Evaluation of Patient-Rated Stiffness Associated With Fibromyalgia: A Post-Hoc Analysis of 4 Pooled, Randomized Clinical Trials of Duloxetine

Environmentally benign first derivative synchronous spectrofluorimetry for the analysis of two binary mixtures containing duloxetine with avanafil or tadalafil in spiked plasma samples

Antidepressants can cause sexual dysfunction side effects, necessitating the co-administration of phosphodiesterase type 5 inhibitors. The simultaneous determination of these drugs in biological fluids is critical for therapeutic drug monitoring. For the first time, two binary mixtures containing duloxetine with either avanafil or tadalafil were estimated utilizing simple green spectrofluorimetric methods without the need for a previous separation step. The study was based on first derivative synchronous spectrofluorimetry in ethanol using a change in wavelength difference (∆λ) of 20 and 25 nm for the first and second combinations, respectively. Duloxetine and avanafil were estimated at 297.7 and 331 nm in their binary mixture, while duloxetine and tadalafil were determined at 290.3 and 297.7 nm, respectively. The linearity was achieved over the ranges of 0.1-1.5 μg mL-1 for both duloxetine and avanafil and 0.01-0.40 μg mL-1 for tadalafil, with limits of detection of 0.013, 0.022, and 0.004 μg mL-1 for duloxetine, avanafil, and tadalafil, respectively. Successful application of the developed approaches was accomplished for the estimation of the two mixtures in dosage forms as well as human plasma with excellent percentage recoveries (96-103.75% in plasma), which supports their suitability for use in quality control laboratories and pharmacokinetic studies. Moreover, the adopted approaches' greenness was evidenced by applying three tools.

Tolerability and efficacy of duloxetine for the prevention of persistent musculoskeletal pain after trauma and injury: a pilot three-group randomized controlled trial

ABSTRACT

This study investigated the tolerability and preliminary efficacy of duloxetine as an alternative nonopioid therapeutic option for the prevention of persistent musculoskeletal pain (MSP) among adults presenting to the emergency department with acute MSP after trauma or injury. In this randomized, double-blind, placebo-controlled study, eligible participants (n = 78) were randomized to 2 weeks of a daily dose of one of the following: placebo (n = 27), 30 mg duloxetine (n = 24), or 60 mg duloxetine (n = 27). Tolerability, the primary outcome, was measured by dropout rate and adverse effects. Secondary outcomes assessed drug efficacy as measured by (1) the proportion of participants with moderate to severe pain (numerical rating scale ≥ 4) at 6 weeks (pain persistence); and (2) average pain by group over the six-week study period. We also explored treatment effects by type of trauma (motor vehicle collision [MVC] vs non-MVC). In both intervention groups, duloxetine was well tolerated and there were no serious adverse events. There was a statistically significant difference in pain over time for the 60 mg vs placebo group ( P = 0.03) but not for the 30 mg vs placebo group ( P = 0.51). In both types of analyses, the size of the effect of duloxetine was larger in MVC vs non-MVC injury. Consistent with the role of stress systems in the development of chronic pain after traumatic stress, our data indicate duloxetine may be a treatment option for reducing the transition from acute to persistent MSP. Larger randomized controlled trials are needed to confirm these promising results.

Predictors of Pain Reduction Among Fibromyalgia Patients Using Medical Cannabis: A Long-Term Prospective Cohort Study

OBJECTIVE

Many patients with fibromyalgia (FM) report using cannabis as a strategy to improve pain. Given that pain often co-occurs with symptoms of anxiety and depression (i.e., negative affect) and sleep problems among patients with FM, improvements in these symptoms might indirectly contribute to reductions in pain intensity following cannabis use. The main objective of the study was to examine whether changes in pain intensity following initiation of medical cannabis among patients with FM could be attributed to concurrent changes (i.e., reductions) in negative affect and sleep problems.

METHODS

This was a 12-month prospective cohort study among patients with FM (n = 323) initiating medical cannabis under the care of physicians. Patients were assessed at baseline, and follow-up assessment visits occurred every 3 months after initiation of medical cannabis. Patients' levels of pain intensity, negative affect, and sleep problems were assessed across all visits.

RESULTS

Multilevel mediation analyses indicated that reductions in patients' levels of pain intensity were partly explained by concurrent reductions in sleep problems and negative affect (both P < 0.001). This remained significant even when accounting for patients' baseline characteristics or changes in medical cannabis directives over time (all P > 0.05).

CONCLUSION

Our findings provide preliminary insight into the potential mechanisms of action underlying pain reductions among patients with FM who are using medical cannabis. Given the high attrition rate (i.e., 75%) observed in the present study at 12 months, our findings cannot be generalized to all patients with FM who are using medical cannabis.

Tactile Detection in Fibromyalgia: A Systematic Review and a Meta-Analysis

Fibromyalgia is a chronic pain syndrome characterized by sensorimotor deficits and distortions of body representation, that could both be caused by alterations in sensory processing. Several studies suggest a hypersensitivity to various sensory stimulations in fibromyalgia but results on detection of both noxious and non-noxious tactile stimulation, which are particularly relevant for body representation and motor control, remain conflicting. Therefore, the aim of this study is to systematically review and quantify the detection thresholds to noxious and non-noxious tactile stimuli in individuals with fibromyalgia compared to pain-free controls. A systematic review and a meta-analysis were performed in the MEDLINE, EMBASE, CINAHL, Cochrane, PsycInfo and Web of Science databases using keywords related to fibromyalgia, tactile pain detection threshold, tactile detection threshold and quantitative sensory testing. Nineteen studies were included in the review, with 12 in the meta-analysis. Despite the heterogeneity of the results, the data from both the review and from the meta-analysis suggest a trend toward hyperalgesia and no difference of sensitivity to non-noxious tactile stimuli in participants with fibromyalgia compared to healthy controls. This contradicts the hypothesis of a general increase in responsiveness of the central nervous system to noxious and non-noxious stimulations in fibromyalgia. This study shows no alteration of the sensitivity to non-noxious tactile stimulation in fibromyalgia, suggesting that an altered unimodal processing is not sufficient to explain symptoms such as sensorimotor impairments and body representation distortions. Future research should investigate whether alterations in multisensory integration could contribute to these symptoms.

Placebo effect in pharmacological management of fibromyalgia: a meta-analysis

INTRODUCTION

The management of fibromyalgia involves a combination of pharmacological and non-pharmacological treatments.

SOURCE OF DATA

Recently published literature in PubMed, Google Scholar and Embase databases.

AREAS OF AGREEMENT

Several pharmacological and non-pharmacological strategies have been proposed for the management of fibromyalgia. However, the management of fibromyalgia remains controversial. The administration of placebo has proved to be more effective than no treatment in many clinical settings and evidence supports the 'therapeutic' effects of placebo on a wide range of symptoms.

AREAS OF CONTROVERSY

The placebo effect is believed to impact the clinical outcomes, but its actual magnitude is controversial.

GROWING POINTS

A meta-analysis comparing pharmacological management versus placebo administration for fibromyalgia was conducted.

AREAS TIMELY FOR DEVELOPING RESEARCH

Drug treatment resulted to be more effective than placebo administration for the management of fibromyalgia. Nevertheless, placebo showed a beneficial effect in patients with fibromyalgia. Treatment-related adverse events occurred more frequently in the drug treatment.

LEVEL OF EVIDENCE

I, Bayesian network meta-analysis of double-blind randomized clinical trials.

BMI but not age and sex negatively impact on the outcome of pharmacotherapy in fibromyalgia: a systematic review

INTRODUCTION

The impact of sex, age, body mass index (BMI) in fibromyalgia is still unclear. A systematic review was conducted to investigate whether sex, age and BMI influence the clinical outcomes and rate of adverse events.

METHODS

The present study was performed according to the PRISMA guidelines. The literature search was performed in February 2021. All the RCTs investigating pharmacological strategies for fibromyalgia were accessed.

RESULTS

Data from 51 RCTs (17,311 patients) were collected. Short Form 36 emotional, Social function and physical role subscales showed evidence of a negative association with BMI (P = 0.02, P = 0.002 and P = 0.0001, respectively). Depression and anxiety subscales of the Hospital Anxiety and Depression score demonstrated evidence of a positive association with age (P = 0.04 and P = 0.001, respectively) and sex (P = 0.00005 and P = 0.0001, respectively). Visual analog scale evidenced a positive association with BMI (P = 0.04). Clinical Global Impression Severity scale demonstrated evidence of a negative association with BMI (P = 0.02).

CONCLUSION

Irrespective from the pharmacological approach, a higher BMI is negatively associated with a favorable outcome in patients with fibromyalgia. The association with sex and age remains controversial.

LEVEL OF EVIDENCE

I, systematic review of RCTs.

The Importance of Daily Activity for Reducing Fibromyalgia Symptoms: A Retrospective "Real World" Data Comparison of two Multimodal Treatment Programs

Objectives

This study aims to evaluate the effectiveness of two multidisciplinary fibromyalgia programs with different intensities.

Materials and methods

In this retrospective real-world comparison of patient data, pre- and post-program datasets of Short Form 36 (SF36) and Fibromyalgia Impact Questionnaire (FIQ) were obtained from a total of 210 female patients in two fibromyalgia multidisciplinary day hospital programs including one intensive program with daily treatments summing up to 20 treatment days during four weeks (P20, n=70) versus a less intensive program with 12 treatment days during four weeks (P12, n=140).

Results

Multiple subscales of SF36 and FIQ were improved in the pre-post comparison in both groups. In the comparison between the two groups, a statistically significantly higher improvement was found in the P20 group compared to the P12 group for the FIQ subscales of stiffness (p=0.001) and the number of days during which the patient felt “good” (p=0.007).

Conclusion

An intensive program of daily treatments and activity seems to be more effective in reducing fibromyalgia-associated stiffness and improving the number of days during which patients feel good than a less intensive program.

The impact of depressive and bipolar symptoms on socioeconomic status, core symptoms, function and severity of fibromyalgia

AIM

To evaluate the prevalence of depressive and bipolar symptoms in a cohort of consecutive fibromyalgia (FM) patients seen in a tertiary care center and to determine the relationship between depressive and manic symptoms with FM symptoms, socioeconomic status, severity and function.

METHODS

Three hundred and five FM patients were enrolled; demographic, clinical and questionnaire data were collected. Depressive symptoms were measured by the Patient Health Questionnaire (PHQ-9), manic symptoms by the Mood Disorders Questionnaire (MDQ).

RESULTS

The FM cohort had the following characteristics: age 43.53 (11.7) years; 86.5% white; 82.7% female; PHQ-9 ≥ 10, 59.7%, mean 11.9 (7.3); no depression 11.4%, mild 29.1%, moderate 27.5%, moderate severe 17.7%, severe 14%; anxiety 41.6%; 21.3% had either an MDQ score ≥ 7 and/or reported a past diagnosis of bipolar disorder (BD). Increasing levels of depression severity, as well as a positive screen for BD were significantly associated with increasing prevalence and severity of FM symptoms, longer duration of morning stiffness, and increased severity of FM. Increasing levels of depression were significantly associated with increase in prevalence of reported past sexual abuse, and a decline in socioeconomic status, including higher disability and unemployment rates.

CONCLUSION

Patients with severe FM disease activity, high load of symptoms, prolonged morning stiffness, increased disability, lower socioeconomic status and those who take a lot of medications for FM should be evaluated for depressive and manic symptoms.

Prevalence comparisons of somatic and psychiatric symptoms between community nonpatients without pain, acute pain patients, and chronic pain patients

OBJECTIVES

Somatic/psychiatric symptoms are frequently found in chronic pain patients (CPPs). The objectives of this study were to determine 1) which somatic/psychiatric symptoms are more commonly found in acute pain patients (APPs) and CPPs vs community nonpatients without pain (CNPWPs) and 2) if somatic/psychiatric symptom prevalence differs between APPs and CPPs.

DESIGN

The above groups were compared statistically for endorsement of 15 symptoms: fatigue, numbness/tingling, dizziness, difficulty opening/closing mouth, muscle weakness, difficulty staying asleep, depression, muscle tightness, nervousness, irritability, memory, falling, nausea, concentration, and headaches.

RESULTS

After controlling for age, gender, and level of pain, APPs and CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for 11 and 13 symptoms, respectively, vs CNPWPs. After controlling for age, gender, and level of pain, CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for eight symptoms vs APPs. Symptoms were highly correlated in both APPs and CPPs.

CONCLUSIONS

CPPs are characterized to a significantly greater extent than comparison groups by somatic/psychiatric symptoms that are highly intercorrelated. This has implications for clinical practice and future research.

Drugs for chronic pain in children: a commentary on clinical practice and the absence of evidence

Pediatric chronic pain is widespread, under-recognized and undertreated. Best management usually involves a multimodal approach coordinated by a multidisciplinary team. The present commentary specifically discusses common pharmacological approaches to chronic pain in children, identifies gaps in knowledge and suggests several research directions that would benefit future clinical care.