%-5.2%). CONCLUSIONS AND RELEVANCE Placebo administration was associated with a substantial incidence of grade 3 to 4 placebo AEs in modern cancer adjuvant trials. This finding should be considered by investigators, sponsors, regulatory authorities, and patient support groups.
Collapse
Affiliation(s)
- Matías Rodrigo Chacón
- Research Department, Argentine Association of Clinical Oncology, Buenos Aires, Argentina
| | - Diego Hernán Enrico
- Research Department, Argentine Association of Clinical Oncology, Buenos Aires, Argentina
| | - Jeannette Burton
- Research Department, Argentine Association of Clinical Oncology, Buenos Aires, Argentina
| | | | - Viviana Marina Videla
- Research Department, Argentine Association of Clinical Oncology, Buenos Aires, Argentina
| |
Collapse
|
17
|
Damien J, Colloca L, Bellei-Rodriguez CÉ, Marchand S. Pain Modulation: From Conditioned Pain Modulation to Placebo and Nocebo Effects in Experimental and Clinical Pain. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:255-296. [PMID: 30146050 DOI: 10.1016/bs.irn.2018.07.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Accumulating evidence reveal important applications of endogenous pain modulation assessment in healthy controls and in patients in clinical settings, as dysregulations in the balance of pain modulatory circuits may facilitate pain and promote chronification of pain. This article reviews data on pain modulation, focusing on the mechanisms and translational aspects of pain modulation from conditioned pain modulation (CPM) to placebo and nocebo effects in experimental and clinical pain. The specific roles of expectations, learning, neural and neurophysiological mechanisms of the central nervous system are briefly reviewed herein. The interaction between CPM and placebo systems in pain inhibitory pathways is highly relevant in the clinic and in randomized controlled trials yet remains to be clarified. Examples of clinical implications of CPM and its relationship to placebo and nocebo effects are provided. A greater understanding of the role of pain modulation in various pain states can help characterize the manifestation and development of chronic pain and assist in predicting the response to pain-relieving treatments. Placebo and nocebo effects, intrinsic to every treatment, can be used to develop personalized therapeutic approaches that improve clinical outcomes while limiting unwanted effects.
Collapse
Affiliation(s)
- Janie Damien
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Luana Colloca
- Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States; Departments of Psychiatry and Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Carmen-Édith Bellei-Rodriguez
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Serge Marchand
- Research Center of the Centre hospitalier universitaire de Sherbrooke (CHUS), Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; Fonds de Recherche du Québec-Santé (FRQS), Montréal, QC, Canada.
| |
Collapse
|
18
|
Zis P, Hadjivassiliou M, Sarrigiannis PG, Jenkins TM, Mitsikostas DD. Nocebo in chronic inflammatory demyelinating polyneuropathy; a systematic review and meta-analysis of placebo-controlled clinical trials. J Neurol Sci 2018; 388:79-83. [DOI: 10.1016/j.jns.2018.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 12/19/2022]
|
19
|
Nocebo Effect in Menière's Disease: A Meta-analysis of Placebo-controlled Randomized Controlled Trials. Otol Neurotol 2018; 38:1370-1375. [PMID: 28832394 DOI: 10.1097/mao.0000000000001555] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To estimate the frequency and strength of nocebo effects in trials for Menière disease (MD). DATA SOURCES A literature search was conducted in PUBMED. The search terms we used were " Menière or Menière's," "treatment," and "placebo." Limitations included article type to be Clinical Trial or Randomized Controlled Trial, text availability to be Full text, Species to be Humans and Language to be English. STUDY SELECTION We included placebo-controlled pharmaceutical RCTs that referred specifically to MD and recruited at least 10 adults in each arm. We excluded those studies with JADAD score ≤3. DATA EXTRACTION Thirty-six articles were screened identifying 12 eligible studies. Studies were included after consensus of both authors. DATA SYNTHESIS The meta-analysis was conducted using the RevMan programme as suggested by the Cochrane Collaboration Group. Data were analyzed using a random effects model. CONCLUSION Nocebo is an important confounding factor of the reported AEs in RCTs for treatment of MD and subsequently in the clinical practice. The pooled estimate of the percentage of placebo-treated patients with at least one AE was 42.3% (95% CI 8.1% to 16.3%), in comparison to 53.8% (95% CI 48.0% to 59.5%) for active drug-treated patients. Reporting of RCTs in MD is suboptimal and we recommend authors to endorse the CONSORT checklist.
Collapse
|
20
|
Calcitonin gene-related peptide monoclonal antibodies for migraine prevention: comparisons across randomized controlled studies. Curr Opin Neurol 2018; 30:272-280. [PMID: 28240610 DOI: 10.1097/wco.0000000000000438] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The results of phase 2 randomized controlled trials for the prevention of episodic and chronic migraine demonstrating the efficacy and safety of four mAbs targeting the calcitonin gene-related peptide (CGRP) pathway [ALD403 (eptinezumab), AMG334 (erenumab), LY2951742 (galcanezumab) and TEV48125 (fremanezumab)] have been published recently, and phase 3 trials are in process. This development will change headache management fundamentally. We aim to summarize and compare the phase 2 data. RECENT FINDINGS The change from baseline in the number of migraine days at the end of treatment in high-frequency episodic migraine was -1 (at weeks 5-8), -1.1 (at weeks 9-12), -1.2 (at weeks 9-12) and -2.6 (at weeks 9-12) days for ALD403, AMG344, LY2951742 and TEV48125 (225 mg), respectively. Number needed to treats for responders and odds ratio for any adverse event were 4.7, 6.2, 4.0 and 4.0 and 1.09, 0.96, 1.07 and 1.05, respectively. SUMMARY All four CGRP antibodies display comparable efficacy that does not differ significantly from that of the currently available oral antimigraine drugs. However, their safety and tolerability profiles as well as low frequency of administration looks promising but remains to be verified in long-term and large-scale trials. Considerations related to pregnancy, risk for cardiovascular effects and cost are subject for further evaluation.
Collapse
|
21
|
Nocebo Responses in Brain Diseases: A Systematic Review of the Current Literature. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:443-462. [DOI: 10.1016/bs.irn.2018.07.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
22
|
Shafiq F, Mitsikostas DD, Zis P. Nocebo in motor neuron disease: systematic review and meta-analysis of placebo-controlled clinical trials. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:576-582. [DOI: 10.1080/21678421.2017.1335325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Faiza Shafiq
- Department of Neurology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK,
| | | | - Panagiotis Zis
- Department of Neurology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK,
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| |
Collapse
|
23
|
Zis P, Shafiq F, Mitsikostas DD. Nocebo effect in refractory partial epilepsy during pre-surgical monitoring: Systematic review and meta-analysis of placebo-controlled clinical trials. Seizure 2017; 45:95-99. [DOI: 10.1016/j.seizure.2016.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/28/2016] [Accepted: 12/02/2016] [Indexed: 12/19/2022] Open
|
24
|
Learning to experience side effects after antidepressant intake - Results from a randomized, controlled, double-blind study. Psychopharmacology (Berl) 2017; 234:329-338. [PMID: 27807605 PMCID: PMC5225191 DOI: 10.1007/s00213-016-4466-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 10/12/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Side effects play a key role in patients' failure to take antidepressants. There is evidence that verbal suggestions and informed consent elicit expectations that can in turn trigger the occurrence of side effects. Prior experience or learning mechanisms are also assumed to contribute to the development of side effects, although their role has not been thoroughly investigated. In this study, we examined whether an antidepressant's side effects can be learned via Pavlovian conditioning. METHODS Participants (n = 39) were randomly allocated to one of two groups and were exposed to a classical conditioning procedure. During acquisition, 19 participants received amitriptyline and 20 participants received a placebo pill. Pills were taken for four nights together with a novel-tasting drink. After a washout phase, both groups received a placebo pill together with the novel-tasting drink (evocation). Side effects were assessed via the Generic Assessment of Side Effects Scale prior to acquisition (baseline), after acquisition, and after evocation. A score of antidepressant-specific side effects was calculated. RESULTS Participants taking amitriptyline reported significantly more antidepressant-specific side effects after acquisition compared to both baseline and the placebo group. After evocation, participants who underwent the conditioning procedure with amitriptyline reported significantly more antidepressant-specific side effects than those who never received amitriptyline, even though both groups received a placebo. CONCLUSIONS Our results indicate that antidepressant side effects can be learned using a conditioning paradigm and evoked via a placebo pill when applied with the same contextual factors as the verum.
Collapse
|
25
|
Lessons Learned From Nocebo Effects in Clinical Trials for Pain Conditions and Neurodegenerative Disorders. J Clin Psychopharmacol 2016; 36:475-82. [PMID: 27580494 DOI: 10.1097/jcp.0000000000000556] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
It has been demonstrated that patients in the placebo arm of a clinical trial may experience adverse events (AEs), which may lead to nonadherence and dropout. However, so far, it is unknown to which extent this phenomenon is observed consistently across different diseases such as pain and neurodegenerative disorders.The current review shows for the first time that different diseases share a common risk for patients in terms of a negative outcome: a large percentage of placebo-treated patients experience AEs in pain conditions (up to 59%) and neurodegenerative disorders (up to 66%). In addition, the rate of patients who discontinue because of AEs is up to 10% and 11% in pain conditions and neurodegenerative disorders, respectively.We highlight methodological shortcomings with the aim of suggesting how the detection and reporting of AEs can be improved in future trials. The insights from the current review should be taken into consideration when designing clinical trials to tailor individualized treatments.
Collapse
|
26
|
|
27
|
|
28
|
Mitsikostas DD, Rapoport AM. New players in the preventive treatment of migraine. BMC Med 2015; 13:279. [PMID: 26555040 PMCID: PMC4641418 DOI: 10.1186/s12916-015-0522-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/02/2015] [Indexed: 01/03/2023] Open
Abstract
Migraine is a common, chronic disorder of the brain causing much disability, as well as personal, familial and societal impact. Several oral preventive agents are available in different countries for the prevention of migraine, but none have performed better than 50% improvement in 50% of patients in a clinical trial. Additionally, each has various possible adverse events making their tolerability less than optimal. Recently, three monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) ligand (LY2951742, ALD403 and TEV-48125) and one targeting the CGRP receptor (AMG 334) have completed phase 2 trials, and the results have been reported. These early results show them all to be somewhat more effective than placebo, with no serious adverse events. Three have been studied for episodic migraine, and only TEV-48125 has been studied for both high frequency episodic and chronic migraine. Moreover, preliminary data suggests that neurostimulation is effective in migraine treatment, including stimulation of the sphenopalatine ganglion, transcutaneous supraorbital and supratrochlear nerve, and transcutaneous vagus nerve. In this article, these innovative therapies will be reviewed.
Collapse
Affiliation(s)
- Dimos D Mitsikostas
- Neurology Department, Athens Naval Hospital, 70 Dinokratous Street, 11521, Athens, Greece.
| | - Alan M Rapoport
- The David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.,, 4255 Jefferson Avenue, Suite 27, Woodside, California, CA, 94062, USA
| |
Collapse
|
29
|
Zis P, Mitsikostas DD. Nocebo in Alzheimer's disease; meta-analysis of placebo-controlled clinical trials. J Neurol Sci 2015; 355:94-100. [DOI: 10.1016/j.jns.2015.05.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/03/2015] [Accepted: 05/20/2015] [Indexed: 12/19/2022]
|
30
|
Taylor FR, Cooper WM, Kaniecki RG, Ward TN, Roberts JL. Abstracts and Citations. Headache 2015. [DOI: 10.1111/head.12520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
31
|
Abstract
The role of psychosocial context around patient and therapy can be studied through randomized clinical trials. The analysis of the results of clinical trials, and considering the adverse events (AEs) in the placebo groups, provides an important perspective of study for this phenomenon. In double-blind, randomized clinical trials, the side effects reported in placebo-treated groups are not associated with pharmacological treatment, but other factors should be taken into account to explain these symptoms. This phenomenon may be conceptualized as 'nocebo effects' relating to negative expectations for treatment outcome, even though a role of prior learning in the form of conditioning with active treatments cannot be excluded. This approach makes it possible to observe how associating the placebo groups with a particular drug can cause specific AEs that are consistent with those observed in the active group. This phenomenon was described in a systematic review that examined placebo AEs in tricyclic antidepressant randomized clinical trials. The authors depicted nocebo effects in antidepressant placebos similar to the AE profiles of the real drugs, which they were matched with. These key findings contrast with the belief that nocebo effects were simply nonspecific. Moreover, they emphasize the need to develop standardized procedures for collecting information about AEs in randomized, double-blind, placebo-controlled trials determining drug efficacy.
Collapse
Affiliation(s)
- Martina Amanzio
- Department of Psychology, University of Turin, National Institute of Turin (NIT), Turin, Italy
| |
Collapse
|
32
|
Mitsikostas DD, Edvinsson L, Jensen RH, Katsarava Z, Lampl C, Negro A, Osipova V, Paemeleire K, Siva A, Valade D, Martelletti P. Refractory chronic cluster headache: a consensus statement on clinical definition from the European Headache Federation. J Headache Pain 2014; 15:79. [PMID: 25430992 PMCID: PMC4256964 DOI: 10.1186/1129-2377-15-79] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 12/31/2022] Open
Abstract
Chronic cluster headache (CCH) often resists to prophylactic pharmaceutical treatments resulting in patients’ life damage. In this rare but pragmatic situation escalation to invasive management is needed but framing criteria are lacking. We aimed to reach a consensus for refractory CCH definition for clinical and research use. The preparation of the final consensus followed three stages. Internal between authors, a larger between all European Headache Federation members and finally an international one among all investigators that have published clinical studies on cluster headache the last five years. Eighty-five investigators reached by email. Proposed criteria were in the format of the International Classification of Headache Disorders III-beta (description, criteria, notes, comments and references). Following this evaluation eight drafts were prepared before the final. Twenty-four (28.2%) international investigators commented during two rounds. Refractory CCH is described in the present consensus as a situation that fulfills the criteria of ICHD-3 beta for CCH with at least three severe attacks per week despite at least three consecutive trials of adequate preventive treatments. The condition is rare, but difficult to manage and invasive treatments may be needed. The consensus addresses five specific clinical and paraclinical diagnostic criteria followed by three notes and specific comments. Although refractory CCH may be not a separate identity these specific diagnostic criteria should help clinicians and investigators to improve patient’s quality of life.
Collapse
Affiliation(s)
- Dimos D Mitsikostas
- Athens Naval Hospital, Neurology Department, 77A Vas, Sofias Avenue, 11521 Athens, Greece.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Mitsikostas DD, Deligianni CI. Q-No: a questionnaire to predict nocebo in outpatients seeking neurological consultation. Neurol Sci 2014; 36:379-81. [DOI: 10.1007/s10072-014-1959-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 09/17/2014] [Indexed: 12/17/2022]
|
34
|
Mitsikostas DD, Mantonakis L, Chalarakis N. Nocebo in clinical trials for depression: a meta-analysis. Psychiatry Res 2014; 215:82-6. [PMID: 24210741 DOI: 10.1016/j.psychres.2013.10.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 09/14/2013] [Accepted: 10/20/2013] [Indexed: 12/19/2022]
Abstract
Nocebo refers to adverse events (AEs) related to negative expectations that medical treatment will likely harm instead of heal and can be assessed in placebo-controlled randomized clinical trials (RCTs). We sought to examine the AEs following placebo administration in RCTs for depression (D). After a systematic Medline search for RCTs in depression published in the last decade we assessed percentages of placebo-treated patients reporting at least one AE or discontinuing due to placebo intolerance and searched for factors influencing nocebo's extent. Data were extracted from 21 RCTs fulfilling search criteria. Of 3255 placebo-treated patients, 44.7% (95% CI: 22.3-68.3%) reported at least one AE, and 4.5% (95% CI: 3.4-5.8%) discontinued placebo treatment due to intolerance. AE rates in placebo and active drug treated patients were correlated quantitatively (r=0.915, p<0.001) and qualitatively, but not dropout rates (r=0.047). We conclude that almost one out of 20 placebo treated patients discontinued treatment due to AEs, indicating a significant nocebo in trials for depression treatment adversely affecting adherence and efficacy of current treatments in clinical practice, with additional implications for trial designing.
Collapse
Affiliation(s)
- Dimos D Mitsikostas
- Neurology Department, Athens Naval Hospital, 77A Vas. Sofias Avenue, 11521 Athens, Greece.
| | - Leonidas Mantonakis
- First Psychiatric Department, Aeginition Hospital, Athens University, Athens, Greece
| | - Nikolaos Chalarakis
- First Psychiatric Department, Aeginition Hospital, Athens University, Athens, Greece
| |
Collapse
|
35
|
Elman I, Borsook D, Volkow ND. Pain and suicidality: insights from reward and addiction neuroscience. Prog Neurobiol 2013; 109:1-27. [PMID: 23827972 PMCID: PMC4827340 DOI: 10.1016/j.pneurobio.2013.06.003] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/03/2013] [Accepted: 06/18/2013] [Indexed: 01/09/2023]
Abstract
Suicidality is exceedingly prevalent in pain patients. Although the pathophysiology of this link remains unclear, it may be potentially related to the partial congruence of physical and emotional pain systems. The latter system's role in suicide is also conspicuous during setbacks and losses sustained in the context of social attachments. Here we propose a model based on the neural pathways mediating reward and anti-reward (i.e., allostatic adjustment to recurrent activation of the reward circuitry); both are relevant etiologic factors in pain, suicide and social attachments. A comprehensive literature search on neurobiology of pain and suicidality was performed. The collected articles were critically reviewed and relevant data were extracted and summarized within four key areas: (1) physical and emotional pain, (2) emotional pain and social attachments, (3) pain- and suicide-related alterations of the reward and anti-reward circuits as compared to addiction, which is the premier probe for dysfunction of these circuits and (4) mechanistically informed treatments of co-occurring pain and suicidality. Pain-, stress- and analgesic drugs-induced opponent and proponent states of the mesolimbic dopaminergic pathways may render reward and anti-reward systems vulnerable to sensitization, cross-sensitization and aberrant learning of contents and contexts associated with suicidal acts and behaviors. These findings suggest that pain patients exhibit alterations in the brain circuits mediating reward (depressed function) and anti-reward (sensitized function) that may affect their proclivity for suicide and support pain and suicidality classification among other "reward deficiency syndromes" and a new proposal for "enhanced anti-reward syndromes". We suggest that interventions aimed at restoring the balance between the reward and anti-reward networks in patients with chronic pain may help decreasing their suicide risk.
Collapse
Affiliation(s)
- Igor Elman
- Providence VA Medical Center and Cambridge Health Alliance, Harvard Medical School, 26 Central Street, Somerville, MA 02143, USA.
| | | | | |
Collapse
|
36
|
Stathis P, Smpiliris M, Konitsiotis S, Mitsikostas DD. Nocebo as a potential confounding factor in clinical trials for Parkinson's disease treatment: a meta‐analysis. Eur J Neurol 2012; 20:527-533. [DOI: 10.1111/ene.12014] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 09/17/2012] [Indexed: 12/19/2022]
Affiliation(s)
- P. Stathis
- Neurology Department Sismanoglion Hospital AthensGreece
| | - M. Smpiliris
- Neurology Department Sismanoglion Hospital AthensGreece
| | - S. Konitsiotis
- Neurology Department University of Ioannina IoanninaGreece
| | | |
Collapse
|
37
|
Häuser W, Hansen E, Enck P. Nocebo phenomena in medicine: their relevance in everyday clinical practice. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:459-65. [PMID: 22833756 DOI: 10.3238/arztebl.2012.0459] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 03/28/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nocebo phenomena are common in clinical practice and have recently become a popular topic of research and discussion among basic scientists, clinicians, and ethicists. METHODS We selectively searched the PubMed database for articles published up to December 2011 that contained the key words "nocebo" or "nocebo effect." RESULTS By definition, a nocebo effect is the induction of a symptom perceived as negative by sham treatment and/or by the suggestion of negative expectations. A nocebo response is a negative symptom induced by the patient's own negative expectations and/or by negative suggestions from clinical staff in the absence of any treatment. The underlying mechanisms include learning by Pavlovian conditioning and reaction to expectations induced by verbal information or suggestion. Nocebo responses may come about through unintentional negative suggestion on the part of physicians and nurses. Information about possible complications and negative expectations on the patient's part increases the likelihood of adverse effects. Adverse events under treatment with medications sometimes come about by a nocebo effect. CONCLUSION Physicians face an ethical dilemma, as they are required not just to inform patients of the potential complications of treatment, but also to minimize the likelihood of these complications, i.e., to avoid inducing them through the potential nocebo effect of thorough patient information. Possible ways out of the dilemma include emphasizing the fact that the proposed treatment is usually well tolerated, or else getting the patient's permission to inform less than fully about its possible side effects. Communication training in medical school, residency training, and continuing medical education would be desirable so that physicians can better exploit the power of words to patients' benefit, rather than their detriment.
Collapse
Affiliation(s)
- Winfried Häuser
- Department of Internal Medicine I, Klinikum Saarbrücken, Saarbrücken, Germany.
| | | | | |
Collapse
|