1
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Vellucci R, Fornasari D. Appropriate use of tapentadol: focus on the optimal tapering strategy. Curr Med Res Opin 2023; 39:123-129. [PMID: 36427080 DOI: 10.1080/03007995.2022.2148459] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Due to its opioid and non-opioid mechanism of action, tapentadol is considered an atypical opioid with improved gastrointestinal tolerability versus traditional opioids. As for all opioid analgesics it is important to understand how to discontinue a treatment when it is not needed anymore. The aim of this article was to provide an overview of opioid therapy in non-cancer pain, with a specific focus on tapering of tapentadol in patients with chronic non-cancer pain, and suggestions on how to achieve tapering. METHODS Studies for this narrative review were identified via PubMed using a structured search strategy, focusing on management of chronic non-cancer pain with opioids, and the efficacy, tolerability, and pharmacology of tapentadol prolonged release. Publications were limited to English-language articles published within the last ∼10 years. RESULTS The review discusses the use and discontinuation of opioids in general, as well clinical data on discontinuation of tapentadol specifically. We provide a flow chart, which can be used by clinicians in the context of their own clinical experience to appropriately taper tapentadol in patients with chronic non-cancer pain. The flow chart can be easily tailored to individual patient characteristics, duration of tapentadol treatment, response to progressive dosage reduction, and likelihood of withdrawal symptom occurrence. CONCLUSIONS While tapentadol is associated with a low frequency of opioid withdrawal symptoms after abrupt discontinuation, use of a tapering strategy is prudent. Tapering strategies developed for opioids in general can potentially be safely individualized in tapentadol-treated patients, although research on tapering strategies for tapentadol is required.
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Affiliation(s)
- Renato Vellucci
- University of Florence, Pain and Palliative Care Clinic, University Hospital of Careggi, Florence, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
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2
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Barbosa AG, Tintino CD, Pessoa RT, de Lacerda Neto LJ, Martins AO, de Oliveira MR, Coutinho HD, Cruz-Martins N, Quintans Junior LJ, Wilairatana P, de Menezes IR. Anti-inflammatory and antinociceptive effect of Hyptis martiusii BENTH leaves essential oil. BIOTECHNOLOGY REPORTS 2022; 35:e00756. [PMID: 35942239 PMCID: PMC9356156 DOI: 10.1016/j.btre.2022.e00756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/24/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Andreza G.R. Barbosa
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
| | - Cícera D.M.O. Tintino
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
| | - Renata T. Pessoa
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
| | - Luiz J. de Lacerda Neto
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
| | - Anita O.B.P.B. Martins
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
| | - Maria R.C. de Oliveira
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
- Graduate Program in Biotechnology-Northeast Biotechnology Network (RENORBIO), State University of Ceará (UECE), Fortaleza, Ceará, Brazil
| | - Henrique D.M. Coutinho
- Laboratory of Microbiology and Molecular Biology; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
- Corresponding authors.
| | - Natália Cruz-Martins
- Faculty of Medicine, University of Porto, Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Porto, Portugal
- Institute of Research and Advanced Training in Health Sciences and Technologies (CESPU), Rua Central de Gandra, 1317, 4585-116, Gandra PRD, Portugal
- TOXRUN - Toxicology Research Unit, University Institute of Health Sciences, CESPU, CRL, 4585-116, Gandra, Portugal
| | - Lucindo J. Quintans Junior
- Laboratory of Neuroscience and Pharmacological Assays; Department of Physiology, Federal University of Sergipe, Avenue Marechal Rondon, S/N, CEP 49100-000, São Cristóvão, Sergipe, Brazil
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Corresponding authors.
| | - Irwin R.A. de Menezes
- Laboratory of Pharmacology and Molecular Chemistry; Department of Biological Chemistry, Regional University of Cariri, Rua Coronel Antônio Luis 1161, Pimenta, CEP 63105-000, Crato, Ceará, Brazil
- Corresponding authors.
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3
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Vincenzi M, Milella MS, D’Ottavio G, Caprioli D, Reverte I, Maftei D. Targeting Chemokines and Chemokine GPCRs to Enhance Strong Opioid Efficacy in Neuropathic Pain. Life (Basel) 2022; 12:life12030398. [PMID: 35330149 PMCID: PMC8955776 DOI: 10.3390/life12030398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 12/21/2022] Open
Abstract
Neuropathic pain (NP) originates from an injury or disease of the somatosensory nervous system. This heterogeneous origin and the possible association with other pathologies make the management of NP a real challenge. To date, there are no satisfactory treatments for this type of chronic pain. Even strong opioids, the gold-standard analgesics for nociceptive and cancer pain, display low efficacy and the paradoxical ability to exacerbate pain sensitivity in NP patients. Mounting evidence suggests that chemokine upregulation may be a common mechanism driving NP pathophysiology and chronic opioid use-related consequences (analgesic tolerance and hyperalgesia). Here, we first review preclinical studies on the role of chemokines and chemokine receptors in the development and maintenance of NP. Second, we examine the change in chemokine expression following chronic opioid use and the crosstalk between chemokine and opioid receptors. Then, we examine the effects of inhibiting specific chemokines or chemokine receptors as a strategy to increase opioid efficacy in NP. We conclude that strong opioids, along with drugs that block specific chemokine/chemokine receptor axis, might be the right compromise for a favorable risk/benefit ratio in NP management.
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Affiliation(s)
- Martina Vincenzi
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy;
- Correspondence: (M.V.); (I.R.)
| | - Michele Stanislaw Milella
- Toxicology and Poison Control Center Unit, Department of Emergency, Anesthesia and Critical Care, Policlinico Umberto I Hospital-Sapienza University of Rome, 00161 Rome, Italy;
| | - Ginevra D’Ottavio
- Santa Lucia Foundation (IRCCS Fondazione Santa Lucia), 00143 Rome, Italy; (G.D.); (D.C.)
- Laboratory Affiliated to Institute Pasteur Italia-Fondazione Cenci Bolognetti, Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy
| | - Daniele Caprioli
- Santa Lucia Foundation (IRCCS Fondazione Santa Lucia), 00143 Rome, Italy; (G.D.); (D.C.)
- Laboratory Affiliated to Institute Pasteur Italia-Fondazione Cenci Bolognetti, Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy
| | - Ingrid Reverte
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy;
- Santa Lucia Foundation (IRCCS Fondazione Santa Lucia), 00143 Rome, Italy; (G.D.); (D.C.)
- Correspondence: (M.V.); (I.R.)
| | - Daniela Maftei
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, 00185 Rome, Italy;
- Santa Lucia Foundation (IRCCS Fondazione Santa Lucia), 00143 Rome, Italy; (G.D.); (D.C.)
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4
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Manandhar P, Connor M, Santiago M. Tapentadol shows lower intrinsic efficacy at µ receptor than morphine and oxycodone. Pharmacol Res Perspect 2022; 10:e00921. [PMID: 35084120 PMCID: PMC8929351 DOI: 10.1002/prp2.921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022] Open
Abstract
Tapentadol is a centrally acting analgesic with a dual mechanism of action. It acts as an agonist at the µ receptor and inhibitor of noradrenaline reuptake. Clinical trials suggest similar analgesic efficacy of tapentadol, oxycodone, and morphine in acute and chronic pain. Given the limited information about the molecular actions of tapentadol at the µ receptor, we investigated the intrinsic efficacy of tapentadol and compared it with other opioids. β-chlornaltrexamine (β-CNA, 100 nM, 20 min) was used to deplete spare receptors in AtT20 cells stably transfected with human µ receptor wild-type (WT). Opioid-mediated changes in membrane potential were measured in real-time using a membrane potential-sensitive fluorescent dye. Using Black and Leff's operational model, intrinsic efficacy relative to DAMGO was calculated for each opioid. Tapentadol (0.05 ± 0.01) activated the GIRK channel with lesser intrinsic efficacy than morphine (0.17 ± 0.02) and oxycodone (0.16 ± 0.02). We further assessed the signaling of tapentadol in the common µ receptor variants (N40D and A6V) which are associated with altered receptor signaling. We found no difference in the response of tapentadol between these receptor variants.
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Affiliation(s)
- Preeti Manandhar
- Macquarie Medical SchoolMacquarie UniversitySydneyNew South WalesAustralia
| | - Mark Connor
- Macquarie Medical SchoolMacquarie UniversitySydneyNew South WalesAustralia
| | - Marina Santiago
- Macquarie Medical SchoolMacquarie UniversitySydneyNew South WalesAustralia
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5
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Sugiyama Y, Tanaka R, Sato T, Sato T, Saitoh A, Yamada D, Shino M. Incidence of Delirium With Different Oral Opioids in Previously Opioid-Naive Patients. Am J Hosp Palliat Care 2022; 39:1145-1151. [PMID: 35045754 PMCID: PMC9459406 DOI: 10.1177/10499091211065171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Opioids are known to induce delirium, but few studies have closely
investigated differences in incidence of delirium among different opioids.
Objectives: To determine whether there is a clinically significant difference in
the incidence of delirium between oral opioids in previously opioid-naive
patients. Methods: Subjects were 259 opioid-naive in-patients with cancer who
were started on morphine sulfate, oxycodone hydrochloride, or tapentadol
hydrochloride extended-release tablets at our hospital between August 1, 2014,
and September 30, 2018. The incidence of delirium during the first week of
treatment was compared between the drugs. Results: The incidence of delirium was
4.8% (n = 83) for morphine sulfate, 6.9% (n = 131) for oxycodone hydrochloride,
and 6.7% (n = 45) for tapentadol hydrochloride. The incidence did not
significantly differ between oxycodone hydrochloride (OR = .69, 95% CI =
.20–2.30, P [Fisher’s exact test] = .77) or tapentadol
hydrochloride (OR = .71, 95% CI = .15–3.32, P [Fisher’s exact
test] = .70) and morphine sulfate (reference group). Moreover, the incidence did
not significantly differ between tapentadol hydrochloride (OR = 1.03, 95% CI =
.27–3.00, P [Fisher’s exact test] = 1.00) and oxycodone
hydrochloride (reference group). Conclusion: The incidence of delirium in
previously opioid-naive patients did not differ significantly among morphine
sulfate, oxycodone hydrochloride, and tapentadol hydrochloride extended-release
tablets, suggesting similar risk of delirium in opioid-naive patients among
these oral opioids.
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Affiliation(s)
| | - Rei Tanaka
- Department of Pharmacy, 38471Shizuoka Cancer Center, Japan.,Faculty of Pharmaceutical Sciences, 26413Tokyo University of Science, Chiba, Japan
| | - Tetsu Sato
- Department of Pharmacy, 38471Shizuoka Cancer Center, Japan
| | - Tetsumi Sato
- Division of Palliative Medicine, 38471Shizuoka Cancer Center, Japan
| | - Akiyoshi Saitoh
- Faculty of Pharmaceutical Sciences, 26413Tokyo University of Science, Chiba, Japan
| | - Daisuke Yamada
- Faculty of Pharmaceutical Sciences, 26413Tokyo University of Science, Chiba, Japan
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6
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Abstract
Managing chronic pain remains a major unmet clinical challenge. Patients can be treated with a range of interventions, but pharmacotherapy is the most common. These include opioids, antidepressants, calcium channel modulators, sodium channel blockers, and nonsteroidal anti-inflammatory drugs. Many of these drugs target a particular mechanism; however, chronic pain in many diseases is multifactorial and induces plasticity throughout the sensory neuroaxis. Furthermore, comorbidities such as depression, anxiety, and sleep disturbances worsen quality of life. Given the complexity of mechanisms and symptoms in patients, it is unsurprising that many fail to achieve adequate pain relief from a single agent. The efforts to develop novel drug classes with better efficacy have not always proved successful; a multimodal or combination approach to analgesia is an important strategy in pain control. Many patients frequently take more than one medication, but high-quality evidence to support various combinations is often sparse. Ideally, combining drugs would produce synergistic action to maximize analgesia and reduce side effects, although sub-additive and additive analgesia is still advantageous if additive side-effects can be avoided. In this review, we discuss pain mechanisms, drug actions, and the rationale for mechanism-led treatment selection.Abbreviations: COX - cyclooxygenase, CGRP - calcitonin gene-related peptide, CPM - conditioned pain modulation, NGF - nerve growth factor, NNT - number needed to treat, NMDA - N-methyl-d-aspartate, NSAID - nonsteroidal anti-inflammatory drugs, TCA - tricyclic antidepressant, SNRI - serotonin-noradrenaline reuptake inhibitor, QST - quantitative sensory testing.
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Affiliation(s)
- Ryan Patel
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, UK
| | - Anthony H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, UK
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7
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Pujol J, Martínez-Vilavella G, Doreste A, Blanco-Hinojo L, Ojeda F, Llorente-Onaindia J, Polino L, Deus J, Monfort J. Tapentadol effects on brain response to pain in sensitized patients with knee osteoarthritis. Rheumatology (Oxford) 2021; 61:2335-2345. [PMID: 34636838 DOI: 10.1093/rheumatology/keab761] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Pain sensitization, in the form of knee tenderness and anatomically spread hyperalgesia, is notably common in patients with knee osteoarthritis and is often refractory to conventional interventions. Tapentadol, as an opioid receptor agonist and noradrenaline reuptake inhibitor, has been proposed as a potentially effective symptomatic treatment for pain-sensitized osteoarthritis patients. We empirically tested whether tapentadol could attenuate brain response to painful stimulation on the tender knee using functional MRI. METHODS Pressure painful stimulation was applied to the articular interline and the tibial surface, a commonly sensitized site surrounding the joint. Thirty patients completed the crossover trial designed to compare prolonged release tapentadol and placebo effects administered over 14 days. RESULTS We found no effects in the direction of the prediction. Instead, patients administered with tapentadol showed stronger activation in response to pressure on the tender site in the right prefrontal cortex and somatosensory cortices. The somatosensory effect was compatible with the spread of neural activation around the knee cortical representation. Consistent with the functional MRI findings, the patients showed higher clinical ratings of pain sensitization under tapentadol and a significant positive association was identified between the number of tapentadol tablets and the evoked subjective pain. CONCLUSION The tapentadol effect paradoxically involved both the spread of the somatosensory cortex response and a stronger activation in prefrontal areas with a recognized role in the appraisal of pain sensations. Further studies are warranted to explore how osteoarthritis patients may benefit from powerful analgesic drugs without the associated risks of prolonged use. EudraCT-[2016-005082-31].
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Affiliation(s)
- Jesus Pujol
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain
| | | | - Andrea Doreste
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, Spain
| | - Laura Blanco-Hinojo
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, Spain
| | - Fabiola Ojeda
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | | | - Luciano Polino
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
| | - Joan Deus
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, Spain.,Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, Spain
| | - Jordi Monfort
- Rheumatology Department, Hospital del Mar, Barcelona, Spain
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8
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Überall MA, Elling C, Eibl C, Müller-Schwefe GH, Lefeber C, Heine M, Heckes B. Tapentadol prolonged release in patients with chronic low back pain: real-world data from the German Pain eRegistry. Pain Manag 2021; 12:211-227. [PMID: 34376059 DOI: 10.2217/pmt-2021-0058] [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: 11/21/2022] Open
Abstract
Aim: Comparison of tapentadol prolonged release (PR) with other oral WHO-III PR opioid analgesics (morphine, oxycodone ± naloxone, hydromorphone) in routine medical care of chronic low back pain. Patients & methods: Noninterventional, retrospective 12-week study using anonymized clinical practice data from the German Pain eRegistry. Six effectiveness, tolerability, and safety criteria were aggregated in a primary composite end point (treatment responder). Propensity scoring matched 2331 datasets per treatment cohort. Results: All six single criteria showed significantly better outcomes for tapentadol PR (all parameters p < 0.001). There were significantly more treatment responders under tapentadol PR (65.7 vs 14.2%; p < 0.001). Conclusion: Tapentadol PR showed significantly better effectiveness and tolerability in severe chronic low back pain unsuccessfully treated with WHO-I/II analgesics compared with the other oral WHO-III PR opioids investigated.
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9
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Ferri CM, Natoli S, Sanz-Ayan P, Magni A, Guerrero C, Lara-Solares A, Liedgens H, Thömmes G, Karra R. Quality of life and functional outcomes with tapentadol prolonged release in chronic musculoskeletal pain: post hoc analysis. Pain Manag 2020; 11:173-187. [PMID: 33241725 DOI: 10.2217/pmt-2020-0084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Aims: To investigate quality of life (QOL) and functionality changes in chronic pain during tapentadol prolonged release (PR) treatment. Patients & methods: Post hoc analysis of data from three Phase III trials in patients with osteoarthritis knee pain or low back pain. QOL and functionality changes were assessed by SF-36 scores. Results: All SF-36 subdomain scores improved progressively to week 3 of tapentadol titration and were sustained during 12-week maintenance treatment. Improvements in SF-36 scores were similar between tapentadol dose groups (e.g., 200 to <300 mg vs ≥500 mg), with no greater effect from higher doses. QOL and functionality improvements were consistently greater with tapentadol PR than oxycodone controlled release. Conclusion: Tapentadol PR provides consistent, clinically relevant improvements in QOL and functionality in chronic pain.
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Affiliation(s)
| | - Silvia Natoli
- University of Rome Tor Vergata, Department of Clinical Science & Translational Medicine & Unit of Pain Therapy, Polyclinic of Tor Vergata, Rome, 00133, Italy
| | - Paz Sanz-Ayan
- Hospital Universitario 12 de Octubre; Department of Rehabilitation, Hospital Universitario 12 de Octubre, Madrid, 28041, Spain
| | - Alberto Magni
- Italian College of General Practitioners & Primary Care, Florence, 50141, Italy
| | - Carlos Guerrero
- Hospital Universitario Fundación Santa Fe, Bogotá 110121, Universidad de los Andes, Colombia
| | - Argelia Lara-Solares
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, 14080, Mexico
| | | | - Guido Thömmes
- R&D - Development - Data Sciences, Grünenthal GmbH, Aachen, 52099, Germany
| | - Ravi Karra
- Global Medical Affairs, Grünenthal GmbH, Aachen, 52099, Germany
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10
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Hartrick CT, Poulin D, Molenaar R, Hartrick A. Dual-Acting Peripherally Restricted Delta/Kappa Opioid (CAV1001) Produces Antinociception in Animal Models of Sub-Acute and Chronic Pain. J Pain Res 2020; 13:2461-2474. [PMID: 33116788 PMCID: PMC7547792 DOI: 10.2147/jpr.s262303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 08/20/2020] [Indexed: 12/15/2022] Open
Abstract
Background The development of highly efficacious alternatives to mu-opioid analgesics represents an urgent unmet medical and public health need. In the presence of inflammation both delta- and kappa-opioid agonists, acting on peripheral sensory neurons, mediate analgesia. The dual-acting, peripherally restricted kappa/delta-opioid agonist, CAV1001, was tested in four rodent pain models. Methods Experiment 1 – Formalin testing in mice. Three doses (1–10 mg/kg) of CAV1001 or ICI204448 at 30 minutes were tested after formalin injection. Spontaneous nocifensive responses were video recorded. Experiment 2 – Complete Freund’s Adjuvant (CFA)-induced arthritis. CFA was injected into the ankle joint of rats. Joint compression thresholds (JCT) were measured. CAV1001 was compared to celecoxib. Experiment 3 – Spinal nerve ligation (SNL) in rats. Paw compression thresholds (PCT) were measured. CAV1001 was compared to gabapentin. Experiment 4 – MMRT-1 bone cancer implantation into the rat tibia. Weight-bearing was assessed. CAV1001 was compared to morphine. Results In Phase 2 of the formalin model, CAV1001 (1 mg/kg) significantly reduced pain behaviors to a degree comparable to the peripherally restricted kappa-opioid agonist, ICI204448 (10 mg/kg). CAV1001 (10 mg/kg) effectively eliminated pain behaviors associated with phase 2. In the CFA-induced arthritis model, a significant increase in JCTs, similar to the comparator celecoxib, was observed with CAV1001 at 1 mg/kg at 2 hours; CAV1001 (10 mg/kg) was effective at 1 hour. In the SNL model, both the comparator gabapentin and CAV1001 (5 mg/kg) significantly reduced PCT at 2 hours, but at 4 hours, the CAV1001 thresholds improved to baseline. CAV1001 10 mg/kg significantly improved weight bearing at 4-hour post-dosing compared to baseline following MMRT-1 implantation. Conclusion CAV1001 demonstrated efficacy in several different preclinical pain models. Time- and dose-dependent differences in the efficacy of CAV1001 amongst these rodent pain models parallel the degree of underlying inflammation.
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11
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The Potential Role of Dual Mechanistic Opioids in Combating Opioid Misuse. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00414-5] [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]
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12
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Coluzzi F, Rolke R, Mercadante S. Pain Management in Patients with Multiple Myeloma: An Update. Cancers (Basel) 2019; 11:E2037. [PMID: 31861097 PMCID: PMC6966684 DOI: 10.3390/cancers11122037] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
Most patients with multiple myeloma (MM) suffer from chronic pain at every stage of the natural disease process. This review focuses on the most common causes of chronic pain in MM patients: (1) pain from myeloma bone disease (MBD); (2) chemotherapy-induced peripheral neuropathy as a possible consequence of proteasome inhibitor therapy (i.e., bortezomib-induced); (3) post-herpetic neuralgia as a possible complication of varicella zoster virus reactivation because of post-transplantation immunodepression; and (4) pain in cancer survivors, with increasing numbers due to the success of antiblastic treatments, which have significantly improved overall survival and quality of life. In this review, non-pain specialists will find an overview including a detailed description of physiopathological mechanisms underlying central sensitization and pain chronification in bone pain, the rationale for the correct use of analgesics and invasive techniques in different pain syndromes, and the most recent recommendations published on these topics. The ultimate target of this review was to underlie that different types of pain can be observed in MM patients, and highlight that only after an accurate pain assessment, clinical examination, and pain classification, can pain be safely and effectively addressed by selecting the right analgesic option for the right patient.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04100 Latina, Italy
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, 52062 Aachen, Germany;
| | - Sebastiano Mercadante
- Main regional center for Pain Relief & Supportive Care, La Maddalena Cancer Center, 90100 Palermo, Italy;
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13
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Anand P, Dickenson A, Finco G, Marinangeli F, Polati E, Romualdi P, Tzschentke TM, Canonico PL. Novel insights on the management of pain: highlights from the ‘Science of Relief’ meeting. Pain Manag 2019; 9:521-533. [DOI: 10.2217/pmt-2019-0031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The ‘Science of Relief’ event, held in Milan on 10–11 May 2019, was aimed at promoting dialog between different stakeholders among scientific associations, pharma industry, healthcare services and related institutions. The goal was to renew interest and attention on the management of pain, sharing new solutions in order to bring the patients and their quality of life to the center of attention. An international group of scientists and clinicians presented and discussed new and known evidence in the field of chronic pain, from physiopathology and diagnosis to the choice of appropriate and timely pharmacological treatments. This paper reports the highlights of those presentations.
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Affiliation(s)
- Praveen Anand
- Department of Neurology, Imperial College London, Hammersmith Hospital, London, UK
| | | | - Gabriele Finco
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari. UOC Anestesia e Rianimazione, Centro Terapia del Dolore Azienda Ospedaliero-Universitaria di Cagliari
| | - Franco Marinangeli
- Dipartimento di Medicina clinica, Università degli Studi, Sanità pubblica, Scienza della vita e dell’ambiente dell’Aquila
| | - Enrico Polati
- Anestesia, Rianimazione e Terapia del Dolore, Università di Verona, Verona, Italy
| | - Patrizia Romualdi
- Dipartimento di Farmacia e Biotecnologie, Università di Bologna, Bologna
| | | | - Pier Luigi Canonico
- Dipartimento di Scienze del Farmaco, Università del Piemonte Orientale “Amedeo Avogadro”, Novara, Italy
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Pino CA. PAIN MANAGEMENT IN CANCER. Cancer 2019. [DOI: 10.1002/9781119645214.ch26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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van de Donk T, van Velzen M, Dahan A, Niesters M. Cornea nerve fibre state determines analgesic response to tapentadol in fibromyalgia patients without effective endogenous pain modulation. Eur J Pain 2019; 23:1586-1595. [PMID: 31162787 PMCID: PMC6790686 DOI: 10.1002/ejp.1435] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tapentadol is a centrally acting analgesic with μ-agonistic activity combined with noradrenaline reuptake inhibition. Its mechanism of action relies on improvement of descending pain inhibition. In the current study, tapentadol's ability to enhance conditioned pain modulation (CPM, an experimental measure of descending pain inhibition) was evaluated in fibromyalgia patients with absent or reduced CPM responses. METHODS A total of 34 fibromyalgia patients completed this double-blind trial. Patients were randomized to receive treatment with tapentadol sustained-release or placebo for a 3-month period with 1-month follow-up. At baseline, the cornea nerve fibre state (CNFS) was quantified to determine the presence of nerve fibre pathology and assess its value in the prediction of the analgesic response. RESULTS Tapentadol significantly increased CPM responses during treatment with an average increase from baseline of 20.5 ± 12.5% (tapentadol) versus 3.0 ± 11.2% (placebo; p = 0.042). No treatment effect was observed for the absolute pain scores, however, analgesia responder rate analyses demonstrated a treatment effect in favour of tapentadol. Pain relief (a reduction in pain score ≥ 30%) was predicted by the presence of a normal CNFS (p = 0.035). Patients with an abnormal CNFS had no analgesic effect from tapentadol despite an increase in CPM. CONCLUSIONS In chronic pain patients with fibromyalgia, the increase in endogenous pain inhibition by tapentadol was translated into analgesia in patients with a normal CNFS. In those with abnormal CNFS, tapentadol treatment was without analgesic effect. SIGNIFICANCE In this double-blind randomized placebo-controlled trial, we showed that tapentadol significantly enhanced the descending pain inhibition in fibromyalgia patients. Tapentadol-induced pain relief was only present in patients with a normal CNFS.
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Affiliation(s)
- Tine van de Donk
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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Romualdi P, Grilli M, Canonico PL, Collino M, Dickenson AH. Pharmacological rationale for tapentadol therapy: a review of new evidence. J Pain Res 2019; 12:1513-1520. [PMID: 31190962 PMCID: PMC6526917 DOI: 10.2147/jpr.s190160] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Chronic pain could be considered as a neurological disorder. Therefore, appropriate selection of the therapy, which should consider the pathophysiological mechanisms of pain, can result in a successful analgesic outcome. Tapentadol is an analgesic drug which acts both as a μ-opioid receptor (MOR) agonist and as a noradrenaline reuptake inhibitor (NRI), thereby generating a synergistic action in terms of analgesic efficacy, but not for the burden of adverse effects. Therefore, tapentadol can be defined as the first “MOR-NRI” drug. This molecule holds the potential to address at least some of the current limitations of analgesic therapy due to its unique mechanism of action and has shown to be safe and effective in the treatment of chronic pain of cancer and noncancer etiologies including nociceptive, neuropathic and mixed pain. In particular, the MOR component of tapentadol activity predominantly allows for analgesia in nociceptive pain; on the other hand, the NRI component contributes, now in a predominant manner, for analgesic efficacy in cases of neuropathic pain states. This paper will discuss recent pieces of evidence on the pathophysiology of pain, the background on tapentadol and then present some new studies on how the unique mechanism of action of tapentadol provides a key role in its analgesic efficacy in a number of pain states and with a favorable safety profile.
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Affiliation(s)
- Patrizia Romualdi
- Department of Pharmacy and Biotechnologies Alma Mater Studiorum, University of Bologna, Bologna 40126, Italy
| | - Mariagrazia Grilli
- Laboratory of Neuroplasticity, Department Pharmaceutical Sciences, University of Piemonte Orientale, Novara 28100, Italy
| | - Pier Luigi Canonico
- Departiment of Pharmacological Sciences, University of Piemonte Orientale, Novara 28100, Italy
| | - Massimo Collino
- Department of Drug Science and Technology, University of Turin, Turin 10121, Italy
| | - Anthony H Dickenson
- Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK,
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Lockwood SM, Dickenson AH. A combination pharmacotherapy of tapentadol and pregabalin to tackle centrally driven osteoarthritis pain. Eur J Pain 2019; 23:1185-1195. [PMID: 30821870 PMCID: PMC6618140 DOI: 10.1002/ejp.1386] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 01/29/2019] [Accepted: 02/24/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Many Osteoarthritis (OA) patients report with clinical features to their pain that cannot be explained by purely peripheral mechanisms. Yet, the analgesic agents available that tackle centrally driven chronic pain often provide only partial pain relief, or have dose-limiting side effects. We explored a combination therapy of the centrally acting analgesic agents tapentadol and pregabalin, to investigate if they could be used in combination to provide superior analgesia. METHODS Using electrophysiological single-unit recordings taken from spinal wide dynamic range neurons, Diffuse Noxious Inhibitory Controls (DNIC) were assessed as a marker of potential changes in descending controls in a monoiodoacetate (MIA) model of OA. We investigated if a subcutaneous injection of tapentadol or pregabalin, both alone and in combination, inhibited neuronal responses and restored the expression of DNIC, quantified as a reduction in neuronal firing in the presence of a conditioning noxious stimulus. RESULTS Tapentadol restored DNIC-induced neuronal inhibition in MIA animals, while pregabalin inhibited pre-conditioned mechanically evoked neuronal responses but did not restore DNIC. Given in combination, tapentadol and pregabalin restored DNIC expression and also inhibited spinal neuronal responses. CONCLUSIONS We propose that there is both central sensitization and an imbalance in inhibitory and facilitatory descending controls in MIA animals. The combination therapy of tapentadol and pregabalin restored descending noradrenergic inhibitory tone and also inhibited nociceptive transmission at the level of the spinal cord. SIGNIFICANCE This study shows that pregabalin and tapentadol target different mechanisms of centrally driven chronic pain associated with osteoarthritis, and that when administered together can restore descending inhibitory tone whilst also tackling spinal neuronal hyperexcitability and may therefore provide superior analgesia.
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Affiliation(s)
| | - Anthony H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
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18
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Lockwood SM, Bannister K, Dickenson AH. An investigation into the noradrenergic and serotonergic contributions of diffuse noxious inhibitory controls in a monoiodoacetate model of osteoarthritis. J Neurophysiol 2018; 121:96-104. [PMID: 30461363 DOI: 10.1152/jn.00613.2018] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Osteoarthritis (OA) is a debilitating conditioning with pain as the major clinical symptom. Understanding the mechanisms that drive OA-associated chronic pain is crucial for developing the most effective analgesics. Although the degradation of the joint is the initial trigger for the development of chronic pain, the discordance between radiographic joint damage and the reported pain experience in patients, coupled with clinical features that cannot be explained by purely peripheral mechanisms, suggest there are often other factors at play. Therefore, this study considers the central contributions of chronic pain, using a monoiodoacetate (MIA) model of OA. Particularly, this study explores the functionality of descending controls over the course of the model by assessing diffuse noxious inhibitory controls (DNIC). Early-phase MIA animals have a functional DNIC system, whereas DNIC are abolished in late-phase MIA animals, indicating a dysregulation in descending modulation over the course of the model. In early-phase animals, blocking the actions of spinal α2-adrenergic receptors completely abolishes DNIC, whereas blocking the actions of spinal 5-HT7 receptors only partially decreases the magnitude of DNIC. However, activating the spinal α2-adrenergic or 5-HT7 receptors in late-phase MIA animals restored DNIC-induced neuronal inhibition. This study confirms that descending noradrenergic signaling is crucial for DNIC expression. Furthermore, we suggest a compensatory increase in descending serotonergic inhibition acting at 5-HT7 receptors as the model progresses such that receptor activation is sufficient to override the imbalance in descending controls and mediate neuronal inhibition. NEW & NOTEWORTHY This study showed that there are both noradrenergic and serotonergic components contributing to the expression of diffuse noxious inhibitory controls (DNIC). Furthermore, although a tonic descending noradrenergic tone is always crucial for the expression of DNIC, variations in descending serotonergic signaling over the course of the model mean this component plays a more vital role in states of sensitization.
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Affiliation(s)
- S M Lockwood
- Department of Neuroscience, Physiology and Pharmacology, University College London , London , United Kingdom
| | - K Bannister
- Wolfson CARD, Hodgkin Building, Kings College London , London , United Kingdom
| | - A H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London , London , United Kingdom
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Radic T, Stollenwerk A, Elling C. Comment on Gressler et al.: Serotonin Syndrome in Tapentadol Literature: Systematic Review of Original Research. J Pain Palliat Care Pharmacother 2018; 32:192-193. [PMID: 30380966 DOI: 10.1080/15360288.2018.1489444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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20
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Abstract
Tapentadol prolonged release (tapentadol PR) [Palexia® SR in EU] is a long-acting tablet formulation of the strong central analgesic tapentadol, which acts as both a μ-opioid receptor (MOR) agonist and a noradrenaline reuptake inhibitor. Tapentadol PR is approved for chronic pain in various countries, with its EU indication (severe chronic pain manageable only with opioid analgesics) being the focus here. Well-designed trials and clinical practice data support tapentadol PR use in this setting. Short term, tapentadol PR was an effective and generally well tolerated analgesic for moderate to severe pain of varying aetiologies, including neuropathic pain. It provided analgesia at least as good as that of conventional strong opioids and appeared more favourable in terms of gastrointestinal tolerability, likely due to less potent MOR binding. Severe back pain with a neuropathic component responded well to moderate-dose tapentadol PR in some patients, while for others, an increase to the maximum recommended tapentadol PR dosage provided analgesia at least as good as that of moderate-dose tapentadol PR plus pregabalin and appeared to have some CNS tolerability benefits. Data also support the use of tapentadol PR in opioid rotation, including when conventional opioids are intolerable. Longer-term data in musculoskeletal pain conditions indicate continued benefit over up to 2 years' treatment with tapentadol PR with no evidence of tolerance. Thus, tapentadol PR is a useful option for the management of severe chronic pain.
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Affiliation(s)
- Emma D Deeks
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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21
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Zapata‐Morales JR, Alonso‐Castro ÁJ, Pérez‐Gutiérrez S, Rojas‐Bedolla EI, Sánchez‐Enriquez S, Rivas‐Carrillo JD, Serafín‐Higuera NA, Isiordia‐Espinoza MA. Participation of ATP‐sensitive K+ channels and μ‐opioid receptors in the antinociceptive synergism of the paracetamol–tapentadol co‐administration in the formalin‐induced pain assay in mice. Drug Dev Res 2018; 79:400-405. [DOI: 10.1002/ddr.21476] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Juan R. Zapata‐Morales
- Departamento de Farmacia, División de Ciencias Naturales y ExactasUniversidad de Guanajuato Guanajuato Mexico
| | - Ángel J. Alonso‐Castro
- Departamento de Farmacia, División de Ciencias Naturales y ExactasUniversidad de Guanajuato Guanajuato Mexico
| | - Salud Pérez‐Gutiérrez
- Departamento de Sistemas BiológicosUniversidad Autónoma Metropolitana, Unidad Xochimilco Ciudad de México Mexico
| | - Edgar Isaac Rojas‐Bedolla
- Departamento de Farmacia, División de Ciencias Naturales y ExactasUniversidad de Guanajuato Guanajuato Mexico
| | - Sergio Sánchez‐Enriquez
- Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los AltosUniversidad de Guadalajara Tepatitlán Jalisco Mexico
| | - Jorge David Rivas‐Carrillo
- Departamento de FisiologíaCentro Universitario de Ciencias de la Salud, Universidad de Guadalajara Guadalajara Jalisco Mexico
| | | | - Mario A. Isiordia‐Espinoza
- Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los AltosUniversidad de Guadalajara Tepatitlán Jalisco Mexico
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22
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Raffa RB, Elling C, Tzschentke TM. Does 'Strong Analgesic' Equal 'Strong Opioid'? Tapentadol and the Concept of 'µ-Load'. Adv Ther 2018; 35:1471-1484. [PMID: 30206823 PMCID: PMC6182641 DOI: 10.1007/s12325-018-0778-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The distinct properties of the centrally-acting analgesic tapentadol derive from the combined contributions of an opioid component and a nonopioid component. However, the opioid component's relative contribution to analgesic and adverse effects has not previously been elucidated. Tapentadol's analgesic effect derives from the combined contribution of an opioid mechanism and a nonopioid mechanism, the extent of which can vary for different pains. Likewise, the interaction can vary for various adverse effects. Hence, the contribution of each mechanism to adverse effects can be different from the contribution to analgesia. We here estimate the percent contribution of each component of the mechanism of action to analgesia and to adverse effects. AREAS COVERED Several approaches to in vitro and in vivo data to estimate the contribution of tapentadol's opioid component to analgesia and to the two important opioid adverse effects, respiratory depression and constipation. The results are then compared with clinical data. EXPERT OPINION Traditional opioids, such as morphine, oxycodone, and others, produce their analgesic effects primarily through a single mechanism-the activation of µ-opioid receptors (MOR). Therefore, the contribution of the opioid component to adverse effects is 100%. In contrast, the newer strong analgesic tapentadol produces its analgesic effect via two separate and complementary analgesic mechanisms, only one of which is µ-opioid. We applied standard drug-receptor theory and novel techniques to in vitro and in vivo data to estimate by several different ways the μ-load of tapentadol (the % contribution of the opioid component to the adverse effect magnitude relative to a pure/classical µ-opioid at equianalgesia) in respiratory depression and constipation, and we compared the results to clinical evidence. The estimate is remarkably consistent over the various approaches and indicates that the μ-load of tapentadol is ≤ 40% (relative to pure MOR agonists, which have, by definition, a µ-load of 100%). FUNDING Grünenthal GmbH.
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Affiliation(s)
- Robert B Raffa
- College of Pharmacy, University of Arizona, Tucson, AZ, USA.
- Temple University, Philadelphia, PA, USA.
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23
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Abstract
BACKGROUND Tapentadol is a novel atypical opioid. Anecdotal evidence suggests that tapentadol has a lower toxicity than conventional opioids. OBJECTIVES To evaluate all single-drug mortality due to tapentadol and assess serious adverse events caused by tapentadol. METHODS The Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) reporting guidelines, an evidence-based minimum set of items for reporting in systematic reviews, were followed in this systematic review. RESULTS 24 peer-reviewed papers were identified. They indicate that tapentadol toxicity can cause mortality and serious adverse effects. CONCLUSION(S) At least four confirmed fatalities, and serious adverse effects have been documented for individuals abusing or using tapentadol as prescribed. Serious adverse effects of tapentadol use may include respiratory depression, confusion, coma, hallucination/delusion, seizures, tachycardia, hypertension, agitation, tremor, miosis, hypotension, dyspnea, electrolyte abnormality, atrial fibrillation or severe upper abdominal pain. Tapentadol is unlikely to cause serotonin syndrome. The toxicity of tapentadol is significantly less than pure mu opioids, such as oxycodone.
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Affiliation(s)
- Jessie S Channell
- Medical School, The University of Western Australia, Perth, Western Australia
| | - Stephan Schug
- Medical School, The University of Western Australia, Perth, Western Australia
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24
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Zajączkowska R, Przewłocka B, Kocot-Kępska M, Mika J, Leppert W, Wordliczek J. Tapentadol – A representative of a new class of MOR-NRI analgesics. Pharmacol Rep 2018; 70:812-820. [DOI: 10.1016/j.pharep.2018.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/20/2017] [Accepted: 01/23/2018] [Indexed: 12/20/2022]
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25
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Nadipelly J, Sayeli V, Kadhirvelu P, Shanmugasundaram J, Cheriyan BV, Subramanian V. Effect of certain trimethoxy flavones on paclitaxel - induced peripheral neuropathy in mice. Integr Med Res 2018; 7:159-167. [PMID: 29984177 PMCID: PMC6026363 DOI: 10.1016/j.imr.2018.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 02/19/2018] [Accepted: 03/28/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The anti - nociceptive effect of 7, 2', 3' - trimethoxy flavone, 7, 2', 4' - trimethoxy flavone, 7, 3', 4' - trimethoxy flavone and 7, 5, 4' - trimethoxy flavone against inflammatory, neurogenic and thermal pain in mice was reported earlier. The present study was designed to investigate the effect of the above trimethoxy flavones in amelioration of peripheral neuropathy induced by paclitaxel. METHODS Peripheral neuropathy was induced in mice by administration of a single i.p. dose (10 mg/kg) of paclitaxel. The manifestations of peripheral neuropathy such as tactile allodynia, cold allodynia and thermal hyperalgesia were assessed 24 h later by employing hair aesthesiometer test, acetone bubble test and hot water tail immersion test respectively. Further, the role of inflammatory cytokines like TNF - α, IL - 1β and free radicals in the action of trimethoxy flavones was investigated using in vitro assays. RESULTS The test compounds dose dependently attenuated paclitaxel - induced tactile allodynia, cold allodynia and thermal hyperalgesia in mice. The test compounds inhibited TNF - α, IL - 1β and free radicals in a concentration dependent manner. CONCLUSION The investigated trimethoxy flavones attenuated paclitaxel - induced peripheral neuropathy in mice. The inhibition of cytokines and free radicals in addition to many neuronal mechanisms reported earlier may contribute to this beneficial effect.
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Affiliation(s)
- Jagan Nadipelly
- Faculty of Medicine, Department of Pharmacology, Texila American University, Georgetown, Guyana
| | - Vijaykumar Sayeli
- Department of Pharmacology, Mamatha Medical College & Hospital, Khammam, India
| | - Parimala Kadhirvelu
- Department of Pharmacology, Meenakshi Medical College and Research Institute, Meenakshi Academy of Higher Education and Research, Kanchipuram, India
| | - Jaikumar Shanmugasundaram
- Department of Pharmacology, Meenakshi Medical College and Research Institute, Meenakshi Academy of Higher Education and Research, Kanchipuram, India
| | - Binoy Varghese Cheriyan
- Department of Pharmaceutical Chemistry, VISTAS, Vels School of Pharmaceutical Sciences, Chennai, India
| | - Viswanathan Subramanian
- Department of Pharmacology, Meenakshi Medical College and Research Institute, Meenakshi Academy of Higher Education and Research, Kanchipuram, India
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Selectivity profiling of NOP, MOP, DOP and KOP receptor antagonists in the rat spinal nerve ligation model of mononeuropathic pain. Eur J Pharmacol 2018. [DOI: 10.1016/j.ejphar.2018.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Opioid and noradrenergic contributions of tapentadol to the inhibition of locus coeruleus neurons in the streptozotocin rat model of polyneuropathic pain. Neuropharmacology 2018; 135:202-210. [PMID: 29551688 DOI: 10.1016/j.neuropharm.2018.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 12/23/2022]
Abstract
Tapentadol is an analgesic that acts as an agonist of µ opioid receptors (MOR) and that inhibits noradrenaline reuptake. Data from healthy rats show that tapentadol inhibits neuronal activity in the locus coeruleus (LC), a nucleus regulated by both the noradrenergic and opioid systems. Thus, we set out to investigate the effect of tapentadol on LC activity in streptozotocin (STZ)-induced diabetic rats, a model of diabetic polyneuropathy, by analyzing single-unit extracellular recordings of LC neurons. Four weeks after inducing diabetes, tapentadol dose-response curves were obtained from animals pre-treated with RX821002 or naloxone (alpha2-adrenoceptors and opioid receptors antagonists, respectively). In STZ rats, the spontaneous activity of LC neurons (0.9 ± 0.1 Hz) was lower than in naïve animals (1.5 ± 0.1 Hz), and tapentadol's inhibitory effect was also weaker. Alpha2-adrenoceptors blockade by RX821002 (100 μg/kg i.v.) in STZ animals significantly increased the spontaneous activity (from 0.8 ± 0.1 to 1.4 ± 0.2 Hz) and it dampened the inhibition of LC neurons produced by tapentadol. However, opioid receptors blockade following naloxone pre-treatment (5 mg/kg i.v.) did not alter the spontaneous firing rate (0.9 ± 0.2 vs 0.9 ± 0.2 Hz) or the inhibitory effect of tapentadol on LC neurons in STZ animals. Thus, diabetic polyneuropathy appears to exert neuroplastic changes in LC neurotransmission, enhancing the sensitivity of alpha2-adrenoceptors and dampening opioid receptors expression. Tapentadol's activity seems to be predominantly mediated through its noradrenergic effects rather than its influence on opioid receptors in the STZ model of diabetic polyneuropathy.
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Raffa RB, Pergolizzi JV, Taylor R, Ossipov MH. Nature's first "atypical opioids": Kratom and mitragynines. J Clin Pharm Ther 2018. [PMID: 29520812 DOI: 10.1111/jcpt.12676] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Advances in pain research have led to an understanding that many pains are driven by more than one underlying (patho)physiologic cause (ie, they are "multimechanistic") and that better pain relief is obtained with fewer adverse effects when an analgesic is correspondingly multimechanistic. At least two of the more-modern analgesics combine opioid and non-opioid mechanisms, and have become known as "atypical opioids." Less well known is that just as Nature evolved opioids, it also evolved atypical opioids, presaging modern drug discovery efforts. COMMENT Traditional (typical) opioids are extracts or analogs of substances derived from the poppy plant. They produce their analgesic and adverse effects primarily through a single, opioid mechanism (albeit with individual differences). Two most recent analgesics were developed to have both an opioid mechanism and, a second, non-opioid mechanism of action (inhibition of monoamine neurotransmitter reuptake). Little known is that Nature had already evolved a plant source of compounds with the same properties. WHAT IS NEW AND CONCLUSION As debate about the use and abuse potential of kratom swirls, conflicting, often contradicting, opinions are expressed. A review of the basic pharmacology of kratom reveals the explanation for the bifurcation in viewpoints: kratom has both opioid and non-opioid properties. Fascinatingly, just as the poppy plant (Papaver) evolved the typical opioids, Mitragyna evolved the mitragynines-Nature's "atypical opioids."
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Affiliation(s)
- R B Raffa
- University of Arizona College of Pharmacy, Tucson, AZ, USA.,Temple University School of Pharmacy, Philadelphia, PA, USA
| | | | - R Taylor
- NEMA Research, Inc., Naples, FL, USA
| | - M H Ossipov
- Research Professor Emeritus, University of Arizona College of Medicine, Tucson, AZ, USA
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Faria J, Barbosa J, Moreira R, Queirós O, Carvalho F, Dinis-Oliveira RJ. Comparative pharmacology and toxicology of tramadol and tapentadol. Eur J Pain 2018; 22:827-844. [PMID: 29369473 DOI: 10.1002/ejp.1196] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2018] [Indexed: 12/18/2022]
Abstract
Moderate-to-severe pain represents a heavy burden in patients' quality of life, and ultimately in the society and in healthcare costs. The aim of this review was to summarize data on tramadol and tapentadol adverse effects, toxicity, potential advantages and limitations according to the context of clinical use. We compared data on the pharmacological and toxicological profiles of tramadol and tapentadol, after an extensive literature search in the US National Library of Medicine (PubMed). Tramadol is a prodrug that acts through noradrenaline and serotonin reuptake inhibition, with a weak opioid component added by its metabolite O-desmethyltramadol. Tapentadol does not require metabolic activation and acts mainly through noradrenaline reuptake inhibition and has a strong opioid activity. Such features confer tapentadol potential advantages, namely lower serotonergic, dependence and abuse potential, more linear pharmacokinetics, greater gastrointestinal tolerability and applicability in the treatment of chronic and neuropathic pain. Although more studies are needed to provide clear guidance on the opioid of choice, tapentadol shows some advantages, as it does not require CYP450 system activation and has minimal serotonergic effects. In addition, it leads to less side effects and lower abuse liability. However, in vivo and in vitro studies have shown that tramadol and tapentadol cause similar toxicological damage. In this context, it is important to underline that the choice of opioid should be individually balanced and a tailored decision, based on previous experience and on the patient's profile, type of pain and context of treatment. SIGNIFICANCE This review underlines the need for a careful prescription of tramadol and tapentadol. Although both are widely prescribed synthetic opioid analgesics, their toxic effects and potential dependence are not completely understood yet. In particular, concerning tapentadol, further research is needed to better assess its toxic effects.
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Affiliation(s)
- J Faria
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - J Barbosa
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - R Moreira
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal
| | - O Queirós
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal
| | - F Carvalho
- Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal
| | - R J Dinis-Oliveira
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
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Zapata-Morales JR, Alonso-Castro ÁJ, Granados-Soto V, Sánchez-Enriquez S, Isiordia-Espinoza MA. Assessment of the antinociceptive and ulcerogenic activity of the tapentadol-diclofenac combination in rodents. Drug Dev Res 2018; 79:38-44. [PMID: 29314177 DOI: 10.1002/ddr.21420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/16/2017] [Indexed: 12/12/2022]
Abstract
Preclinical Research & Development The objective of the present study was to evaluate the tapentadol-diclofenac combination in three dose-ratios in the mouse acetic acid-induced visceral pain and their ulcerogenic activity on the stomachal mucous. Dose-response curves were generated for tapentadol, diclofenac, and their combination in the acetic acid-induced writhing test in mice. Moreover, the stomachs of animals were surgically removal and gastrointestinal ulcerogenic action of the combination was assessed. The isobolographic analysis, interaction index, and ANOVA were used to analyze the data. The isobolographic analysis and interaction index showed a similar antinociceptive activity for the three combinations of the analgesic mixture. Moreover, tapentadol and the proportions 1:1 or 3:1 of the analgesic combination caused a mild gastrointestinal damage. These data indicate that the systemic co-administration of tapentadol and diclofenac produced a synergistic interaction in the acetic acid-induced visceral pain test with an acceptable gastric damage profile in mice.
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Affiliation(s)
- Juan R Zapata-Morales
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato, México
| | - Ángel J Alonso-Castro
- Departamento de Farmacia, División de Ciencias Naturales y Exactas, Universidad de Guanajuato, Guanajuato, México
| | - Vinicio Granados-Soto
- Departamento de Farmacobiología, Centro de Investigación y Estudios Avanzados (Cinvestav), sede Sur, Ciudad de, México, México
| | - Sergio Sánchez-Enriquez
- Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos, Jalisco, México
| | - Mario A Isiordia-Espinoza
- Departamento de Clínicas, División de Ciencias Biomédicas, Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos, Jalisco, México
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Rickli A, Liakoni E, Hoener MC, Liechti ME. Opioid-induced inhibition of the human 5-HT and noradrenaline transporters in vitro: link to clinical reports of serotonin syndrome. Br J Pharmacol 2018; 175:532-543. [PMID: 29210063 PMCID: PMC5773950 DOI: 10.1111/bph.14105] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 11/03/2017] [Accepted: 11/08/2017] [Indexed: 01/27/2023] Open
Abstract
Background and Purpose Opioids may inhibit the 5‐HT transporter (SERT) and the noradrenaline transporter (NET). NET inhibition may contribute to analgesia, and SERT inhibition or interactions with 5‐HT receptors may cause serotonergic toxicity. However, the effects of different opioids on the human SERT, NET and 5‐HT receptors have not been sufficiently studied. Experimental Approach We determined the potencies of different opioids to inhibit the SERT and NET in vitro using human transporter‐transfected HEK293 cells. We also tested binding affinities at 5‐HT1A, 5‐HT2A and 5‐HT2C receptors. Additionally, we assessed clinical cases of the serotonin syndrome associated with each opioid reported by PubMed and a World Health Organization database. Key Results Dextromethorphan, l(R)‐methadone, racemic methadone, pethidine, tramadol and tapentadol inhibited the SERT at or close to observed drug plasma or estimated brain concentrations in patients. Tapentadol was the most potent NET inhibitor. Pethidine, tramadol, l(R)‐methadone, racemic methadone, dextromethorphan and O‐desmethyltramadol also inhibited the NET. 6‐Monoacetylmorphine, buprenorphine, codeine, dihydrocodeine, heroin, hydrocodone, hydromorphone, morphine, oxycodone and oxymorphone did not inhibit the SERT or NET. Fentanyl interacted with 5‐HT1A receptors and methadone, pethidine and fentanyl with 5‐HT2A receptors, in the low micromolar range. Opioids most frequently associated with the serotonin syndrome are tramadol, fentanyl, tapentadol, oxycodone, methadone and dextromethorphan. Conclusions and Implications Some synthetic opioids interact with the SERT and NET at potentially clinically relevant concentrations. SERT inhibition by tramadol, tapentadol, methadone, dextromethorphan and pethidine may contribute to the serotonin syndrome. Direct effects on 5‐HT1A and/or 5‐HT2A receptors could be involved with methadone and pethidine.
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Affiliation(s)
- Anna Rickli
- Clinical Pharmacology and Toxicology, Department of Biomedicine, Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marius C Hoener
- Neuroscience Research, pRED, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Matthias E Liechti
- Clinical Pharmacology and Toxicology, Department of Biomedicine, Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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Abstract
Introduction Tapentadol is a centrally acting analgesic that has been available for the management of acute and chronic pain in routine clinical practice since 2009. Methods This is the first integrated descriptive analysis of post-marketing safety data following the use of tapentadol in a broad range of pain conditions relating to the topics overall safety, dose administration above approved dosages, administration during pregnancy, serotonin syndrome, respiratory depression, and convulsion. The data analyzed pertain to spontaneous reports from healthcare and non-healthcare professionals and were put in the context of safety information known from interventional and non-interventional trials. Results The first years of routine clinical practice experience with tapentadol have confirmed the tolerability profile that emerged from the clinical trials. Moreover, the reporting of expected side effects such as respiratory depression and convulsion was low and no major risks were identified. The evaluation of available post-marketing data did not confirm the theoretical risk of serotonin syndrome nor did it reveal unexpected side effects with administration of higher than recommended doses. Conclusion More than 8 years after its first introduction, the favorable overall safety profile of tapentadol in the treatment of various pain conditions is maintained in the general population. Funding Grünenthal GmbH. Electronic supplementary material The online version of this article (10.1007/s12325-017-0654-0) contains supplementary material, which is available to authorized users.
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Abstract
Opioid analgesia continues to be the primary pharmacologic intervention for managing acute pain and malignant pain in both hospitalized and ambulatory patients. The increasing use of opioids in chronic nonmalignant pain is more problematic. Opioid treatment is complicated with the risks raised by adverse effects, especially cognitive disturbance, respiratory depression but also the risk of tolerance, opioid abuse and drug-disease interactions. Despite the growing number of available opioids within the last years, adequate trials of opioid rotation are lacking and most of the information is anecdotal. This article reviews the clinical evidence surrounding the switch from transdermal buprenorphine to tapentadol in malignant and non-malignant pain. Tapentadol acts on both the μ-opioid receptors (MOR) and on the neuronal reuptake of noradrenaline with a limited usefulness in acute pain management while buprenorphine is a mixed agonist-antagonist, and both present some advantages over other opioids. Both drugs show particular pharmacodynamic and pharmacokinetic properties which reduce the risks of development of tolerance, opioid abuse, diversion and determine fewer hormone changes than the "classical opioids" making these opioids more attractive than other opioids in long term opioid treatment. However, in the absence of powered clinical trials, the evidence to support the method used for transdermal buprenorphine rotation to tapentadol is weak.
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Affiliation(s)
- Adriana Miclescu
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Sweden
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Carmona-Bayonas A, Jiménez Fonseca P, Virizuela Echaburu J. Tapentadol for Cancer Pain Management: A Narrative Review. Pain Pract 2017; 17:1075-1088. [PMID: 28084045 DOI: 10.1111/papr.12556] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 11/01/2016] [Accepted: 11/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Pain is one of the most common symptoms in patients with cancer. The aim of this review is to summarize the most recent literature regarding tapentadol use in oncology patients and moderate or severe pain. DATABASES AND DATA TREATMENT We have conducted a review of the literature using PubMed, The Cochrane Library, EMBASE, and Google Scholar for all manuscripts published between 2008 and 2016, using the key words "tapentadol," "cancer," "pain," "tumor," and "malignant." RESULTS Nine studies met the inclusion criteria (four randomized clinical trials and five prospective cohort studies). The scope of the literature was diverse, with 15 instruments used to measure different aspects of pain (intensity, health status, quality of life, psychometric and well-being, perception of change, and neuropathic pain). All these studies concluded that tapentadol is seemingly a well-tolerated and efficacious agent for moderate-severe cancer pain, with few typically mild adverse reactions. However, the most significant detected weaknesses of research were that (1) existing studies do not clearly show a superiority of tapentadol with respect to previous generation opioids, (2) low-to-moderate sample sizes prevent obtaining robust conclusions about effectiveness, (3) there was an absence of noninferiority trials comparing tapentadol vs. fentanyl or oxycodone-naloxone, and (4) there was scarce generalizability of prospective observational studies. CONCLUSION Tapentadol is seemingly an effective, well-tolerated alternative for moderate or severe cancer pain. Most prospective cohort studies have relatively small samples, are restricted to few research centers, and lack detailed subgroup information. More experience is required to draw valid generalizable conclusions.
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Affiliation(s)
- Alberto Carmona-Bayonas
- Hematology and Medical Oncology Department, Morales Meseguer University Hospital, Regional Center of Hemodonation of Murcia, IMIB-Arrixaca, University of Murcia, Murcia, Spain
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Recent Advances in the Pharmacological Management of Neuropathic Pain. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bakker AC, La Rosa S, Sherman LS, Knight P, Lee H, Pancza P, Nievo M. Neurofibromatosis as a gateway to better treatment for a variety of malignancies. Prog Neurobiol 2016; 152:149-165. [PMID: 26854064 DOI: 10.1016/j.pneurobio.2016.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 01/25/2016] [Accepted: 01/25/2016] [Indexed: 12/23/2022]
Abstract
The neurofibromatoses (NF) are a group of rare genetic disorders that can affect all races equally at an incidence from 1:3000 (NF1) to a log unit lower for NF2 and schwannomatosis. Since the research community is reporting an increasing number of malignant cancers that carry mutations in the NF genes, the general interest of both the research and pharma community is increasing and the authors saw an opportunity to present a novel, fresh approach to drug discovery in NF. The aim of the paper is to challenge the current drug discovery approach to NF, whereby existing targeted therapies that are either in the clinic or on the market for other disease indications are repurposed for NF. We offer a suggestion for an alternative drug discovery approach. In the new approach, selective and tolerable targeted therapies would be developed for NF and later expanded to patients with more complex diseases such as malignant cancer in which the NF downstream pathways are deregulated. The Children's Tumor Foundation, together with some other major NF funders, is playing a key role in funding critical initiatives that will accelerate the development of better targeted therapies for NF patients, while these novel, innovative treatments could potentially be beneficial to molecularly characterized cancer patients in which NF mutations have been identified.
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Affiliation(s)
- Annette C Bakker
- Children's Tumor Foundation, 120, Wall Street, 16th Floor, New York 10005, United States
| | - Salvatore La Rosa
- Children's Tumor Foundation, 120, Wall Street, 16th Floor, New York 10005, United States
| | - Larry S Sherman
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, 505 NW 185th Avenue, Beaverton, OR 97006, United States
| | - Pamela Knight
- Children's Tumor Foundation, 120, Wall Street, 16th Floor, New York 10005, United States
| | - Hyerim Lee
- Children's Tumor Foundation, 120, Wall Street, 16th Floor, New York 10005, United States
| | - Patrice Pancza
- Children's Tumor Foundation, 120, Wall Street, 16th Floor, New York 10005, United States
| | - Marco Nievo
- Children's Tumor Foundation, 120, Wall Street, 16th Floor, New York 10005, United States.
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Greco MC, Navarra P, Tringali G. The analgesic agent tapentadol inhibits calcitonin gene-related peptide release from isolated rat brainstem via a serotonergic mechanism. Life Sci 2015; 145:161-5. [PMID: 26706288 DOI: 10.1016/j.lfs.2015.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 10/23/2015] [Accepted: 12/14/2015] [Indexed: 12/26/2022]
Abstract
AIMS In this study we tested the hypothesis that tapentadol inhibits GGRP release from the rat brainstem through a mechanism mediated by the inhibition of NA reuptake; as a second alternative hypothesis, we investigated whether tapentadol inhibits GGRP release via the inhibition of 5-HT reuptake. METHODS Rat brainstems were explanted and incubated in short-term experiments. CGRP released in the incubation medium was taken as a marker of CGRP release from the central terminals of trigeminal neurons within the brainstem. CGRP levels were measured by radioimmunoassay under basal conditions or in the presence of tapentadol; NA, 5-HT, clonidine, yohimbine and ondansetron were used as pharmacological tools to investigate the action mechanism of tapentadol. RESULTS The α2-antagonist yohimbine failed to counteract the effects of tapentadol. Moreover, neither NA nor the α2-agonist clonidine per se inhibited K(+)-stimulated CGRP release, thereby indicating that the effects of tapentadol are nor mediated through the block of NA reuptake. Further experiments showed that 5-HT and tramadol, which inhibits both NA and 5-HT reuptake, significantly reduced K(+)-stimulated CGRP release. Moreover, the 5-HT3 antagonist ondansetron was able to counteract the effects of tapentadol in this system. SIGNIFICANCE This study provided pharmacological evidence that tapentadol inhibits stimulated CGRP release from the rat brainstem in vitro through a mechanism involving an increase in 5-HT levels in the system and the subsequent activation of 5-HT3 receptors.
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Affiliation(s)
| | - Pierluigi Navarra
- Institute of Pharmacology, Catholic University Medical School, Rome, Italy.
| | - Giuseppe Tringali
- Institute of Pharmacology, Catholic University Medical School, Rome, Italy
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Abstract
Tapentadol, a new analgesic drug with a dual mechanism of action (μ-opioid receptor agonism and norepinephrine reuptake inhibition), is indicated for the treatment of moderate to severe acute and chronic pain. In this paper, the possible additional involvement of the nitric oxide synthase (NOS) system in the antinociceptive activity of tapentadol was investigated using an unspecific inhibitor of NOS, L-NOArg, a relatively specific inhibitor of neuronal NOS, 7-NI, a relatively selective inhibitor of inducible NOS, L-NIL, and a potent inhibitor of endothelial NOS, L-NIO. Tapentadol (1-10 mg/kg, intraperitoneal) increased the threshold for mechanical (Randall-Selitto test) and thermal (tail-flick test) nociceptive stimuli in a dose-dependent manner. All four NOS inhibitors, administered intraperitoneally in the dose range 0.1-10 mg/kg, potentiated the analgesic action of tapentadol at a low dose of 2 mg/kg in both models of pain. We conclude that NOS systems participate in tapentadol analgesia.
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Knezevic NN, Tverdohleb T, Knezevic I, Candido KD. Unique pharmacology of tapentadol for treating acute and chronic pain. Expert Opin Drug Metab Toxicol 2015. [DOI: 10.1517/17425255.2015.1072169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Coluzzi F, Raffa RB, Pergolizzi J, Rocco A, Locarini P, Cenfra N, Cimino G, Mattia C. Tapentadol prolonged release for patients with multiple myeloma suffering from moderate-to-severe cancer pain due to bone disease. J Pain Res 2015; 8:229-38. [PMID: 26064064 PMCID: PMC4431495 DOI: 10.2147/jpr.s83490] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Context Myeloma bone disease (MBD) is a devastating complication of multiple myeloma that leads to severe pain. Objectives The aim of this study was to evaluate the efficacy and tolerability of tapentadol prolonged release (PR) in the management of patients with MBD suffering from moderate-to-severe cancer pain. Methods A 12-week prospective study was carried out in 25 opioid-naïve MBD patients. Patients initially received twice-daily doses of tapentadol PR 50 mg. Doses were then managed to maintain adequate relief or dose-limiting toxicity. The following parameters were recorded at weekly intervals for 4 weeks, and then at weeks 8 and 12: pain, opioid-related adverse effects, use of other analgesics, DN4 (Douleur Neuropathique 4) score. Quality of life (SF-36 [36-item short-form health survey]) was measured at baseline and at final evaluation. Results Of 25 patients, 22 completed the study. Pain intensity significantly decreased from baseline to all the week intervals (P<0.01). Quality of life significantly improved with respect to all SF-36 subscale parameters (P<0.01), and so did both the physical and mental status (P<0.01). Tapentadol PR significantly reduced DN4 mean value (P<0.01) and the number of patients with neuropathic component (DN4 ≥4) (P<0.01). After 8 weeks of treatment, all patients were negative for the DN4 score. Tapentadol PR was well tolerated, and the use of other analgesics was reduced during the study period. Conclusion Tapentadol PR started in doses of 100 mg/day was effective and well tolerated in opioid-naïve MBD patients with moderate-to-severe pain. Tapentadol PR can be considered a first-choice opioid in cancer patients suffering from mixed pain with a neuropathic component.
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Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Unit of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Polo Pontino, Sapienza University of Rome, Latina, Italy ; SIAARTI Study Group on Acute and Chronic Pain, Rome, Italy
| | - Robert B Raffa
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA, USA
| | - Joseph Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alessandra Rocco
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Unit of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Polo Pontino, Sapienza University of Rome, Latina, Italy
| | - Pamela Locarini
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Unit of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Polo Pontino, Sapienza University of Rome, Latina, Italy
| | - Natalia Cenfra
- Department of Cellular Biotechnology and Hematology, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Cimino
- Department of Cellular Biotechnology and Hematology, Sapienza University of Rome, Rome, Italy
| | - Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Unit of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Polo Pontino, Sapienza University of Rome, Latina, Italy ; SIAARTI Study Group on Acute and Chronic Pain, Rome, Italy
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Affiliation(s)
| | - S. Chang
- St Bartholomew's Hospital; London UK
| | - V. Mehta
- Pain & Anaesthesia Research Centre; St Bartholomew's Hospital; London UK
- Queen Mary University; London UK
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Lange T, Krings D, Waldmann-Rex S. [Clinical practice data regarding tapentadol prolonged release treatment for severe chronic pain - improvement of analgesia, functional competence and quality of life in particular under tapentadol monotherapy]. MMW Fortschr Med 2015; 157:12-21. [PMID: 26013114 DOI: 10.1007/s15006-015-2932-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/10/2015] [Indexed: 06/04/2023]
Abstract
STUDY OBJECTIVE To assess effectiveness and tolerability of tapentadol prolonged release (PR, Palexia® retard) for the treatment of severe chronic pain under routine clinical practice conditions in Germany. METHODS In this prospective non-interventional study, data regarding previous and concomitant analgesic treatment, tapentadol dosage, pain intensity, functionality, quality of life, and tolerability of tapentadol PR were collected over a 3-month observation period. A total of 5,002 patients were included in the effectiveness analysis; a subgroup analysis assessed effectiveness for all patients receiving tapentadol monotherapy (n = 1476). RESULTS Nearly all patients of the total study population (95.9%) had already received analgesic long-term treatment (31.7% strong opioids) prior to the start of the study. Treatment with tapentadol PR (mean daily dose 216 ± 103 mg at end of observation) resulted in a reduction in pain intensity of 3.9 points from 7.2 ± 1.4 at baseline (95%CI -3.93; -3.83; p ≤ 0.001; NRS-11); clinically relevant pain relief ≥ 50% was documented for 65.1% of the patients. All 4 evaluated aspects regarding pain-related functionality, and quality of life of the patients also improved significantly. Compared to the total patient population, pain relief was greater in the subgroup receiving tapentadol monotherapy; baseline pain intensity was comparable between the groups. Pain-related functional impairment also declined to a slightly greater extent, and quality of life was rated more positively at end of observation. CONCLUSIONS Analgesic treatment with tapentadol PR in routine clinical practice resulted in a marked reduction of severe chronic pain with significant improvements of functionality and quality of life. On the basis of these results and the favourable safety profile, tapentadol PR can thus be considered an alternative to classical opioids in the treatment of severe chronic pain.
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Affiliation(s)
- Thomas Lange
- Anästhesie und Schmerztherapie, Rudolstadt, Deutschland
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Lasting Prolonged-Release Tapentadol for Moderate/Severe Non-Cancer Musculoskeletal Chronic Pain. Pain Ther 2015; 4:107-17. [PMID: 25558866 PMCID: PMC4470964 DOI: 10.1007/s40122-014-0030-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Indexed: 12/12/2022] Open
Abstract
Introduction Despite opioids’ recognized role in the treatment of moderate/severe musculoskeletal chronic pain, their long-term benefits need investigation. We explored the lasting analgesic efficacy, tolerability, influence on life quality, and chronicity stage of the novel prolonged release (PR) opioid, tapentadol, in 30 outpatients. Methods We evaluated patients’ pain intensity and relief (Numerical Rating Scale; NRS), adverse effects, sleep quality, treatment satisfaction, health status (12-questions Health-Survey; SF-12), chronicity stage (Italian Mainz Pain-Staging System; I-MPSS) at 10, 30, 60, and 90 days after tapentadol prescription. Results At follow-ups, the investigated outcomes showed an overall statistically significant (Wilcoxon signed-rank test) improvement and remained stable over time, as did the health status and chronicity stage. Adverse effects were limited, transitory, and tolerable. Conclusions Twelve weeks of PR tapentadol in outpatients with moderate/severe chronic musculoskeletal pain showed satisfactory analgesic efficacy and tolerability, and had a positive influence on life quality and chronicity stage. The results are robust enough to warrant a subsequent study with a larger sample and a longer observation period.
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Sánchez del Águila MJ, Schenk M, Kern KU, Drost T, Steigerwald I. Practical Considerations for the Use of Tapentadol Prolonged Release for the Management of Severe Chronic Pain. Clin Ther 2015; 37:94-113. [DOI: 10.1016/j.clinthera.2014.07.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 05/28/2014] [Accepted: 07/16/2014] [Indexed: 01/11/2023]
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Abstract
INTRODUCTION Pain is commonly experienced by patients with cancer, particularly those with advanced disease. Alleviating pain is an important goal of cancer treatment. Opioids are the cornerstone of the analgesic treatment. AREAS COVERED Pharmacology, characteristics, and use of opioids in clinical practice are presented. EXPERT OPINION Although the use of opioids is largely accepted as a fundamental step for controlling cancer pain, existing data supporting this statement are poor. All opioids provide analgesia and are effective in controlling cancer pain. New drugs have been developed and experience is accumulating among clinicians. Despite these drugs having different pharmacokinetic and chemical properties, there is no proof that one opioid is better than another one. Thus, the optimum benefit depends on the experience of the users. Clinicians should weight evidence, clinical experience, patient preferences, and treatment costs when choosing the optimal treatment for an individual patient with cancer pain. New opioids with specific receptor activities are under investigation.
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Affiliation(s)
- Sebastiano Mercadante
- La Maddalena Cancer Center - Pain Relief and Palliative Care Unit , Via san lorenzo 312, Palermo 90145 , Italy
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Abstract
BACKGROUND The history of discovery of analgesic drugs has followed a trajectory from original serendipitous discovery of plant-derived substances to laboratory creation of customized molecules that are intentionally designed to interact with specific receptors of neurotransmitters involved in either the transmission of the pain signal or the attenuation of such a signal. The drugs most recently developed have been designed to provide incremental greater separation between pain relief and adverse effects. The result has been drugs that have individualized pharmacodynamic and pharmacokinetic characteristics that represent specific advances in basic science and translate into unique clinical profiles. Several of the drugs include non-opioid components. They retain some of the features of opioids, but have distinct clinical characteristics that differentiate them from traditional opioids. Thus they defy simple classification as opioids. SCOPE A summary is provided of the development of the modern view of multi-mechanistic pain and its treatment using analgesics that have multi-mechanisms of action (consisting of both opioid and non-opioid components). Descriptions of examples of such current analgesics and of those that have pharmacokinetic characteristics that result in atypical opioid clinical profiles are given. FINDINGS By serendipity or design, several current strong analgesics have opioid components of action, but have an additional non-opioid mechanism of action or some pharmacokinetic feature that gives them an atypical opioid clinical profile and renders them not easily classified as classical opioids. CONCLUSION An appreciation that there are now opioid analgesics that differentiate from classical opioids in ways that defy their simplistic classification as opioids suggests that recognition of subclasses of opioid analgesics would be more accurate scientifically and would be more informative for healthcare providers and regulators. This would likely lead to positive outcomes for the clinical use and regulatory control of the current drugs, and provide direction/strategy for the discovery of new drugs.
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Affiliation(s)
- Robert B Raffa
- Temple University School of Pharmacy , Philadelphia, PA , USA
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Aira Z, Barrenetxea T, Buesa I, Azkue JJ. Plasticity of α2-adrenergic spinal antinociception following nerve injury: selective, bidirectional interaction with the delta opioid receptor. Brain Res 2014; 1594:190-203. [PMID: 25446445 DOI: 10.1016/j.brainres.2014.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 11/04/2014] [Accepted: 11/06/2014] [Indexed: 11/25/2022]
Abstract
Interactions of opioid receptors with other receptor families can be made use of to improve analgesia and reduce adverse effects of opioid analgesics. We investigated interactions of the α2-adrenergic receptor (α2AR) with opioid receptors of the mu (MOR) and delta (DOR) types in the spinal dorsal horn in an animal model of neuropathic pain induced by spinal nerve ligation. Nine days after nerve injury, immunoreactivity for the α2AR subtype A (α2AAR) was increased both in tissue homogenates and at pre- and post-synaptic sites in transverse sections. The efficacy of spinally administered α2AAR agonist guanfacine at reducing C-fiber-evoked field potentials was increased in nerve-ligated rats. This reducing effect was impaired by simultaneous administration of DOR antagonist naltrindole, but not MOR antagonist CTOP, suggesting that concurrent DOR activation was required for α2AAR-mediated inhibition. While DOR agonist deltorphin II and MOR agonist DAMGO both effectively depressed C-fiber-evoked spinal field potentials, DOR- but not MOR-mediated depression was enhanced by subclinical guanfacine. In conscious, nerve-ligated rats, chronically administered deltorphin II produced stable thermal and mechanical antinociception over the 9 following days after nerve injury without apparent signs of habituation. Such an effect was dramatically enhanced by co-administration of a low dose of guanfacine, which reversed thermal and mechanical thresholds to levels near those prior to injury. The results suggest that spinal, α2AAR-mediated antinociception is increased after nerve injury and based on DOR co-activation. We demonstrate in vivo that α2AAR/DOR interaction can be exploited to provide effective behavioral antinociception during neuropathic pain.
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Affiliation(s)
- Zigor Aira
- Department of Neurosciences, School of Medicine and Dentistry, University of the Basque Country, PO Box 699, 48080 Bilbao, Spain
| | - Teresa Barrenetxea
- Department of Neurosciences, School of Medicine and Dentistry, University of the Basque Country, PO Box 699, 48080 Bilbao, Spain
| | - Itsaso Buesa
- Department of Neurosciences, School of Medicine and Dentistry, University of the Basque Country, PO Box 699, 48080 Bilbao, Spain
| | - Jon Jatsu Azkue
- Department of Neurosciences, School of Medicine and Dentistry, University of the Basque Country, PO Box 699, 48080 Bilbao, Spain.
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Mercadante S, Porzio G, Adile C, Aielli F, Cortegiani A, Dickenson A, Casuccio A. Tapentadol at medium to high doses in patients previously receiving strong opioids for the management of cancer pain. Curr Med Res Opin 2014; 30:2063-8. [PMID: 24926734 DOI: 10.1185/03007995.2014.934793] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy and tolerability of tapentadol (TP) for a period of 4 weeks in patients who were already treated by opioids. METHODS A convenience sample of 30 patients was selected for a prospective observational cohort study. Cancer patients who were receiving at least 60 mg of oral morphine equivalents were selected. Patients discontinued their previous opioid analgesics before starting TP, in doses calculated according the previous opioid consumption (1:3.3 ratio with oral morphine equivalents). The subsequent doses were changed according to the patients' needs for a period of 4 weeks. Oral morphine was offered as a breakthrough pain medication. Pain and symptom intensity were recorded at weekly intervals. Distress score (DS) was calculated from the sum of symptom intensities. TP opioid escalation indexes (TPEI) for the study period were calculated. RESULTS Nineteen patients were male, and the mean age was 63.5 years (±11.5). The mean Karnofsky status was 62.9 (±10). The mean dose of oral morphine equivalents before switching to TP was 112 mg (±57) and the initial mean dose of TP was 343 mg (±150). Pain intensity significantly decreased. Tapentadol escalation index in percentage was 1.26 (TPEI% ± 2.6) and Tapentadol escalation index in mg was 2.76 (TPEImg ± 4.96). No significant relationships were found with primary tumor (TPEI%, p = 0.204; TPEImg, p = 0.180), pain mechanism (TPEI%, p = 0.863; TPEImg, p = 0.846), age (TPEI%, p = 0.882; TPEImg, p = 0.884), or gender (TPEI%, p = 0.287; TPEImg, p = 0.325). DS decreased, but non-significantly (p = 0.1). Ten patients did not complete the study period: five patients discontinued TP for uncontrolled pain, despite increasing doses of TP over 600 mg/day. Two patients discontinued TP for adverse effects and three patients dropped out, one patient for poor compliance and two patients for unrecorded reasons. CONCLUSION In our sample, TP used in doses of 350-450 mg/day was well tolerated and effective in opioid tolerant patients with cancer pain and could be considered as a flexible drug to be used for the management of moderate to severe cancer pain. Like most studies in patients with cancer pain, it was limited by its open-label, uncontrolled design, the number of patients lost in follow-up, and discontinuation of the treatment for several reasons. Further studies in a large number of patients should confirm these preliminary results.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia & Intensive Care and Pain Relief & Supportive Care, La Maddalena Cancer Center , Palermo , Italy
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