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George DS, Jayaraj ND, Pacifico P, Ren D, Sriram N, Miller RE, Malfait AM, Miller RJ, Menichella DM. The Mas-related G protein-coupled receptor d (Mrgprd) mediates pain hypersensitivity in painful diabetic neuropathy. Pain 2024; 165:1154-1168. [PMID: 38147415 PMCID: PMC11017747 DOI: 10.1097/j.pain.0000000000003120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 12/28/2023]
Abstract
ABSTRACT Painful diabetic neuropathy (PDN) is one of the most common and intractable complications of diabetes. Painful diabetic neuropathy is characterized by neuropathic pain accompanied by dorsal root ganglion (DRG) nociceptor hyperexcitability, axonal degeneration, and changes in cutaneous innervation. However, the complete molecular profile underlying the hyperexcitable cellular phenotype of DRG nociceptors in PDN has not been elucidated. This gap in our knowledge is a critical barrier to developing effective, mechanism-based, and disease-modifying therapeutic approaches that are urgently needed to relieve the symptoms of PDN. Using single-cell RNA sequencing of DRGs, we demonstrated an increased expression of the Mas-related G protein-coupled receptor d (Mrgprd) in a subpopulation of DRG neurons in the well-established high-fat diet (HFD) mouse model of PDN. Importantly, limiting Mrgprd signaling reversed mechanical allodynia in the HFD mouse model of PDN. Furthermore, in vivo calcium imaging allowed us to demonstrate that activation of Mrgprd-positive cutaneous afferents that persist in diabetic mice skin resulted in an increased intracellular calcium influx into DRG nociceptors that we assess in vivo as a readout of nociceptors hyperexcitability. Taken together, our data highlight a key role of Mrgprd-mediated DRG neuron excitability in the generation and maintenance of neuropathic pain in a mouse model of PDN. Hence, we propose Mrgprd as a promising and accessible target for developing effective therapeutics currently unavailable for treating neuropathic pain in PDN.
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Affiliation(s)
| | | | | | - Dongjun Ren
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | | | - Rachel E. Miller
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | - Anne-Marie Malfait
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | - Richard J. Miller
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniela Maria Menichella
- Departments of Neurology and
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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2
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Wang Q, Ye Y, Yang L, Xiao L, Liu J, Zhang W, Du G. Painful diabetic neuropathy: The role of ion channels. Biomed Pharmacother 2024; 173:116417. [PMID: 38490158 DOI: 10.1016/j.biopha.2024.116417] [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] [Received: 11/30/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/17/2024] Open
Abstract
Painful diabetic neuropathy (PDN) is a common chronic complication of diabetes that causes neuropathic pain and negatively affects the quality of life. The management of PDN is far from satisfactory. At present, interventions are primarily focused on symptomatic treatment. Ion channel disorders are a major cause of PDN, and a complete understanding of their roles and mechanisms may provide better options for the clinical treatment of PDN. Therefore, this review summarizes the important role of ion channels in PDN and the current drug development targeting these ion channels.
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Affiliation(s)
- Qi Wang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yifei Ye
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Linghui Yang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lifan Xiao
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wensheng Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Guizhi Du
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, Translational Neuroscience Centre, West China Hospital, Sichuan University, Chengdu, China; National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.
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3
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Anastasiou G, Liberopoulos E, Tentolouris N, Papanas N. Diabetic Sensorimotor Polyneuropathy: An Overview on Epidemiology, Risk Factors, Classification, Diagnosis, and Treatment. INT J LOW EXTR WOUND 2024:15347346241240513. [PMID: 38533581 DOI: 10.1177/15347346241240513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Diabetic distal symmetric sensorimotor polyneuropathy (DSPN) is a common complication of diabetes with devastating consequences. Hyperglycaemia is the major aetiological factor, while emerging data demonstrate that cardiometabolic risk factors also contribute to its development. Diagnosis of DSPN involves interview of medical and neurological history, foot inspection, and sensory and motor function examination with specific tests such as temperature and pinprick perception for small nerve fibers, and vibration and light touch assessments for large nerve fibers. Management includes optimised glycaemic control, treatment of cardiovascular risk factors, and symptomatic treatment aiming at improving life quality. This article provides an overview on epidemiology, risk factors, classification, diagnosis and current treatment of DSPN.
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Affiliation(s)
- Georgia Anastasiou
- Department of Internal Medicine, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Evangelos Liberopoulos
- First Propedeutic Department of Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Tentolouris
- First Propedeutic Department of Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
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Ahmadzadeh AM, Pourali G, Mirheidari SB, Shirazinia M, Hamedi M, Mehri A, Amirbeik H, Saghebdoust S, Tayarani-Najaran Z, Sathyapalan T, Forouzanfar F, Sahebkar A. Medicinal Plants for the Treatment of Neuropathic Pain: A Review of Randomized Controlled Trials. Curr Pharm Biotechnol 2024; 25:534-562. [PMID: 37455451 DOI: 10.2174/1389201024666230714143538] [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] [Received: 12/24/2022] [Revised: 05/21/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023]
Abstract
Neuropathic pain is a disabling condition caused by various diseases and can profoundly impact the quality of life. Unfortunately, current treatments often do not produce complete amelioration and can be associated with potential side effects. Recently, herbal drugs have garnered more attention as an alternative or a complementary treatment. In this article, we summarized the results of randomized clinical trials to evaluate the effects of various phytomedicines on neuropathic pain. In addition, we discussed their main bioactive components and potential mechanisms of action to provide a better view of the application of herbal drugs for treating neuropathic pain.
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Affiliation(s)
- Amir Mahmoud Ahmadzadeh
- Transplant Research Center, Clinical Research Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ghazaleh Pourali
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Matin Shirazinia
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdieh Hamedi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Mehri
- Endoscopic and Minimally Invasive Surgery Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hesam Amirbeik
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Zahra Tayarani-Najaran
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Medical Toxicology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Thozhukat Sathyapalan
- Academic Diabetes, Endocrinology and Metabolism, Allam Diabetes Centre Hull Royal Infirmary Anlaby Road HU3 2JZ, Hull, UK.m
| | - Fatemeh Forouzanfar
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Neuroscience, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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5
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Tesfaye S, Kempler P. Conventional management and current guidelines for painful diabetic neuropathy. Diabetes Res Clin Pract 2023; 206 Suppl 1:110765. [PMID: 38245323 DOI: 10.1016/j.diabres.2023.110765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/30/2023] [Indexed: 01/22/2024]
Abstract
Painful Diabetic Peripheral Neuropathy (PDN) is common, affecting around a quarter of patients with both type 1 and type 2 diabetes, and can lead to significant curtailment of functionality and quality of life. Patients may present with unremitting burning, aching or "electric-shock" type pains in their feet, legs and later, in the hands. Conventional management approaches must focus not only on pain relief, but also on concurrent sleep problems, mood disorders and functionality. The mainstay of treatment is pharmacotherapy. Most current international guidelines recommend a choice of four drugs: amitriptyline, duloxetine, pregabalin or gabapentin, as initial treatment for PDN. Recent evidence from the OPTION-DM trial demonstrated that these drugs and their combinations have equivalent efficacy. Moreover, combination treatment provided significant pain relief to patients with inadequate response to the maximum tolerated dose of monotherapy. PDN refractory to pharmacotherapy can be treated with capsaicin 8% or high frequency spinal cord stimulation.
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Affiliation(s)
- Solomon Tesfaye
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.
| | - Peter Kempler
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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Chen J, Frizzi K, Zardouz S, Province-Azalde R, Furnish T, Wallace M, Castellanos J, Tayerani A, Halter K, Lam K, Banducci S, Chieu A, Calcutt N. High-frequency spinal cord stimulation (10 kHz) alters sensory function and nerve fiber density in painful diabetic neuropathy: a pilot prospective open-label study. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:S33-S40. [PMID: 37833050 DOI: 10.1093/pm/pnad096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/06/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Spinal cord stimulation at 10 kHz has provided effective pain relief and improved function in painful diabetic peripheral neuropathy. This study aims to confirm the clinical outcomes for 10-kHz spinal cord stimulation treatment of painful diabetic peripheral neuropathy and explore its impact on objective quantitative measures of nerve pathology and function. METHODS This single-academic center, prospective, open-label, observational study examined the pain relief success of 10-kHz spinal cord stimulation in patients >18 years of age with diabetic peripheral neuropathy. Patients underwent skin biopsies to measure intra-epidermal nerve fiber densities and corneal confocal microscopy measurements before implantation and at the 3-, 6-, and 12-month follow-up visits. Numerical rating scale for pain, visual analog scale, neuropathy pain scale, Short Form-36, and Neuropen (pin prick and monofilament) assessments were also conducted. RESULTS Eight patients met the criteria and were enrolled in the study. A successful trial was achieved in 7 subjects, and 6 completed the study. Significant pain relief (P < .001) was achieved at all follow-up visits. Neurological assessments showed reduced numbers of "absent" responses and increased "normal" responses from baseline to 12 months. Both proximal and distal intra-epidermal nerve fiber densities were higher at 12 months than at baseline (P < .01). Confocal microscopy measurements showed a steady increase in nerve density from baseline (188.8% increase at 12 months; P = .029). CONCLUSIONS We observed pain relief and improvements in sensory function after stimulation that were accompanied by increases in lower-limb intra-epidermal nerve fiber density and corneal nerve density. Further evaluation with a blinded and controlled study is needed to confirm the preliminary findings in this study.
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Affiliation(s)
- Jeffrey Chen
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | - Katie Frizzi
- Department of Pathology, University of California San Diego, La Jolla, CA, United States
| | - Shawn Zardouz
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | | | - Tim Furnish
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | - Mark Wallace
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | - Joel Castellanos
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | - Alireza Tayerani
- Department of Pathology, University of California San Diego, La Jolla, CA, United States
| | - Kenneth Halter
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | - Katie Lam
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego, La Jolla, CA, United States
| | | | - Alex Chieu
- Nevro Corp, Redwood City, CA, United States
| | - Nigel Calcutt
- Department of Pathology, University of California San Diego, La Jolla, CA, United States
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7
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Kaur M, Misra S, Swarnkar P, Patel P, Das Kurmi B, Das Gupta G, Singh A. Understanding the role of hyperglycemia and the molecular mechanism associated with diabetic neuropathy and possible therapeutic strategies. Biochem Pharmacol 2023; 215:115723. [PMID: 37536473 DOI: 10.1016/j.bcp.2023.115723] [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] [Received: 04/24/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
Diabetic neuropathy is a neuro-degenerative disorder that encompasses numerous factors that impact peripheral nerves in the context of diabetes mellitus (DM). Diabetic peripheral neuropathy (DPN) is very prevalent and impacts 50% of diabetic patients. DPN is a length-dependent peripheral nerve lesion that primarily causes distal sensory loss, discomfort, and foot ulceration that may lead to amputation. The pathophysiology is yet to be fully understood, but current literature on the pathophysiology of DPN revolves around understanding various signaling cascades involving the polyol, hexosamine, protein-kinase C, AGE, oxidative stress, and poly (ADP ribose) polymerase pathways. The results of research have suggested that hyperglycemia target Schwann cells and in severe cases, demyelination resulting in central and peripheral sensitization is evident in diabetic patients. Various diagnostic approaches are available, but detection at an early stage remains a challenge. Traditional analgesics and opioids that can be used "as required" have not been the mainstay of treatment thus far. Instead, anticonvulsants and antidepressants that must be taken routinely over time have been the most common treatments. For now, prolonging life and preserving the quality of life are the ultimate goals of diabetes treatment. Furthermore, the rising prevalence of DPN has substantial consequences for occupational therapy because such therapy is necessary for supporting wellness, warding off other chronic-diseases, and avoiding the development of a disability; this is accomplished by engaging in fulfilling activities like yoga, meditation, and physical exercise. Therefore, occupational therapy, along with palliative therapy, may prove to be crucial in halting the onset of neuropathic-symptoms and in lessening those symptoms once they have occurred.
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Affiliation(s)
- Mandeep Kaur
- Department of Pharmacology, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga142001, Punjab, India
| | - Sakshi Misra
- Department of Pharmacology, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga142001, Punjab, India
| | - Priyanka Swarnkar
- Department of Pharmacology, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga142001, Punjab, India
| | - Preeti Patel
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga 142001, Punjab, India
| | - Balak Das Kurmi
- Department of Pharmaceutics, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga 142001, Punjab, India
| | - Ghanshyam Das Gupta
- Department of Pharmaceutics, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga 142001, Punjab, India
| | - Amrita Singh
- Department of Pharmacology, ISF College of Pharmacy, GT Road, Ghal Kalan, Moga142001, Punjab, India.
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Armstrong DG, Grunberger G. Stimulating Results Signal a New Treatment Option for People Living With Painful Diabetic Neuropathy. J Diabetes Sci Technol 2023; 17:1387-1391. [PMID: 35770993 PMCID: PMC10563543 DOI: 10.1177/19322968221099542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Painful diabetic neuropathy (PDN) is a progressive condition that deprives many patients of quality of life. With limited treatment options available, successful pain management can be difficult to achieve. METHODS We reviewed results of recent data evaluating high frequency spinal cord stimulation (SCS). RESULTS from the SENZA-PDN randomized clinical trial (NCT03228420), the largest such trial to date, demonstrated 10-kHz spinal cord stimulation substantially reduced PDN refractory to conventional medical management along with improvements in health-related quality-of-life measures that were sustained over 12 months. These data supported the recent U.S. Food & Drug Administration (FDA) approval for 10-kHz SCS in PDN patients and contributed to the body of evidence on SCS available to health care professionals managing the effects of PDN. CONCLUSION High frequency spinal cord simulation appears to hold promise in treatment of painful diabetic neuropathy. We look forward to future works in the literature that will further elucidate these promising findings.
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Affiliation(s)
- David G. Armstrong
- Department of Surgery, Southwestern Academic Limb Salvage Alliance, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - George Grunberger
- Grunberger Diabetes Institute, Bloomfield Hills, MI, USA
- Internal Medicine, Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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9
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Abd-Elsayed AA, Marcondes LP, Loris ZB, Reilly D. Painful Diabetic Peripheral Neuropathy - A Survey of Patient Experiences. J Pain Res 2023; 16:2269-2285. [PMID: 37425223 PMCID: PMC10329444 DOI: 10.2147/jpr.s409876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose An online survey was conducted in the USA to obtain information about the knowledge and experiences of patients with painful diabetic peripheral neuropathy (pDPN). Patients and Methods 506 adults with diabetes and pDPN affecting the feet for ≥6 months, for which pain medication had been prescribed for ≥6 months, completed an online survey questionnaire in March 2021. Results 79% of respondents had type 2 diabetes, 60% were male, 82% were Caucasian and 87% had comorbidities. Pain was significant to severe in 49% of respondents, and 66% had disability due to nerve pain. Anticonvulsants, over-the-counter pills and supplements were the most commonly used medications. Topical creams/patches were prescribed in 23% of respondents. 70% had tried multiple medications for their pain. 61% of respondents had to see ≥2 doctors before receiving a correct diagnosis of pDPN. 85% of respondents felt that the doctor understood their pain and its impact on their life. 70% had no difficulty finding the information they wanted. 34% felt insufficiently informed about their condition. A medical professional was the primary, and most trusted, source of information. Frustration, worry, anxiety and uncertainty were the most commonly reported emotions. Respondents were generally eager to find new medications for pain relief and desperate for a cure. Lifestyle changes because of nerve pain were most commonly associated with physical disabilities and sleep disturbance. Better treatments and freedom from pain were the overriding perspectives when considering the future. Conclusion Patients with pDPN are generally well informed about their pain and trust their doctor but remain unsatisfied with their current treatment and struggle to find a lasting solution for their pain. Early identification and diagnosis of pain in diabetics, and education about treatments, is important to minimize the impact of pain on quality of life and emotional well-being.
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Affiliation(s)
- Alaa A Abd-Elsayed
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Preston FG, Riley DR, Azmi S, Alam U. Painful Diabetic Peripheral Neuropathy: Practical Guidance and Challenges for Clinical Management. Diabetes Metab Syndr Obes 2023; 16:1595-1612. [PMID: 37288250 PMCID: PMC10243347 DOI: 10.2147/dmso.s370050] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023] Open
Abstract
Painful diabetic peripheral neuropathy (PDPN) is present in nearly a quarter of people with diabetes. It is estimated to affect over 100 million people worldwide. PDPN is associated with impaired daily functioning, depression, sleep disturbance, financial instability, and a decreased quality of life. Despite its high prevalence and significant health burden, it remains an underdiagnosed and undertreated condition. PDPN is a complex pain phenomenon with the experience of pain associated with and exacerbated by poor sleep and low mood. A holistic approach to patient-centred care alongside the pharmacological therapy is required to maximise benefit. A key treatment challenge is managing patient expectation, as a good outcome from treatment is defined as a reduction in pain of 30-50%, with a complete pain-free outcome being rare. The future for the treatment of PDPN holds promise, despite a 20-year void in the licensing of new analgesic agents for neuropathic pain. There are over 50 new molecular entities reaching clinical development and several demonstrating benefit in early-stage clinical trials. We review the current approaches to its diagnosis, the tools, and questionnaires available to clinicians, international guidance on PDPN management, and existing pharmacological and non-pharmacological treatment options. We synthesise evidence and the guidance from the American Association of Clinical Endocrinology, American Academy of Neurology, American Diabetes Association, Diabetes Canada, German Diabetes Association, and the International Diabetes Federation into a practical guide to the treatment of PDPN and highlight the need for future research into mechanistic-based treatments in order to prioritise the development of personalised medicine.
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Affiliation(s)
- Frank G Preston
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
| | - David R Riley
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Uazman Alam
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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11
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Da Vitoria Lobo ME, Madden R, Liddell S, Hirashima M, Hulse RP. Spinal cord vascular degeneration impairs duloxetine penetration. FRONTIERS IN PAIN RESEARCH 2023; 4:1190440. [PMID: 37325676 PMCID: PMC10262048 DOI: 10.3389/fpain.2023.1190440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Chronic pain is a prevalent physically debilitating health-related morbidity. Frontline analgesics are inadequate, providing only partial pain relief in only a proportion of the patient cohort. Here, we explore whether alterations in spinal cord vascular perfusion are a factor in reducing the analgesic capability of the noradrenaline reuptake inhibitor, duloxetine. Method An established rodent model of spinal cord vascular degeneration was used. Endothelial-specific vascular endothelial growth factor receptor 2 knockout mouse was induced via hydroxytamoxifen administered via intrathecal injection. Duloxetine was administered via intraperitoneal injection, and nociceptive behavioural testing was performed in both WT and VEGFR2KO mice. LC-MS/MS was performed to explore the accumulation of duloxetine in the spinal cord in WT and VEGFR2KO mice. Results Spinal cord vascular degeneration leads to heat hypersensitivity and a decline in capillary perfusion. The integrity of noradrenergic projections (dopa - hydroxylase labelled) in the dorsal horn remained unaltered in WT and VEGFR2KO mice. There was an association between dorsal horn blood flow with the abundance of accumulated duloxetine in the spinal cord and analgesic capacity. In VEGFR2KO mice, the abundance of duloxetine in the lumbar spinal cord was reduced and was correlated with reduced anti-nociceptive capability of duloxetine. Discussion Here, we show that an impaired vascular network in the spinal cord impairs the anti-nociceptive action of duloxetine. This highlights that the spinal cord vascular network is crucial to maintaining the efficacy of analgesics to provide pain relief.
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Affiliation(s)
- M. E Da Vitoria Lobo
- Cancer Biology, Division of Cancer and Stem Cells, School of Medicine University of Nottingham, Nottingham, United Kingdom
| | - R Madden
- Cancer Biology, Division of Cancer and Stem Cells, School of Medicine University of Nottingham, Nottingham, United Kingdom
| | - S Liddell
- Exonate Ltd., Nottingham, United Kingdom
| | - M Hirashima
- Division of Pharmacology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - R. P Hulse
- Cancer Biology, Division of Cancer and Stem Cells, School of Medicine University of Nottingham, Nottingham, United Kingdom
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
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12
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Lu JS, Yang L, Chen J, Xiong FF, Cai P, Wang XY, Xiong BJ, Chen ZH, Chen L, Yang J, Yu CX. Basolateral amygdala astrocytes modulate diabetic neuropathic pain and may be a potential therapeutic target for koumine. Br J Pharmacol 2022; 180:1408-1428. [PMID: 36519959 DOI: 10.1111/bph.16011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 10/20/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND PURPOSE New remedies are required for the treatment of diabetic neuropathic pain (DNP) due to insufficient efficacy of available therapies. Here, we used chemogenetic approaches combined with in vivo pharmacology to elucidate the role of basolateral amygdala (BLA) astrocytes in DNP pathogenesis and provide new insights into therapeutic strategies for DNP. EXPERIMENTAL APPROACH A streptozotocin-induced DNP model was established. Designer receptors exclusively activated by designer drugs (DREADDs) were used to regulate astrocyte activity. Mechanical hyperalgesia was assessed using the electronic von Frey test. Anxiety-like behaviours were detected using open field and elevated plus maze tests. Astrocytic activity was detected by immunofluorescence, and cytokine content was determined by ELISA. KEY RESULTS BLA astrocytes were regulated by DREADDs, and inhibition of BLA astrocytes attenuated mechanical allodynia and pain-related negative emotions in DNP rats. In contrast, temporary activation of BLA astrocytes induced allodynia without anxious behaviours in naive rats. In addition, koumine (KM) alleviated mechanical allodynia and anxiety-like behaviours in DNP rats, inhibited the activation of BLA astrocytes and suppressed the inflammatory response. Furthermore, persistent activation of BLA astrocytes through chemogenetics mimicked chronic pain, and KM alleviated the pain hypersensitivity and anxiety-like behaviours. CONCLUSION AND IMPLICATIONS DREADDs bidirectionally regulate the activity of BLA astrocytes, which proves for the first time the role of BLA astrocyte activation in the pathogenesis of DNP and represents a novel therapeutic strategy for DNP. KM ameliorates DNP, perhaps by inhibiting the activation of BLA astrocytes and reveal KM as a potential candidate for treating DNP.
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Affiliation(s)
- Jing-Shan Lu
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Center for Safety Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Lan Yang
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jian Chen
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Fang-Fang Xiong
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Ping Cai
- Fujian Province Key Laboratory of Environment and Health, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Xin-Yao Wang
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Bo-Jun Xiong
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Ze-Hong Chen
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Li Chen
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jian Yang
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Drug Target Discovery and Structural and Functional Research, School of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Natural Medicine Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Chang-Xi Yu
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Drug Target Discovery and Structural and Functional Research, School of Pharmacy, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Natural Medicine Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, China
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13
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Inhibition of SARS-CoV-2 Viral Channel Activity Using FDA-Approved Channel Modulators Independent of Variants. Biomolecules 2022; 12:biom12111673. [PMID: 36421688 PMCID: PMC9687591 DOI: 10.3390/biom12111673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/29/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background: SARS-CoV-2 has undergone mutations, yielding clinically relevant variants. Hypothesis: We hypothesized that in SARS-CoV-2, two highly conserved Orf3a and E channels directly related to the virus replication were a target for the detection and inhibition of the viral replication, independent of the variant, using FDA-approved ion channel modulators. Methods: A combination of a fluorescence potassium ion assay with channel modulators was developed to detect SARS-CoV-2 Orf3a/E channel activity. Two FDA-approved drugs, amantadine (an antiviral) and amitriptyline (an antidepressant), which are ion channel blockers, were tested as to whether they inhibited Orf3a/E channel activity in isolated virus variants and in nasal swab samples from COVID-19 patients. The variants were confirmed by PCR sequencing. Results: In isolated SARS-CoV-2 Alpha, Beta, and Delta variants, the channel activity of Orf3a/E was detected and inhibited by emodin and gliclazide (IC50 = 0.42 mM). In the Delta swab samples, amitriptyline and amantadine inhibited the channel activity of viral proteins, with IC50 values of 0.73 mM and 1.11 mM, respectively. In the Omicron swab samples, amitriptyline inhibited the channel activity, with an IC50 of 0.76 mM. Conclusions: We developed an efficient method to screen FDA-approved ion channel modulators that could be repurposed to detect and inhibit SARS-CoV-2 viral replication, independent of variants.
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14
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Da Vitoria Lobo ME, Weir N, Hardowar L, Al Ojaimi Y, Madden R, Gibson A, Bestall SM, Hirashima M, Schaffer CB, Donaldson LF, Bates DO, Hulse RP. Hypoxia-induced carbonic anhydrase mediated dorsal horn neuron activation and induction of neuropathic pain. Pain 2022; 163:2264-2279. [PMID: 35353768 PMCID: PMC9578530 DOI: 10.1097/j.pain.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/27/2022]
Abstract
ABSTRACT Neuropathic pain, such as that seen in diabetes mellitus, results in part from central sensitisation in the dorsal horn. However, the mechanisms responsible for such sensitisation remain unclear. There is evidence that disturbances in the integrity of the spinal vascular network can be causative factors in the development of neuropathic pain. Here we show that reduced blood flow and vascularity of the dorsal horn leads to the onset of neuropathic pain. Using rodent models (type 1 diabetes and an inducible endothelial-specific vascular endothelial growth factor receptor 2 knockout mouse) that result in degeneration of the endothelium in the dorsal horn, we show that spinal cord vasculopathy results in nociceptive behavioural hypersensitivity. This also results in increased hypoxia in dorsal horn neurons, depicted by increased expression of hypoxia markers such as hypoxia inducible factor 1α, glucose transporter 3, and carbonic anhydrase 7. Furthermore, inducing hypoxia through intrathecal delivery of dimethyloxalylglycine leads to the activation of dorsal horn neurons as well as mechanical and thermal hypersensitivity. This shows that hypoxic signalling induced by reduced vascularity results in increased hypersensitivity and pain. Inhibition of carbonic anhydrase activity, through intraperitoneal injection of acetazolamide, inhibited hypoxia-induced pain behaviours. This investigation demonstrates that induction of a hypoxic microenvironment in the dorsal horn, as occurs in diabetes, is an integral process by which neurons are activated to initiate neuropathic pain states. This leads to the conjecture that reversing hypoxia by improving spinal cord microvascular blood flow could reverse or prevent neuropathic pain.
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Affiliation(s)
- Marlene E. Da Vitoria Lobo
- Division of Cancer and Stem Cells, School of Medicine, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Nick Weir
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Lydia Hardowar
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Yara Al Ojaimi
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Ryan Madden
- Division of Cancer and Stem Cells, School of Medicine, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Alex Gibson
- Division of Cancer and Stem Cells, School of Medicine, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Samuel M. Bestall
- Pain Centre Versus Arthritis and School of Life Sciences, The Medical School QMC, University of Nottingham, Nottingham, United Kingdom
| | - Masanori Hirashima
- Division of Pharmacology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Chris B. Schaffer
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, United States
| | - Lucy F. Donaldson
- Pain Centre Versus Arthritis and School of Life Sciences, The Medical School QMC, University of Nottingham, Nottingham, United Kingdom
| | - David O. Bates
- Division of Cancer and Stem Cells, School of Medicine, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
- Centre of Membrane and Protein and Receptors (COMPARE), University of Birmingham and University of Nottingham, Midlands, United Kingdom
| | - Richard Philip Hulse
- Division of Cancer and Stem Cells, School of Medicine, Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
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15
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Abstract
Distal symmetric diabetic peripheral polyneuropathy (DPN) is the most common form of neuropathy in the world, affecting 30 to 50% of diabetic individuals and resulting in significant morbidity and socioeconomic costs. This review summarizes updates in the diagnosis and management of DPN. Recently updated clinical criteria facilitate bedside diagnosis, and a number of new technologies are being explored for diagnostic confirmation in specific settings and for use as surrogate measures in clinical trials. Evolving literature indicates that distinct but overlapping mechanisms underlie neuropathy in type 1 versus type 2 diabetes, and there is a growing focus on the role of metabolic factors in the development and progression of DPN. Exercise-based lifestyle interventions have shown therapeutic promise. A variety of potential disease-modifying and symptomatic therapies are in development. Innovations in clinical trial design include the incorporation of detailed pain phenotyping and biomarkers for central sensitization.
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Affiliation(s)
- Qihua Fan
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - A Gordon Smith
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
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16
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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17
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Kitano Y, Shinozuka T. Inhibition of Na V1.7: the possibility of ideal analgesics. RSC Med Chem 2022; 13:895-920. [PMID: 36092147 PMCID: PMC9384491 DOI: 10.1039/d2md00081d] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/25/2022] [Indexed: 08/03/2023] Open
Abstract
The selective inhibition of NaV1.7 is a promising strategy for developing novel analgesic agents with fewer adverse effects. Although the potent selective inhibition of NaV1.7 has been recently achieved, multiple NaV1.7 inhibitors failed in clinical development. In this review, the relationship between preclinical in vivo efficacy and NaV1.7 coverage among three types of voltage-gated sodium channel (VGSC) inhibitors, namely conventional VGSC inhibitors, sulphonamides and acyl sulphonamides, is discussed. By demonstrating the PK/PD discrepancy of preclinical studies versus in vivo models and clinical results, the potential reasons behind the disconnect between preclinical results and clinical outcomes are discussed together with strategies for developing ideal analgesic agents.
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Affiliation(s)
- Yutaka Kitano
- R&D Division, Daiichi Sankyo Co., Ltd. 1-2-58 Hiromachi Shinagawa-ku Tokyo 140-8710 Japan
| | - Tsuyoshi Shinozuka
- R&D Division, Daiichi Sankyo Co., Ltd. 1-2-58 Hiromachi Shinagawa-ku Tokyo 140-8710 Japan
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18
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Smith S, Normahani P, Lane T, Hohenschurz-Schmidt D, Oliver N, Davies AH. Prevention and Management Strategies for Diabetic Neuropathy. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081185. [PMID: 36013364 PMCID: PMC9410148 DOI: 10.3390/life12081185] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/17/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022]
Abstract
Diabetic neuropathy (DN) is a common complication of diabetes that is becoming an increasing concern as the prevalence of diabetes rapidly rises. There are several types of DN, but the most prevalent and studied type is distal symmetrical polyneuropathy, which is the focus of this review and is simply referred to as DN. It can lead to a wide range of sensorimotor and psychosocial symptoms and is a major risk factor for diabetic foot ulceration and Charcot neuropathic osteoarthropathy, which are associated with high rates of lower limb amputation and mortality. The prevention and management of DN are thus critical, and clinical guidelines recommend several strategies for these based on the best available evidence. This article aims to provide a narrative review of DN prevention and management strategies by discussing these guidelines and the evidence that supports them. First, the epidemiology and diverse clinical manifestations of DN are summarized. Then, prevention strategies such as glycemic control, lifestyle modifications and footcare are discussed, as well as the importance of early diagnosis. Finally, neuropathic pain management strategies and promising novel therapies under investigation such as neuromodulation devices and nutraceuticals are reviewed.
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Affiliation(s)
- Sasha Smith
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Pasha Normahani
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Tristan Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - David Hohenschurz-Schmidt
- Pain Research Group, Department of Surgery and Cancer, Imperial College London, London SW10 9NH, UK;
| | - Nick Oliver
- Section of Metabolic Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W2 1PG, UK;
- Division of Medicine and Integrated Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Alun Huw Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
- Correspondence:
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19
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Bhargava SK, Singh TG, Mannan A, Singh S, Singh M, Gupta S. Pharmacological evaluation of Thuja occidentalis for the attenuation of neuropathy via AGEs and TNF-α inhibition in diabetic neuropathic rats. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:60542-60557. [PMID: 35420347 DOI: 10.1007/s11356-022-20106-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
When diabetes neuropathy occurs, the oxidative stress caused by chronic hyperglycemia may result in chronic neuronal damage. To mitigate the effects of hyperglycemia-induced neuronal damage, it may be beneficial to address oxidative stress and inflammation in the body. The current study evaluated the neuroprotective efficacy of Thuja occidentalis in streptozotocin (STZ)-nicotinamide (NAD)-induced diabetic neuropathy in male Wistar rats. A single dose of STZ (65 mg/kg, i.p.) was used to induce diabetic neuropathy in Wistar rats. Serum insulin, glucose, hyperalgesia, oxidative stress, inflammatory markers, and histopathology of the sciatic nerve were evaluated for neuropathy. Wistar rats were treated with varying doses of hydroalcoholic extracts of Thuja occidentalis (HAETO) and gabapentin for 30 days. Thuja occidentalis considerably corrected the levels of inflammatory markers and oxidative stress caused by hyperglycemia; also, it led to the restoration of neuronal functions, indicating that it is effective in treating diabetic neuropathy. Furthermore, the molecular docking of thujone at the active pockets of various inflammatory mediators (IL-1β, IL-6, TGF-β1, and TNF-α) has shown good interactions with critical amino acid residues. These findings indicate that the hydroalcoholic extract of Thuja occidentalis effectively inhibits the development of diabetic neuropathy. The hypoglycemic, antioxidant, anti-hyperalgesia, and anti-inflammatory properties of Thuja occidentalis are thought to be responsible for the neuroprotective benefit.
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Affiliation(s)
| | | | - Ashi Mannan
- Chitkara College of Pharmacy, Chitkara University, Punjab, 140401, India
| | - Shareen Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, 140401, India
| | - Manjinder Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, 140401, India
| | - Saurabh Gupta
- Chitkara College of Pharmacy, Chitkara University, Punjab, 140401, India
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20
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D'Souza RS, Barman R, Joseph A, Abd-Elsayed A. Evidence-Based Treatment of Painful Diabetic Neuropathy: a Systematic Review. Curr Pain Headache Rep 2022; 26:583-594. [PMID: 35716275 DOI: 10.1007/s11916-022-01061-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Painful diabetic neuropathy (PDN) manifests with pain typically in the distal lower extremities and can be challenging to treat. The authors appraised the literature for evidence on conservative, pharmacological, and neuromodulation treatment options for PDN. RECENT FINDINGS Intensive glycemic control with insulin in patients with type 1 diabetes may be associated with lower odds of distal symmetric polyneuropathy compared to patients who receive conventional insulin therapy. First-line pharmacologic therapy for PDN includes gabapentinoids (pregabalin and gabapentin) and duloxetine. Additional pharmacologic modalities that are approved by the Food and Drug Administration (FDA) but are considered second-line agents include tapentadol and 8% capsaicin patch, although studies have revealed modest treatment effects from these modalities. There is level I evidence on the use of dorsal column spinal cord stimulation (SCS) for treatment of PDN, delivering either a 10-kHz waveform or tonic waveform. In summary, this review provides an overview of treatment options for PDN. Furthermore, it provides updates on the level of evidence for SCS therapy in cases of PDN refractory to conventional medical therapy.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross Barman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amira Joseph
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA.
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21
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Chen Y, Wu Q, Jin Z, Qin Y, Meng F, Zhao G. Systematic Review of Voltage-Gated Calcium Channel α2δ Subunit Ligands for the Treatment of Chronic Neuropathic Pain and Insight into Structure-Activity Relationship (SAR) by Pharmacophore Modeling. Curr Med Chem 2022; 29:5097-5112. [PMID: 35392779 DOI: 10.2174/0929867329666220407093727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/20/2022] [Accepted: 02/07/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Neuropathic pain (NP) is a complex symptom related to the nerve damage. The discovery of new drugs for treating chronic NP has been continuing for several decades, while more progress is still needed to be made because of the unsatisfactory efficacy and the side effects of the currently available drugs. Among all the approved drugs for chronic NP, voltage-gated calcium channel (VGCC) α2δ subunit ligands, also known as gabapentinoids, are among the first-line treatment and represent a class of efficacious and relatively safe therapeutic agents. However, new strategies are still needed to be explored due to the unsatisfied response rate. OBJECTIVES To review the latest status of the discovery and development of gabapentinoids for the treatment of chronic NP by covering both the marketed and the preclinical/clinical ones. To analyze the structure-activity relationship (SAR) of gabapentinoids to facilitate the future design of structurally novel therapeutic agents targeting VGCC α2δ subunit. METHODS We searched PubMed Central, Embase, Cochrane Library, Web of Science, Scopus and Espacenet for the literature and patents of diabetic peripheral neuropathic pain, postherpetic neuralgia, fibromyalgia, voltage-gated calcium channel α2δ subunit and related therapeutic agents from incipient to June 10, 2021. The SAR of gabapentinoids were analyzed by pharmacophore modeling using Phase module in Schrödinger suite. RESULTS A variety of gabapentinoids were identified as VGCC α2δ ligands that have ever been under development for the treatment of chronic NP. Among them, four gabapentinoids are marketed, one is at the active late clinical trials, and eight have been discontinued. Pharmacophore models were generated by using Phase module in Schrödinger suite, and common pharmacophores were predicted based on pharmacophoric features and analyzed. CONCLUSION The latest progress of the discovery and development of gabapentinoids for the treatment of chronic NP was reviewed. Moreover, the structure-activity relationship (SAR) of gabapentinoids is analyzed by pharmacophore modeling, which will be valuable for the future design of structurally novel therapeutic agents targeting VGCC α2δ subunit.
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Affiliation(s)
- Yuting Chen
- Zhongshan Institute for Drug Discovery, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhongshan 528400, China
| | - Qingqing Wu
- Zhongshan Institute for Drug Discovery, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhongshan 528400, China
| | - Zhengsheng Jin
- Zhongshan Institute for Drug Discovery, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhongshan 528400, China
| | - Yanlan Qin
- Zhongshan Institute for Drug Discovery, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhongshan 528400, China
| | - Fancui Meng
- Tianjin Institute of Pharmaceutical Research, Tianjin 300301, China
| | - Guilong Zhao
- Zhongshan Institute for Drug Discovery, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhongshan 528400, China
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22
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D'Souza RS, Langford B, Wilson RE, Her YF, Schappell J, Eller JS, Evans TC, Hagedorn JM. The State-of-the-art Pharmacotherapeutic Options for the Treatment of Chronic Non-Cancer Pain. Expert Opin Pharmacother 2022; 23:775-789. [PMID: 35354341 DOI: 10.1080/14656566.2022.2060741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Pharmacotherapeutic options continue to expand for the treatment of chronic non-cancer pain. There has been an increasing emphasis on multimodal analgesia. This strategy employs use of multiple analgesic medications each with a distinct mechanism of action, which when administered concomitantly may provide profound analgesia. AREAS COVERED The authors describe evidence from randomized controlled trials and systematic reviews on a variety of established medications including anti-inflammatory agents, opioids, anti-convulsants, anti-depressants, N-methyl-D-aspartate receptor antagonists, sodium channel blockers, cannabinoids, and alpha-2-receptor blockers. Furthermore, they provide developing evidence on more novel pharmacotherapeutics including alpha lipoic acid, acetyl-L-carnitine, low dose naltrexone, calcitonin gene-related peptide antagonists, targeted toxin therapy, Nav1.7 inhibitors, neurotensin agonists, purinoceptor antagonists, and sigma-1 receptor antagonists. Furthermore, the authors review the safety and adverse effect profile for these agents. EXPERT OPINION In this era of the opioid epidemic, clinicians should first offer non-opioid analgesics and employ a multimodal analgesic strategy. Current guidelines recommend a personalized approach to the chronic pain treatment, in each case accounting for type, location, severity, and chronicity of pain. Clinicians should also carefully consider the risk-to-benefit ratio to the patient based on the drug side effect profile, patient age, and comorbidities.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brendan Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Rachel E Wilson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Justin Schappell
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN, USA
| | - Jennifer S Eller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Timothy C Evans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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23
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Chen JL, Hesseltine AW, Nashi SE, Sills SM, McJunkin TL, Patil S, Bharara M, Caraway DL, Brooks ES. A Real-World Analysis of High-Frequency 10 kHz Spinal Cord Stimulation for the Treatment of Painful Diabetic Peripheral Neuropathy. J Diabetes Sci Technol 2022; 16:282-288. [PMID: 34842489 PMCID: PMC8861794 DOI: 10.1177/19322968211060316] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetes is one of the most prevalent chronic health conditions and diabetic neuropathy one of its most prevalent and debilitating complications. While there are treatments available for painful diabetic peripheral neuropathy (pDPN), their effectiveness is limited. METHOD This retrospective, multi-center, real-world review assessed pain relief and functional improvements for consecutive patients with diabetic neuropathy aged ≥18 years of age who were permanently implanted with a high-frequency (10 kHz) spinal cord stimulation (SCS) device. Available data were extracted from a commercial database. RESULTS In total 89 patients consented to being included in the analysis. Sixty-one percent (54/89) of participants were male and the average age was 64.4 years (SD = 9.1). Most patients (78.7%, 70/89) identified pain primarily in their feet or legs bilaterally. At the last assessment, 79.5% (58/73) of patients were treatment responders, defined as having at least 50% patient-reported pain relief from baseline. The average time of follow-up was 21.8 months (range: 4.3 to 46.3 months). A majority of patients reported improvements in sleep and overall function relative to their baseline. CONCLUSIONS This real-world study in typical clinical practices found 10 kHz SCS provided meaningful pain relief for a substantial proportion of patients refractory to current pDPN management, similar to published literature. This patient population has tremendous unmet needs and this study helps demonstrate the potential for 10 kHz SCS to provide an alternative pain management approach.
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Affiliation(s)
- Jeffrey L. Chen
- Center for Pain, University of
California San Diego, San Diego, CA, USA
- Jeffrey Chen, MD, MHS, Associate Professor
of Anesthesiology, Center for Pain, University of California San Diego, 9300
Campus Point Dr., MC 7651, La Jolla, CA 92037, USA.
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24
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Qureshi Z, Ali MN, Khalid M. An Insight into Potential Pharmacotherapeutic Agents for Painful Diabetic Neuropathy. J Diabetes Res 2022; 2022:9989272. [PMID: 35127954 PMCID: PMC8813291 DOI: 10.1155/2022/9989272] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/11/2021] [Accepted: 12/27/2021] [Indexed: 12/20/2022] Open
Abstract
Diabetes is the 4th most common disease affecting the world's population. It is accompanied by many complications that deteriorate the quality of life. Painful diabetic neuropathy (PDN) is one of the debilitating consequences of diabetes that effects one-third of diabetic patients. Unfortunately, there is no internationally recommended drug that directly hinders the pathological mechanisms that result in painful diabetic neuropathy. Clinical studies have shown that anticonvulsant and antidepressant therapies have proven fruitful in management of pain associated with PDN. Currently, the FDA approved medications for painful diabetic neuropathies include duloxetine, pregabalin, tapentadol extended release, and capsaicin (for foot PDN only). The FDA has also approved the use of spinal cord stimulation system for the treatment of diabetic neuropathy pain. The drugs recommended by other regulatory bodies include gabapentin, amitriptyline, dextromethorphan, tramadol, venlafaxine, sodium valproate, and 5 % lidocaine patch. These drugs are only partially effective and have adverse effects associated with their use. Treating painful symptoms in diabetic patient can be frustrating not only for the patients but also for health care workers, so additional clinical trials for novel and conventional treatments are required to devise more effective treatment for PDN with minimal side effects. This review gives an insight on the pathways involved in the pathogenesis of PDN and the potential pharmacotherapeutic agents. This will be followed by an overview on the FDA-approved drugs for PDN and commercially available topical analgesic and their effects on painful diabetic neuropathies.
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Affiliation(s)
- Zunaira Qureshi
- Department of Biomedical Engineering and Sciences, School of Mechanical and Manufacturing Engineering, National University of Sciences and Technology, H-12, 44000 Islamabad, Pakistan
| | - Murtaza Najabat Ali
- Department of Biomedical Engineering and Sciences, School of Mechanical and Manufacturing Engineering, National University of Sciences and Technology, H-12, 44000 Islamabad, Pakistan
| | - Minahil Khalid
- Department of Biomedical Engineering and Sciences, School of Mechanical and Manufacturing Engineering, National University of Sciences and Technology, H-12, 44000 Islamabad, Pakistan
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25
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Fan Q, Gordon Smith A. Recent updates in the treatment of diabetic polyneuropathy. Fac Rev 2022. [PMID: 36311537 DOI: 10.1270/r/11-30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Distal symmetric diabetic peripheral polyneuropathy (DPN) is the most common form of neuropathy in the world, affecting 30 to 50% of diabetic individuals and resulting in significant morbidity and socioeconomic costs. This review summarizes updates in the diagnosis and management of DPN. Recently updated clinical criteria facilitate bedside diagnosis, and a number of new technologies are being explored for diagnostic confirmation in specific settings and for use as surrogate measures in clinical trials. Evolving literature indicates that distinct but overlapping mechanisms underlie neuropathy in type 1 versus type 2 diabetes, and there is a growing focus on the role of metabolic factors in the development and progression of DPN. Exercise-based lifestyle interventions have shown therapeutic promise. A variety of potential disease-modifying and symptomatic therapies are in development. Innovations in clinical trial design include the incorporation of detailed pain phenotyping and biomarkers for central sensitization.
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Affiliation(s)
- Qihua Fan
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - A Gordon Smith
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
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26
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Sloan G, Alam U, Selvarajah D, Tesfaye S. The Treatment of Painful Diabetic Neuropathy. Curr Diabetes Rev 2022; 18:e070721194556. [PMID: 34238163 DOI: 10.2174/1573399817666210707112413] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/18/2021] [Accepted: 03/08/2021] [Indexed: 11/22/2022]
Abstract
Painful diabetic peripheral neuropathy (painful-DPN) is a highly prevalent and disabling condition, affecting up to one-third of patients with diabetes. This condition can have a profound impact resulting in a poor quality of life, disruption of employment, impaired sleep, and poor mental health with an excess of depression and anxiety. The management of painful-DPN poses a great challenge. Unfortunately, currently there are no Food and Drug Administration (USA) approved disease-modifying treatments for diabetic peripheral neuropathy (DPN) as trials of putative pathogenetic treatments have failed at phase 3 clinical trial stage. Therefore, the focus of managing painful- DPN other than improving glycaemic control and cardiovascular risk factor modification is treating symptoms. The recommended treatments based on expert international consensus for painful- DPN have remained essentially unchanged for the last decade. Both the serotonin re-uptake inhibitor (SNRI) duloxetine and α2δ ligand pregabalin have the most robust evidence for treating painful-DPN. The weak opioids (e.g. tapentadol and tramadol, both of which have an SNRI effect), tricyclic antidepressants such as amitriptyline and α2δ ligand gabapentin are also widely recommended and prescribed agents. Opioids (except tramadol and tapentadol), should be prescribed with caution in view of the lack of definitive data surrounding efficacy, concerns surrounding addiction and adverse events. Recently, emerging therapies have gained local licenses, including the α2δ ligand mirogabalin (Japan) and the high dose 8% capsaicin patch (FDA and Europe). The management of refractory painful-DPN is difficult; specialist pain services may offer off-label therapies (e.g. botulinum toxin, intravenous lidocaine and spinal cord stimulation), although there is limited clinical trial evidence supporting their use. Additionally, despite combination therapy being commonly used clinically, there is little evidence supporting this practise. There is a need for further clinical trials to assess novel therapeutic agents, optimal combination therapy and existing agents to determine which are the most effective for the treatment of painful-DPN. This article reviews the evidence for the treatment of painful-DPN, including emerging treatment strategies such as novel compounds and stratification of patients according to individual characteristics (e.g. pain phenotype, neuroimaging and genotype) to improve treatment responses.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine and the Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Liverpool University Hospital, NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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27
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Albrecht PJ, Houk G, Ruggiero E, Dockum M, Czerwinski M, Betts J, Wymer JP, Argoff CE, Rice FL. Keratinocyte Biomarkers Distinguish Painful Diabetic Peripheral Neuropathy Patients and Correlate With Topical Lidocaine Responsiveness. FRONTIERS IN PAIN RESEARCH 2021; 2:790524. [PMID: 35295428 PMCID: PMC8915676 DOI: 10.3389/fpain.2021.790524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/03/2021] [Indexed: 01/11/2023] Open
Abstract
This study investigated quantifiable measures of cutaneous innervation and algesic keratinocyte biomarkers to determine correlations with clinical measures of patient pain perception, with the intent to better discriminate between diabetic patients with painful diabetic peripheral neuropathy (PDPN) compared to patients with low-pain diabetic peripheral neuropathy (lpDPN) or healthy control subjects. A secondary objective was to determine if topical treatment with a 5% lidocaine patch resulted in correlative changes among the quantifiable biomarkers and clinical measures of pain perception, indicative of potential PDPN pain relief. This open-label proof-of-principle clinical research study consisted of a pre-treatment skin biopsy, a 4-week topical 5% lidocaine patch treatment regimen for all patients and controls, and a post-treatment skin biopsy. Clinical measures of pain and functional interference were used to monitor patient symptoms and response for correlation with quantitative skin biopsy biomarkers of innervation (PGP9.5 and CGRP), and epidermal keratinocyte biomarkers (Nav1.6, Nav1.7, CGRP). Importantly, comparable significant losses of epidermal neural innervation (intraepidermal nerve fibers; IENF) and dermal innervation were observed among PDPN and lpDPN patients compared with control subjects, indicating that innervation loss alone may not be the driver of pain in diabetic neuropathy. In pre-treatment biopsies, keratinocyte Nav1.6, Nav1.7, and CGRP immunolabeling were all significantly increased among PDPN patients compared with control subjects. Importantly, no keratinocyte biomarkers were significantly increased among the lpDPN group compared with control. In post-treatment biopsies, the keratinocyte Nav1.6, Nav1.7, and CGRP immunolabeling intensities were no longer different between control, lpDPN, or PDPN cohorts, indicating that lidocaine treatment modified the PDPN-related keratinocyte increases. Analysis of the PDPN responder population demonstrated that increased pretreatment keratinocyte biomarker immunolabeling for Nav1.6, Nav1.7, and CGRP correlated with positive outcomes to topical lidocaine treatment. Epidermal keratinocytes modulate the signaling of IENF, and several analgesic and algesic signaling systems have been identified. These results further implicate epidermal signaling mechanisms as modulators of neuropathic pain conditions, highlight a novel potential mode of action for topical treatments, and demonstrate the utility of comprehensive skin biopsy evaluation to identify novel biomarkers in clinical pain studies.
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Affiliation(s)
- Phillip J. Albrecht
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
- Division of Health Sciences, University at Albany, Albany, NY, United States
- *Correspondence: Phillip J. Albrecht
| | - George Houk
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | - Elizabeth Ruggiero
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | - Marilyn Dockum
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | | | - Joseph Betts
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
| | - James P. Wymer
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Charles E. Argoff
- Department of Neurology, Albany Medical Center, Albany, NY, United States
| | - Frank L. Rice
- Neuroscience and Pain Research Group, Integrated Tissue Dynamics, LLC, Rensselaer, NY, United States
- Division of Health Sciences, University at Albany, Albany, NY, United States
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28
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Abstract
Diabetic neuropathy is a neurodegenerative disorder that may alter both the somatic and autonomic peripheral nervous systems in the context of diabetes mellitus (DM). It is a prevalent and burdensome chronic complication of DM, that requires timely management. Optimized glycemic control (mainly for type 1 DM), multifactorial intervention (mainly for type 2 DM), with lifestyle intervention/physical exercise, and weight loss represent the basis of management for diabetic distal symmetrical polyneuropathy, and should be implemented early in the disease course. Despite better understanding of the pathogenetic mechanisms of diabetic peripheral neuropathy, there is still a stringent need for more pathogenetic-based agents that would significantly modify the natural history of the disease. The paper reviews the available drugs and current recommendations for the management of distal symmetrical polyneuropathy, including pain management, and for diabetic autonomic neuropathy. Evaluation of drug combinations that would perhaps be more efficient in slowing the progression of the disease or even reversing it, and that would provide a better pain management is still needed.
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Affiliation(s)
- Simona Cernea
- Department M3/Internal Medicine I, "George Emil Palade" University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania; Diabetes, Nutrition and Metabolic Diseases Outpatient Unit, Emergency County Clinical Hospital, Târgu Mureş, Romania.
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
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29
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Alam U. To Be, or Not To Be … a Biomarker? A Question to the FDA. Clin Ther 2021; 43:1438-1440. [PMID: 34535276 DOI: 10.1016/j.clinthera.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Uazman Alam
- Department of Diabetes and Endocrinology Research, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
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30
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Worthington A, Kalteniece A, Ferdousi M, D'Onofrio L, Dhage S, Azmi S, Adamson C, Hamdy S, Malik RA, Calcutt NA, Marshall AG. Spinal Inhibitory Dysfunction in Patients With Painful or Painless Diabetic Neuropathy. Diabetes Care 2021; 44:1835-1841. [PMID: 34385346 DOI: 10.2337/dc20-2797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/13/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Impaired rate-dependent depression of the Hoffman reflex (HRDD) is a marker of spinal inhibitory dysfunction and has previously been associated with painful neuropathy in a proof-of-concept study in patients with type 1 diabetes. We have now undertaken an assessment of HRDD in patients with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 148 participants, including 34 healthy control subjects, 42 patients with painful diabetic neuropathy, and 62 patients with diabetic neuropathy without pain, underwent an assessment of HRDD and a detailed assessment of peripheral neuropathy, including nerve conduction studies, corneal confocal microscopy, and thermal threshold testing. RESULTS Compared with healthy control subjects (P < 0.001) and patients without pain (P < 0.001), we found that HRDD is impaired in patients with type 1 or type 2 diabetes with neuropathic pain. These impairments are unrelated to diabetes type and the presence or severity of neuropathy. In contrast, patients without neuropathic pain (P < 0.05) exhibited enhanced HRDD compared with control subjects. CONCLUSIONS We suggest that loss or impairment of HRDD may help to identify a subpopulation of patients with painful diabetic neuropathy mediated by impaired spinal inhibitory systems who may respond optimally to therapies that target spinal or supraspinal mechanisms. Enhanced RDD in patients without pain may reflect engagement of spinal pain-suppressing mechanisms.
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Affiliation(s)
- Anne Worthington
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Alise Kalteniece
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Maryam Ferdousi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Luca D'Onofrio
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Shaishav Dhage
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Shazli Azmi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K.,Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, U.K
| | - Clare Adamson
- Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, U.K
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Division of Diabetes and Endocrinology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K.,Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Education City
| | - Nigel A Calcutt
- Department of Pathology, University of California, San Diego, La Jolla, CA
| | - Andrew G Marshall
- Division of Neuroscience and Experimental Psychology, Faculty of Medical and Human Sciences, University of Manchester, Manchester, U.K. .,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
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31
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Tapentadol Versus Tramadol: A Narrative and Comparative Review of Their Pharmacological, Efficacy and Safety Profiles in Adult Patients. Drugs 2021; 81:1257-1272. [PMID: 34196947 PMCID: PMC8318929 DOI: 10.1007/s40265-021-01515-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 02/07/2023]
Abstract
We conducted a narrative review of the literature to compare the pharmacological, efficacy and safety profiles of tapentadol and tramadol, and to assess the clinical interest of tapentadol in adult patients. Tapentadol and tramadol share a mixed mechanism of action, including both mu-agonist and monoaminergic properties. Tapentadol is approximately two to three times more potent than tramadol and two to three times less potent than morphine. It has no identified analgesically active metabolite and is not significantly metabolised by cytochrome P450 enzymes, thus overcoming some limitations of tramadol, including the potential for pharmacokinetic drug-drug interactions and interindividual variability due to genetic polymorphisms of cytochrome P450 enzymes. The toxicity profiles of tramadol and tapentadol are similar; however tapentadol is likely to result in less exposure to serotoninergic adverse effects (nausea, vomiting, hypoglycaemia) but cause more opioid adverse effects (constipation, respiratory depression, abuse) than tramadol. The safety of tapentadol in real-world conditions remains poorly documented, particularly in at-risk patient subgroups and also in the ability to assess the risk associated with its residual serotonergic activity (serotonin syndrome, seizures). Because of an earlier market introduction, more real-world safety data are available for tramadol, including data from at-risk patient subgroups. The level of evidence on the efficacy of both tramadol and tapentadol for the treatment of chronic pain is globally low. The trials published to date show overall that tapentadol does not provide a clinically significant analgesic improvement compared to existing treatments, for which the safety profile is much better known. In conclusion, tapentadol is not a first-line opioid but represents an additional analgesic in the therapeutic choices, which some patients may benefit from after careful examination of their clinical situation, co-morbidities and co-medications.
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32
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Sloan G, Selvarajah D, Tesfaye S. Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy. Nat Rev Endocrinol 2021; 17:400-420. [PMID: 34050323 DOI: 10.1038/s41574-021-00496-z] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
Diabetic sensorimotor peripheral neuropathy (DSPN) is a serious complication of diabetes mellitus and is associated with increased mortality, lower-limb amputations and distressing painful neuropathic symptoms (painful DSPN). Our understanding of the pathophysiology of the disease has largely been derived from animal models, which have identified key potential mechanisms. However, effective therapies in preclinical models have not translated into clinical trials and we have no universally accepted disease-modifying treatments. Moreover, the condition is generally diagnosed late when irreversible nerve damage has already taken place. Innovative point-of-care devices have great potential to enable the early diagnosis of DSPN when the condition might be more amenable to treatment. The management of painful DSPN remains less than optimal; however, studies suggest that a mechanism-based approach might offer an enhanced benefit in certain pain phenotypes. The management of patients with DSPN involves the control of individualized cardiometabolic targets, a multidisciplinary approach aimed at the prevention and management of foot complications, and the timely diagnosis and management of neuropathic pain. Here, we discuss the latest advances in the mechanisms of DSPN and painful DSPN, originating both from the periphery and the central nervous system, as well as the emerging diagnostics and treatments.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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33
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Lu J, Yang L, Xu Y, Ai L, Chen J, Xiong F, Hu L, Chen H, Liu J, Yan X, Huang H, Chen L, Yu C. The Modulatory Effect of Motor Cortex Astrocytes on Diabetic Neuropathic Pain. J Neurosci 2021; 41:5287-5302. [PMID: 33753547 PMCID: PMC8211549 DOI: 10.1523/jneurosci.2566-20.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/11/2021] [Accepted: 03/11/2021] [Indexed: 02/01/2023] Open
Abstract
Diabetic neuropathic pain (DNP) is a common complication of diabetes characterized by persistent pain. Emerging evidence links astrocytes to mechanical nociceptive processing, and the motor cortex (MCx) is a cerebral cortex region that is known to play a key role in pain regulation. However, the association between MCx astrocytes and DNP pathogenesis remains largely unexplored. Here, we studied this association using designer receptors exclusively activated by designer drugs to specifically manipulate MCx astrocytes. We proved that the selective inhibition of MCx astrocytes reduced DNP in streptozocin (STZ)-induced DNP models and discovered a potential mechanism by which astrocytes release cytokines, including TNF-α and IL-1β, to increase neuronal activation in the MCx, thereby regulating pain. Together, these results demonstrate a pivotal role for MCx astrocytes in DNP pathogenesis and provide new insight into DNP treatment strategies.
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Affiliation(s)
- Jingshan Lu
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Lan Yang
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Ying Xu
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Lijing Ai
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Jian Chen
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Fangfang Xiong
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Lihuan Hu
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Huoshu Chen
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Jiyuan Liu
- School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Xiongbin Yan
- School of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Huihui Huang
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Li Chen
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
- Fujian Key Laboratory of Drug Target Discovery and Structural and Functional Research, Fujian Medical University, Fuzhou, Fujian 350122, China
| | - Changxi Yu
- Department of Pharmacology, School of Pharmacy, Fujian Medical University, Fuzhou, Fujian 350122, China
- Fujian Key Laboratory of Drug Target Discovery and Structural and Functional Research, Fujian Medical University, Fuzhou, Fujian 350122, China
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34
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Zhang Y, Jin D, Duan Y, Hao R, Chen K, Yu T, Lian F, Tong X. Efficacy of Mudan Granule (Combined With Methylcobalamin) on Type 2 Diabetic Peripheral Neuropathy: Study Protocol for a Double-Blind, Randomized, Placebo-Controlled, Parallel-Arm, Multi-Center Trial. Front Pharmacol 2021; 12:676503. [PMID: 34093204 PMCID: PMC8173202 DOI: 10.3389/fphar.2021.676503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Diabetic peripheral neuropathy (DPN) characterized by nerve damage is a common and disabling chronic microvascular complication in patients with type 2 diabetic mellitus (T2DM), affecting at least half of patients diagnosed with T2DM. Unfortunately, the current treatment for DPN is not ideal. Traditional Chinese medicine (TCM), with a unique theoretical system, has made outstanding contributions in the treatment of T2DM and related complications. Mudan granule, a Chinese patent medicine, has been previously validated that could ameliorate the symptoms, promote nerve tissue repair, increase nerve conduction velocity (NCV) in patients with DPN. However, the previous studies are of variable quality, which limits the clinical application of Mudan granule. Therefore, we designed a double-blind, randomized, placebo-controlled, parallel-arm, multi-center trial to estimate the safety and efficacy of Mudan granule in conjunction with methylcobalamin in individuals suffering from type 2 diabetic peripheral neuropathy. Methods: This work is conducted as a 14-center, double-blind, randomized, placebo-controlled, parallel-arm trial. In all, 402 subjects (aged 30-70 years) will be recruited and randomized in a 1:1 ratio to an intervention group (n = 201; Mudan granule + methylcobalamin) and a control group (n = 201; placebo + methylcobalamin). Treatment is administered in 24 weeks cycles without any treatment interruption between cycles. Michigan Diabetic Neuropathy Score (MDNS) as the primary outcome will be evaluated at baseline, 12 weeks during the intervention period, and after 24 weeks of the intervention. Adverse events and safety assessments will be also documented. The analysis of all data will be carried out based on a predefined statistical analysis plan. Discussion: The outcomes from this study will offer important evidence regarding the safety and efficacy that Mudan granule can be used as an alternative and complementary therapeutic intervention in patients with type 2 diabetic peripheral neuropathy. Clinical trial registration: Registered at https://clinicaltrials.gov/. Trial registration number: NCT04711980. Registered January 2021.
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Affiliation(s)
- Yuehong Zhang
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - De Jin
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yingying Duan
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Rui Hao
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Keyu Chen
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Tongyue Yu
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Fengmei Lian
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaolin Tong
- Department of Endocrinology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Marshall A, Alam U, Themistocleous A, Calcutt N, Marshall A. Novel and Emerging Electrophysiological Biomarkers of Diabetic Neuropathy and Painful Diabetic Neuropathy. Clin Ther 2021; 43:1441-1456. [PMID: 33906790 DOI: 10.1016/j.clinthera.2021.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes. Small and large peripheral nerve fibers can be involved in DPN. Large nerve fiber damage causes paresthesia, sensory loss, and muscle weakness, and small nerve fiber damage is associated with pain, anesthesia, foot ulcer, and autonomic symptoms. Treatments for DPN and painful DPN (pDPN) pose considerable challenges due to the lack of effective therapies. To meet these challenges, there is a major need to develop biomarkers that can reliably diagnose and monitor progression of nerve damage and, for pDPN, facilitate personalized treatment based on underlying pain mechanisms. METHODS This study involved a comprehensive literature review, incorporating article searches in electronic databases (Google Scholar, PubMed, and OVID) and reference lists of relevant articles with the authors' substantial expertise in DPN. This review considered seminal and novel research and summarizes emerging biomarkers of DPN and pDPN that are based on neurophysiological methods. FINDINGS From the evidence gathered from 145 papers, this submission describes emerging clinical neurophysiological methods with potential to act as biomarkers for the diagnosis and monitoring of DPN as well as putative future roles as predictors of response to antineuropathic pain medication in pDPN. Nerve conduction studies only detect large fiber damage and do not capture pathology or dysfunction of small fibers. Because small nerve fiber damage is prominent in DPN, additional biomarkers of small nerve fiber function are needed. Activation of peripheral nociceptor fibers using laser, heat, or targeted electrical stimuli can generate pain-related evoked potentials, which are an objective neurophysiological measure of damage along the small fiber pathways. Assessment of nerve excitability, which provides a surrogate of axonal properties, may detect alterations in function before abnormalities are detected by nerve conduction studies. Microneurography and rate-dependent depression of the Hoffmann-reflex can be used to dissect underlying pain-generating mechanisms arising from the periphery and spinal cord, respectively. Their role in informing mechanistic-based treatment of pDPN as well as facilitating clinical trials design is discussed. IMPLICATIONS The neurophysiological methods discussed, although currently not practical for use in busy outpatient settings, detect small fiber and early large fiber damage in DPN as well as disclosing dominant pain mechanisms in pDPN. They are suited as diagnostic and predictive biomarkers as well as end points in mechanistic clinical trials of DPN and pDPN.
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Affiliation(s)
- Anne Marshall
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Uazman Alam
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Andreas Themistocleous
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nigel Calcutt
- Department of Pathology, University of California, San Diego, La Jolla, California
| | - Andrew Marshall
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Department of Clinical Neurophysiology, The Walton Centre, Liverpool, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
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Bargel S, Becam J, Chanu L, Lanot T, Martin M, Vaucel J, Willeman T, Fabresse N. Les gabapentinoïdes : une revue de la littérature. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2021. [DOI: 10.1016/j.toxac.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Neuropathy is a common complication of long-term diabetes that impairs quality of life by producing pain, sensory loss and limb amputation. The presence of neuropathy in both insulin-deficient (type 1) and insulin resistant (type 2) diabetes along with the slowing of progression of neuropathy by improved glycemic control in type 1 diabetes has caused the majority of preclinical and clinical investigations to focus on hyperglycemia as the initiating pathogenic lesion. Studies in animal models of diabetes have identified multiple plausible mechanisms of glucotoxicity to the nervous system including post-translational modification of proteins by glucose and increased glucose metabolism by aldose reductase, glycolysis and other catabolic pathways. However, it is becoming increasingly apparent that factors not necessarily downstream of hyperglycemia can also contribute to the incidence, progression and severity of neuropathy and neuropathic pain. For example, peripheral nerve contains insulin receptors that transduce the neurotrophic and neurosupportive properties of insulin, independent of systemic glucose regulation, while the detection of neuropathy and neuropathic pain in patients with metabolic syndrome and failure of improved glycemic control to protect against neuropathy in cohorts of type 2 diabetic patients has placed a focus on the pathogenic role of dyslipidemia. This review provides an overview of current understanding of potential initiating lesions for diabetic neuropathy and the multiple downstream mechanisms identified in cell and animal models of diabetes that may contribute to the pathogenesis of diabetic neuropathy and neuropathic pain.
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Twiddy H, Frank B, Alam U. A Consideration of the Psychological Aspects to Managing Patients with Painful Diabetic Neuropathy: An Insight into Pain Management Services at a Tertiary Centre in the UK. Diabetes Ther 2021; 12:487-498. [PMID: 33367982 PMCID: PMC7846618 DOI: 10.1007/s13300-020-00983-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/11/2020] [Indexed: 01/07/2023] Open
Abstract
Painful diabetic neuropathy (pDN) is characterised by both sensory and affective disturbances, suggesting a complex bidirectional relationship of neuropathic pain and mood disorders. Data on pDN indicate that neuropathic pain reduces quality of life, including mood and physical and social functioning. Depression and pain coping strategies such as catastrophising and social support predict pain severity. There is a significant and reciprocal relationship between depressed mood and increased pain. The key features of assessing people with neuropathic pain in relation to psychological aspects of their health are discussed in the context of management in a tertiary pain management centre (The Walton Centre, Liverpool, UK) including cognitive behavioural interventions amongst others to improve the quality of life in patients with pDN. We consider psychological issues as a factor influencing treatment and outcome in patients with pDN.
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Affiliation(s)
- Hannah Twiddy
- Department of Pain Medicine, The Walton Centre, Liverpool, UK.
| | - Bernhard Frank
- Department of Pain Medicine, The Walton Centre, Liverpool, UK
| | - Uazman Alam
- Diabetes and Endocrinology Research, Institute of Cardiovascular and Metabolic Medicine and The Pain Research Institute, University of Liverpool and Liverpool University NHS Hospital Trust, Liverpool, UK
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
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Junad K, Ruchika S, Moin A, Mythili K. Duloxetine for the management of sensory and taste alterations, following iatrogenic damage of the lingual and chorda tympani nerve. Scand J Pain 2021; 21:194-199. [PMID: 32950967 DOI: 10.1515/sjpain-2020-0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/05/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nerve injury may lead to pain and sensory changes such as dysesthesia and paresthesia. Quantitative sensory testing (QST) is a psychophysical testing method used to quantify nerve damage and monitor its recovery. Duloxetine is used in the management of neuropathic pain conditions, but its effect on taste recovery has not been previously reported. CASE REPRESENTATION A 65-year-old female, presented to the orofacial pain clinic, with a chief complaint of a burning sensation on the tongue, taste changes and a feeling of tightness beneath the tongue for five months. She reported that the complaints began subsequent to a complicated dental extraction during which she experienced trauma to the tongue. Patient was advised to take duloxetine 60 mg in divided doses three times daily. The assessment and monitoring of the recovery pattern were performed using QST. Electrical taste detection (mediated by chorda tympani) and electrical detection/tingling thresholds were performed at periodic intervals for up to a year following the nerve injury in the chorda tympani and lingual nerve territory. The patient reported complete recovery in taste sensation with duloxetine and this correlated with the QST results. QST documented at the end of one year revealed the electrical taste detection threshold and electrical detection threshold return to near normal values. CONCLUSIONS QST may be a useful diagnostic tool to assess and monitor lingual and chorda tympani nerve injuries. Duloxetine may aid in the recovery of the taste changes following lingual and chorda tympani nerve injury.
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Affiliation(s)
- Khan Junad
- Eastman Institute for Oral Health, Program Director, Orofacial Pain and TMJ Disorders, 625 Elmwood Ave, Rochester, NY, 14620, USA.,Neocare Headache and Facial Pain Relief Center, Mumbai, Maharashtra, India
| | - Sood Ruchika
- Neocare Headache and Facial Pain Relief Center, Mumbai, Maharashtra, India
| | - Anwer Moin
- Rutgers School of Dental Medicine, Department of Diagnostic Sciences, Newark, NJ, USA
| | - Kalladka Mythili
- Eastman Institute for Oral Health Orofacial Pain and Temporomandibular Joint Disorders, Rochester, NY, USA
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40
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Green tea extract for mild-to-moderate diabetic peripheral neuropathy A randomized controlled trial. Complement Ther Clin Pract 2021; 43:101317. [PMID: 33517103 DOI: 10.1016/j.ctcp.2021.101317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM This randomized study aimed to evaluate the effect of green tea extract (GTE) intake on clinical and neurophysiological parameters in patients with mild-to-moderate diabetic peripheral neuropathy (DPN). PATIENTS AND METHODS The present study included 194 patients with DPN. Patients were randomized into two treatment arms: GTE (n = 96) and placebo (n = 98) arms who received allocated treatment for 16 weeks. Symptoms of DPN were assessed using Toronto Clinical Scoring System (TCSS). Sensorineural pain was assessed using visual analog scale (VAS). Neural dysfunction was evaluated using the vibration perception thresholds (VPT). Assessments were made at baseline and after 4, 8, and 16 weeks of starting treatment. RESULTS At baseline and after 4 weeks of treatment, VAS, TCSS and VPT were comparable in the studied groups. However, after 8 weeks of treatment, patients in GTE group expressed lower VAS scores, significantly lower TCSS scores and significantly lower VPT. As treatment continued, the differences between groups regarding the outcome parameters became more evident at 16 weeks. CONCLUSIONS GTE intake may have a beneficial value in treatment of DPN.
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Jin HY, Moon SS, Calcutt NA. Lost in Translation? Measuring Diabetic Neuropathy in Humans and Animals. Diabetes Metab J 2021; 45:27-42. [PMID: 33307618 PMCID: PMC7850880 DOI: 10.4093/dmj.2020.0216] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/06/2020] [Indexed: 12/21/2022] Open
Abstract
The worldwide diabetes epidemic is estimated to currently afflict almost 500 million persons. Long-term diabetes damages multiple organ systems with the blood vessels, eyes, kidneys and nervous systems being particularly vulnerable. These complications of diabetes reduce lifespan, impede quality of life and impose a huge social and economic burden on both the individual and society. Peripheral neuropathy is a debilitating complication that will impact over half of all persons with diabetes. There is no treatment for diabetic neuropathy and a disturbingly long history of therapeutic approaches showing promise in preclinical studies but failing to translate to the clinic. These failures have prompted re-examination of both the animal models and clinical trial design. This review focuses on the functional and structural parameters used as indices of peripheral neuropathy in preclinical and clinical studies and the extent to which they share a common pathogenesis and presentation. Nerve conduction studies in large myelinated fibers have long been the mainstay of preclinical efficacy screening programs and clinical trials, supplemented by quantitative sensory tests. However, a more refined approach is emerging that incorporates measures of small fiber density in the skin and cornea alongside these traditional assays at both preclinical and clinical phases.
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Affiliation(s)
- Heung Yong Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju,
USA
| | - Seong-Su Moon
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju,
USA
- Division of Endocrinology, Department of Internal Medicine, Nazareth General Hospital, Daegu,
Korea,
USA
| | - Nigel A. Calcutt
- Department of Pathology, University of California San Diego, La Jolla, CA,
USA
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Didangelos T, Karlafti E, Kotzakioulafi E, Kontoninas Z, Margaritidis C, Giannoulaki P, Kantartzis K. Efficacy and Safety of the Combination of Superoxide Dismutase, Alpha Lipoic Acid, Vitamin B12, and Carnitine for 12 Months in Patients with Diabetic Neuropathy. Nutrients 2020; 12:nu12113254. [PMID: 33114210 PMCID: PMC7690794 DOI: 10.3390/nu12113254] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Aim: To investigate the efficacy of Superoxide Dismutase, Alpha Lipoic Acid, Acetyl L-Carnitine, and Vitamin B12 (B12) in one tablet in Diabetic Neuropathy (DN). Patients–methods: In this prospective, double-blind, placebo-controlled study, 85 patients with Diabetes Mellitus Type 2 (DMT2) were randomly assigned, either to receive the combination of four elements (active group, n = 43), or placebo (n = 42) for 12 months. We used the Michigan Neuropathy Screening Instrument Questionnaire and Examination (MNSIQ and MNSIE), measured the vibration perception threshold (BIO), and Cardiovascular Autonomic Reflex Tests (CARTs). Nerve function was assessed by DPN Check [sural nerve conduction velocity (SNCV) and amplitude (SNAP)]. Pain (PS) and quality of life (QL) questionnaires were administered. Results: At follow-up, BIO, MNSIQ, QL, PAIN, and SNCV, SNAP, and B12 levels had significantly improved inactive group (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.027, p = 0.031, and p < 0.001 respectively), whereas the inplacebo group MCR (mean circular resultant) and PAIN deteriorated (p < 0.001, p < 0.001). The changes in MNSIQ, QL, SNCV, BIO, and PAIN differed significantly between groups (p < 0.001, p < 0.001, p = 0.031, p < 0.001, and p < 0.001 respectively). Conclusions: The combination of the four elements in one tablet for 12 months in patients with DMT2 improved all indices of peripheral neuropathy, including SNAP and SNCV, pain, and Quality of Life perception, except CARTs and MNSIE.
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Affiliation(s)
- Triantafyllos Didangelos
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (E.K.); (Z.K.); (C.M.)
- Correspondence: or ; Tel.: +30-6944863803
| | - Eleni Karlafti
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (E.K.); (Z.K.); (C.M.)
| | - Evangelia Kotzakioulafi
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (E.K.); (Z.K.); (C.M.)
| | - Zisis Kontoninas
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (E.K.); (Z.K.); (C.M.)
| | - Charalampos Margaritidis
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (E.K.); (Z.K.); (C.M.)
| | - Parthena Giannoulaki
- Department of Nutrition and Dietetics, University General Hospital of Thessaloniki AHEPA, 54636 Thessaloniki, Greece;
| | - Konstantinos Kantartzis
- Department of Internal Medicine IV, Division of Endocrinology, Diabetology and Nephrology, University of Tübingen, 72076 Tübingen, Germany;
- Institute for Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Centre Munich at the University of Tübingen, 72076 Tübingen, Germany
- German Center for Diabetes Research (DZD), 72076 Tübingen, Germany
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Azmi S, Alam U, Burgess J, Malik RA. State-of-the-art pharmacotherapy for diabetic neuropathy. Expert Opin Pharmacother 2020; 22:55-68. [PMID: 32866410 DOI: 10.1080/14656566.2020.1812578] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The global epidemic of diabetes has led to an epidemic of diabetes complications. Diabetic neuropathy is the most common microvascular complication, of which diabetic peripheral neuropathy (DPN) and autonomic neuropathy (AN) are the most prevalent, affecting ~50% of patients. DPN results in pain with a poor quality of life and a loss of sensation with an increased risk of foot ulceration. Autonomic neuropathy can cause significant morbidity in a minority and is associated with increased mortality. The cornerstone of treatment to prevent or limit the progression of DPN/AN is multifactorial risk factor modification including treatment of glycemia, lipids and blood pressure. Whilst, there are no FDA-approved disease-modifying therapies, there are a number of therapies to relieve symptoms in DPN and AN. AREAS COVERED The authors discuss current approved therapies for painful diabetic neuropathy and autonomic neuropathy. They also address the potential role of improving risk factors to limit the development and progression of diabetic neuropathy and new pathogenetic and pain-relieving treatments. EXPERT OPINION The FDA-approved Pregabalin and Duloxetine over 25 years ago and Tapentadol, 6 years ago for painful diabetic neuropathy. There are currently no FDA-approved disease-modifying treatments for diabetic neuropathy which has been attributed to inappropriate models of the disease with limited translational capacity and major limitations of trial designs and endpoints in clinical trials.
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Affiliation(s)
- Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester NHS Foundation Trust , Manchester, UK
| | - Uazman Alam
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester , Manchester, UK.,Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK.,Department of Diabetes and Endocrinology, Liverpool University Hospital NHS Foundation Trust , Liverpool, UK
| | - Jamie Burgess
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar , Doha, Qatar
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Metsker O, Magoev K, Yakovlev A, Yanishevskiy S, Kopanitsa G, Kovalchuk S, Krzhizhanovskaya VV. Identification of risk factors for patients with diabetes: diabetic polyneuropathy case study. BMC Med Inform Decis Mak 2020; 20:201. [PMID: 32831065 PMCID: PMC7444272 DOI: 10.1186/s12911-020-01215-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Methods of data mining and analytics can be efficiently applied in medicine to develop models that use patient-specific data to predict the development of diabetic polyneuropathy. However, there is room for improvement in the accuracy of predictive models. Existing studies of diabetes polyneuropathy considered a limited number of predictors in one study to enable a comparison of efficiency of different machine learning methods with different predictors to find the most efficient one. The purpose of this study is the implementation of machine learning methods for identifying the risk of diabetes polyneuropathy based on structured electronic medical records collected in databases of medical information systems. METHODS For the purposes of our study, we developed a structured procedure for predictive modelling, which includes data extraction and preprocessing, model adjustment and performance assessment, selection of the best models and interpretation of results. The dataset contained a total number of 238,590 laboratory records. Each record 27 laboratory tests, age, gender and presence of retinopathy or nephropathy). The records included information about 5846 patients with diabetes. Diagnosis served as a source of information about the target class values for classification. RESULTS It was discovered that inclusion of two expressions, namely "nephropathy" and "retinopathy" allows to increase the performance, achieving up to 79.82% precision, 81.52% recall, 80.64% F1 score, 82.61% accuracy, and 89.88% AUC using the neural network classifier. Additionally, different models showed different results in terms of interpretation significance: random forest confirmed that the most important risk factor for polyneuropathy is the increased neutrophil level, meaning the presence of inflammation in the body. Linear models showed linear dependencies of the presence of polyneuropathy on blood glucose levels, which is confirmed by the clinical interpretation of the importance of blood glucose control. CONCLUSION Depending on whether one needs to identify pathophysiological mechanisms for one's prospective study or identify early or late predictors, the choice of model will vary. In comparison with the previous studies, our research makes a comprehensive comparison of different decisions using a large and well-structured dataset applied to different decision support tasks.
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Affiliation(s)
- Oleg Metsker
- Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Kirill Magoev
- ITMO University, Birzhevaya 4, Saint Petersburg, Russia
- University of Amsterdam, Amsterdam, The Netherlands
| | - Alexey Yakovlev
- Almazov National Medical Research Centre, Saint-Petersburg, Russia
- ITMO University, Birzhevaya 4, Saint Petersburg, Russia
| | | | | | | | - Valeria V Krzhizhanovskaya
- ITMO University, Birzhevaya 4, Saint Petersburg, Russia
- University of Amsterdam, Amsterdam, The Netherlands
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45
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Alam U, Sloan G, Tesfaye S. Authors' Reply to Eerdekens et al. "Treating Pain in Diabetic Neuropathy: Current and Developmental Drugs". Drugs 2020; 80:1141-1143. [PMID: 32623592 DOI: 10.1007/s40265-020-01351-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Uazman Alam
- Institute of Cardiovascular and Metabolic Medicine and The Pain Research Institute, University of Liverpool, Liverpool, UK. .,Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK. .,Department of Diabetes and Endocrinology, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
| | - Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
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46
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Eerdekens M, Stupar M, Marcondes L. Comment on: "Treating Pain in Diabetic Neuropathy: Current and Developmental Drugs". Drugs 2020; 80:1139-1140. [PMID: 32623593 PMCID: PMC7347511 DOI: 10.1007/s40265-020-01353-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M Eerdekens
- CCO Global Medical Affairs, Grünenthal GmbH, Zieglerstrasse 6, 52078, Aachen, Germany.
| | - M Stupar
- Global Drug Safety, Grünenthal GmbH, Zieglerstrasse 6, 52078, Aachen, Germany
| | - L Marcondes
- GRT US Holding, 360 Mt. Kemble Ave. 3rd FL, Ste 3, Morristown, NJ, 07960, USA
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47
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Abstract
Video: Treatment of Diabetic Neuropathy podcast recording (MP4 61908 kb).
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Affiliation(s)
- Uazman Alam
- Department of Eye and Vision Sciences and the Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK.
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