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Jin J, Kang DH, Jeon J, Lee HG, Kim WM, Yoon MH, Choi JI. Imbalance in the spinal serotonergic pathway induces aggravation of mechanical allodynia and microglial activation in carrageenan inflammation. Korean J Pain 2023; 36:51-59. [PMID: 36581598 PMCID: PMC9812699 DOI: 10.3344/kjp.22297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/31/2022] Open
Abstract
Background This study investigated the effect of an excess and a deficit of spinal 5-hydroxytryptamine (5-HT) on the mechanical allodynia and neuroglia activation in a rodent pain model of carrageenan inflammation. Methods Male Sprague-Dawley rats were implanted with an intrathecal (i.t.) catheter to administer the drug. To induce an excess or deficit of 5-HT in the spinal cord, animals were given either three i.t. 5-HT injections at 24-hour intervals or a single i.t. injection of 5,7-dihydroxytryptamine (5,7-DHT) before carrageenan inflammation. Mechanical allodynia was measured using the von Frey test for 0-4 hours (early phase) and 24-28 hours (late phase) after carrageenan injection. The changes in the activation of microglia and astrocyte were examined using immunofluorescence of the dorsal horn of the lumbar spinal cord. Results Both an excess and a deficit of spinal 5-HT had no or a minimal effect on the intensity of mechanical allodynia during the early phase but prevented the attenuation of mechanical allodynia during the late phase, which was observed in animals not treated with i.t. 5-HT or 5,7-DHT. Animals with an excess or deficit of 5-HT showed stronger activation of microglia, but not astrocyte, during the early and late phases, than did normal animals. Conclusions Imbalance in the descending 5-HT pathway in the spinal cord could aggravate the mechanical allodynia and enhance the activation of microglia, suggesting that the spinal 5-HT pathway plays an essential role in maintaining the nociceptive processing in balance between facilitation and inhibition in inflammatory pain caused by carrageenan inflammation.
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Affiliation(s)
- Junxiu Jin
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea,BioMedical Sciences Graduate Program (BMSGP), Chonnam National University Medical School, Hwasun, Korea
| | - Dong Ho Kang
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jin Jeon
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyung Gon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea,BioMedical Sciences Graduate Program (BMSGP), Chonnam National University Medical School, Hwasun, Korea
| | - Woong Mo Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea,BioMedical Sciences Graduate Program (BMSGP), Chonnam National University Medical School, Hwasun, Korea,Woong Mo Kim, Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea, Tel: +82-62-220-6894, Fax: +82-62-232-6294, E-mail:
| | - Myung Ha Yoon
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea,BioMedical Sciences Graduate Program (BMSGP), Chonnam National University Medical School, Hwasun, Korea
| | - Jeong Il Choi
- Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea,BioMedical Sciences Graduate Program (BMSGP), Chonnam National University Medical School, Hwasun, Korea,Correspondence: Jeong Il Choi Department of Anesthesiology and Pain Medicine, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea, Tel: +82-62-220-6895, Fax: +82-62-232-6294, E-mail:
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Li CJ, Zhang LG, Liu LB, An MQ, Dong LG, Gu HY, Dai YP, Wang F, Mao CJ, Liu CF. Inhibition of Spinal 5-HT3 Receptor and Spinal Dorsal Horn Neuronal Excitability Alleviates Hyperalgesia in a Rat Model of Parkinson's Disease. Mol Neurobiol 2022; 59:7253-7264. [PMID: 36168076 DOI: 10.1007/s12035-022-03034-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
Pain in Parkinson's disease (PD) is increasingly recognized as a major factor associated with poor life quality of PD patients. However, classic therapeutic drugs supplying dopamine have limited therapeutic effects on PD-related pain. This suggests that there is a mechanism outside the dopamine system that causes pain in PD. Our previous study demonstrated that 6-OHDA induced PD model manifested hyperalgesia to thermal and mechanical stimuli and decreased serotonin (5-hydroxytryptamine; 5-HT) in the spinal dorsal horn (SDH). Several 5-HT receptor subtypes have been confirmed to be associated with nociception in the spinal cord, such as 5-HT1A receptor, 5-HT1B receptor, 5-HT2 receptor, 5-HT3 receptor, and 5-HT7 receptor. Most research has shown that 5-HT1A receptor and 5-HT3 receptor play a key role in pain transmission in the spinal cord. We hypothesized that hyperalgesia of 6-OHDA rats may be related to increased excitability of SDH neurons, and functional change of 5-HT3 receptor may reverse the hyperalgesia of 6-OHDA lesioned rats and decrease cell excitability of SDH neurons. To test this hypothesis, we used whole-cell patch-clamp and pharmacological methods to evaluate the effect of 5-HT3 receptor and 5-HT1A receptor on the hyperalgesia of 6-OHDA rats. The results suggested that increased excitability in SDH neurons could be reversed by 5-HT3 receptor antagonist ondansetron (20 μmol/L) and palosetron (10 μmol/L), but not 5-HT3 receptor agonist m-CPBG (30 μmol/L) and SR 57,727 (10 μmol/L), 5-HT1A receptor agonist 8-OH DPAT (10 μmol/L) and eptapirone (10 μmol/L) and 5-HT1A receptor antagonist WAY-100635 (10 μmol/L) and p-MPPI (10 μmol/L). Intrathecal injection of ondansetron (0.1 mg/kg) but not m-CPBG (0.1 mg/kg), 8-OH DPAT (0.1 mg/kg), and WAY-100635 (0.1 mg/kg) significantly attenuated the mechanical hyperalgesia and thermal hyperalgesia in 6-OHDA lesioned rats. In conclusion, the present study suggests that inhibition of spinal 5-HT3 receptor and SDH neuronal excitability alleviates hyperalgesia in PD rats. Our study provides a novel mechanism or therapeutic strategy for pain in patients with PD.
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Affiliation(s)
- Cheng-Jie Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China.,Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China
| | - Li-Ge Zhang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China.,Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China
| | - Lu-Bing Liu
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China
| | - Meng-Qi An
- Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China
| | - Li-Guo Dong
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China.,Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China
| | - Han-Ying Gu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Yong-Ping Dai
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China
| | - Fen Wang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China. .,Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China.
| | - Cheng-Jie Mao
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China.
| | - Chun-Feng Liu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, China.,Jiangsu Key Laboratory of Neuropsychiatric Diseases and Institute of Neuroscience, Soochow University, Suzhou, China.,Department of Neurology, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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3
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Bardoni R. Serotonergic Modulation of Nociceptive Circuits in Spinal Cord Dorsal Horn. Curr Neuropharmacol 2020; 17:1133-1145. [PMID: 31573888 PMCID: PMC7057206 DOI: 10.2174/1570159x17666191001123900] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/28/2019] [Accepted: 09/26/2019] [Indexed: 01/12/2023] Open
Abstract
Background: Despite the extensive number of studies performed in the last 50 years, aimed at describing the role of serotonin and its receptors in pain modulation at the spinal cord level, several aspects are still not entirely understood. The interpretation of these results is often complicated by the use of different pain models and animal species, together with the lack of highly selective agonists and antagonists binding to serotonin receptors. Method: In this review, a search has been conducted on studies investigating the modulatory action exerted by serotonin on specific neurons and circuits in the spinal cord dorsal horn. Particular attention has been paid to studies employing electro-physiological techniques, both in vivo and in vitro. Conclusion: The effects of serotonin on pain transmission in dorsal horn depend on several factors, including the type of re-ceptors activated and the populations of neurons involved. Recently, studies performed by activating and/or recording from identified neurons have importantly contributed to the understanding of serotonergic modulation on dorsal horn circuits.
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Affiliation(s)
- Rita Bardoni
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy
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4
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Bi H, Sun Z, Chu Q, Li L, Guan X, Zhou Y, Li Z. Analgesic effects of astilbin partially via calcium channels through regulation on CaMKII. FOOD AGR IMMUNOL 2019. [DOI: 10.1080/09540105.2019.1580677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Hui Bi
- Department of Anesthesiology, Stomatology, Jilin University, Changchun, People’s Republic of China
| | - Zhen Sun
- School of Life Sciences, Jilin University, Changchun, People’s Republic of China
| | - Qiubo Chu
- School of Life Sciences, Jilin University, Changchun, People’s Republic of China
| | - Lanzhou Li
- School of Life Sciences, Jilin University, Changchun, People’s Republic of China
| | - Xin Guan
- Department of Pharmacology, School of Basic Medical Sciences, Jilin University, Changchun, People’s Republic of China
| | - Yulin Zhou
- School of Life Sciences, Jilin University, Changchun, People’s Republic of China
| | - Zhiwen Li
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, People’s Republic of China
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Activation of spinal macrophage-inducible C-type lectin induces mechanical allodynia and microglial activation in rats. Neurosci Lett 2019; 690:42-47. [DOI: 10.1016/j.neulet.2018.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/26/2018] [Accepted: 10/08/2018] [Indexed: 12/14/2022]
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Spinal Serotonin 1A Receptor Contributes to the Analgesia of Acupoint Catgut Embedding by Inhibiting Phosphorylation of the N-Methyl-d-Aspartate Receptor GluN1 Subunit in Complete Freund's Adjuvant-Induced Inflammatory Pain in Rats. THE JOURNAL OF PAIN 2019; 20:16.e1-16.e16. [DOI: 10.1016/j.jpain.2018.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/21/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023]
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7
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Song J, Wang X, Huang Y, Qu Y, Zhang G, Wang D. Analgesic effects of Marasmius androsaceus mycelia ethanol extract and possible mechanisms in mice. ACTA ACUST UNITED AC 2018. [PMID: 29513798 PMCID: PMC5856440 DOI: 10.1590/1414-431x20177124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Marasmius androsaceus is a medicinal fungus mainly used to treat various forms of pain in China. This study investigated the analgesic effects of an ethanol extract of M. androsaceus (MAE) and its potential molecular mechanisms. Oral administration of MAE (50, 200, and 1000 mg/kg) had significant analgesic effects in an acid-induced writhing test, a formalin test, and a hot-plate test, with effectiveness similar to tramadol (the positive control drug). The autonomic activity test showed that MAE had no harmful effects on the central nervous system in mice. MAE resulted in significantly enhanced levels of noradrenalin and 5-hydroxytryptamine in serum but suppressed both of these neurotransmitters in the hypothalamus after 30 s of hot-plate stimulation. Co-administration with nimodipine (10 mg/kg; a Ca2+ channel blocker) strongly enhanced the analgesic effect in the hot-plate test compared to MAE alone. Moreover, MAE down-regulated the expression of calmodulin-dependent protein kinase II (CaMKII) in the hypothalamus after a 30-s thermal stimulus. These results suggested that the analgesic ability of MAE is related to the regulation of metabolism by monoamine neurotransmitters and Ca2+/CaMKII-mediated signaling, which can potentially aid the development of peripheral neuropathic pain treatments obtained from M. androsaceus.
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Affiliation(s)
- Jia Song
- School of Life Sciences, Jilin University, Changchun, Jilin, China.,The College of Biotechnology, Tianjin University of Science and Technology, Tianjin, China
| | - Xue Wang
- School of Life Sciences, Jilin University, Changchun, Jilin, China
| | - Yu Huang
- School of Life Sciences, Jilin University, Changchun, Jilin, China
| | - Yidi Qu
- School of Life Sciences, Jilin University, Changchun, Jilin, China
| | - Guirong Zhang
- School of Life Sciences, Jilin University, Changchun, Jilin, China
| | - Di Wang
- School of Life Sciences, Jilin University, Changchun, Jilin, China.,Zhuhai College of Jilin University, Jilin University, Zhuhai, China
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8
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The developmental emergence of differential brainstem serotonergic control of the sensory spinal cord. Sci Rep 2017; 7:2215. [PMID: 28533557 PMCID: PMC5440407 DOI: 10.1038/s41598-017-02509-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/12/2017] [Indexed: 12/29/2022] Open
Abstract
Descending connections from brainstem nuclei are known to exert powerful control of spinal nociception and pain behaviours in adult mammals. Here we present evidence that descending serotonergic fibres not only inhibit nociceptive activity, but also facilitate non-noxious tactile activity in the healthy adult rat spinal dorsal horn via activation of spinal 5-HT3 receptors (5-HT3Rs). We further show that this differential serotonergic control in the adult emerges from a non-modality selective system in young rats. Serotonergic fibres exert background 5-HT3R mediated facilitation of both tactile and nociceptive spinal activity in the first three postnatal weeks. Thus, differential descending serotonergic control of spinal touch and pain processing emerges in late postnatal life to allow flexible and context-dependent brain control of somatosensation.
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9
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Kilinc E, Guerrero-Toro C, Zakharov A, Vitale C, Gubert-Olive M, Koroleva K, Timonina A, Luz LL, Shelukhina I, Giniatullina R, Tore F, Safronov BV, Giniatullin R. Serotonergic mechanisms of trigeminal meningeal nociception: Implications for migraine pain. Neuropharmacology 2016; 116:160-173. [PMID: 28025094 DOI: 10.1016/j.neuropharm.2016.12.024] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 12/02/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
Serotonergic mechanisms play a central role in migraine pathology. However, the region-specific effects of serotonin (5-HT) mediated via multiple types of receptors in the nociceptive system are poorly understood. Using extracellular and patch-clamp recordings, we studied the action of 5-HT on the excitability of peripheral and central terminals of trigeminal afferents. 5-HT evoked long-lasting TTX-sensitive firing in the peripheral terminals of meningeal afferents, the origin site of migraine pain. Cluster analysis revealed that in majority of nociceptive fibers 5-HT induced either transient or persistent spiking activity with prevailing delta and theta rhythms. The 5-HT3-receptor antagonist MDL-72222 or 5-HT1B/D-receptor antagonist GR127935 largely reduced, but their combination completely prevented the excitatory pro-nociceptive action of 5-HT. The 5-HT3 agonist mCPBG activated spikes in MDL-72222-dependent manner but the 5HT-1 receptor agonist sumatriptan did not affect the nociceptive firing. 5-HT also triggered peripheral CGRP release in meninges, which was blocked by MDL-72222.5-HT evoked fast membrane currents and Ca2+ transients in a fraction of trigeminal neurons. Immunohistochemistry showed expression of 5-HT3A receptors in fibers innervating meninges. Endogenous release of 5-HT from degranulated mast cells increased nociceptive firing. Low pH but not histamine strongly activated firing. 5-HT reduced monosynaptic inputs from trigeminal Aδ- and C-afferents to the upper cervical lamina I neurons and this effect was blocked by MDL-72222. Consistent with central inhibitory effect, 5-HT reduced CGRP release in the brainstem slices. In conclusion, 5-HT evokes powerful pro-nociceptive peripheral and anti-nociceptive central effects in trigeminal system transmitting migraine pain.
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Affiliation(s)
- Erkan Kilinc
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland; Abant Izzet Baysal University, Medical Faculty, Department of Physiology, 14280, Bolu, Turkey.
| | - Cindy Guerrero-Toro
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland.
| | - Andrey Zakharov
- Laboratory of Neurobiology, Kazan Federal University, 420008, Kazan, Russia; Department of Physiology, Kazan State Medical University, 420012, Kazan, Russia.
| | - Carmela Vitale
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland.
| | - Max Gubert-Olive
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland.
| | - Ksenia Koroleva
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland; Laboratory of Neurobiology, Kazan Federal University, 420008, Kazan, Russia
| | - Arina Timonina
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland
| | - Liliana L Luz
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135, Porto, Portugal.
| | - Irina Shelukhina
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland; Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry RAS, 117997, Moscow, Russia.
| | - Raisa Giniatullina
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland.
| | - Fatma Tore
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland; Biruni University, School of Medicine, 34010, Istanbul, Turkey.
| | - Boris V Safronov
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135, Porto, Portugal; Neuronal Networks Group, Instituto de Biologia Molecular e Celular (IBMC), Universidade do Porto, 4200-135, Porto, Portugal.
| | - Rashid Giniatullin
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, 70211, Kuopio, Finland; Laboratory of Neurobiology, Kazan Federal University, 420008, Kazan, Russia.
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Kirkpatrick DR, McEntire DM, Smith TA, Dueck NP, Kerfeld MJ, Hambsch ZJ, Nelson TJ, Reisbig MD, Agrawal DK. Transmission pathways and mediators as the basis for clinical pharmacology of pain. Expert Rev Clin Pharmacol 2016; 9:1363-1387. [PMID: 27322358 PMCID: PMC5215101 DOI: 10.1080/17512433.2016.1204231] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Mediators in pain transmission are the targets of a multitude of different analgesic pharmaceuticals. This review explores the most significant mediators of pain transmission as well as the pharmaceuticals that act on them. Areas covered: The review explores many of the key mediators of pain transmission. In doing so, this review uncovers important areas for further research. It also highlights agents with potential for producing novel analgesics, probes important interactions between pain transmission pathways that could contribute to synergistic analgesia, and emphasizes transmission factors that participate in transforming acute injury into chronic pain. Expert commentary: This review examines current pain research, particularly in the context of identifying novel analgesics, highlighting interactions between analgesic transmission pathways, and discussing factors that may contribute to the development of chronic pain after an acute injury.
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Affiliation(s)
- Daniel R. Kirkpatrick
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Dan M. McEntire
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Tyler A. Smith
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Nicholas P. Dueck
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Mitchell J. Kerfeld
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Zakary J. Hambsch
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Taylor J. Nelson
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Mark D. Reisbig
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
| | - Devendra K. Agrawal
- Departments of Clinical and Translational Science and Anesthesiology, Creighton University School of Medicine, Omaha, NE 68178 USA
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