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Allen TK, Mishriky BM, Klinger RY, Habib AS. The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects in women having elective Caesarean section-a systematic review and meta-analysis. Br J Anaesth 2018; 120:228-240. [PMID: 29406172 DOI: 10.1016/j.bja.2017.11.085] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 08/03/2017] [Accepted: 09/05/2017] [Indexed: 12/22/2022] Open
Abstract
Neuraxial clonidine improves postoperative analgesia in the general surgical population. The efficacy and safety of neuraxial clonidine as a postoperative analgesic adjunct in the Caesarean section population still remains unclear. This systematic review and meta-analysis aims to evaluate the effect of perioperative neuraxial clonidine on postoperative analgesia in women having Caesarean section under neuraxial anaesthesia. We included randomized controlled trials comparing the analgesic efficacy of the perioperative administration of neuraxial clonidine alone or in combination with a local anaesthetic and/or opioids in women having elective Caesarean section under neuraxial anaesthesia when compared with placebo. PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE were searched until February 2017. Eighteen studies were included in the meta-analysis. Neuraxial clonidine reduced 24 h morphine consumption [mean difference (MD): -7.2 mg; 95% confidence interval (CI): -11.4, -3.0 mg; seven studies] and prolonged time to first analgesic request (MD: 135 min; 95% CI: 102, 168 min; 16 studies) when compared with the control group. Neuraxial clonidine increased intraoperative hypotension [odds ratio (OR): 2.849; 95% CI: 1.363, 5.957], intraoperative sedation (OR: 2.355; 95% CI: 1.016, 5.459), but reduced the need for intraoperative analgesic supplementation (OR: 0.224; 95% CI: 0.076, 0.663). The effect of clonidine on intraoperative bradycardia, intraoperative and postoperative nausea and vomiting, postoperative sedation, and pruritus were inconclusive. Neuraxial clonidine did not negatively impact neonatal umbilical artery pH or Apgar scores. This review demonstrates that neuraxial clonidine enhances postoperative analgesia in women having Caesarean section with neuraxial anaesthesia, but this has to be balanced against increased maternal adverse effects.
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Affiliation(s)
- T K Allen
- Department of Anaesthesiology, Duke University Hospital, Durham, NC, USA.
| | - B M Mishriky
- East Carolina University Health Sciences Campus, Greenville, NC, USA
| | - R Y Klinger
- Department of Anaesthesiology, Duke University Hospital, Durham, NC, USA
| | - A S Habib
- Department of Anaesthesiology, Duke University Hospital, Durham, NC, USA
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Relation between pro-inflammatory cytokines and acetylcholine levels in relapsing-remitting multiple sclerosis patients. Int J Mol Sci 2012. [PMID: 23202919 PMCID: PMC3497293 DOI: 10.3390/ijms131012656] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory, demyelinating and neurodegenerative disorder. Since acetylcholine (ACh) is known to participate in the inflammatory response, we investigated the possible relationship between pro-inflammatory cytokines and acetylcholine levels in relapsing-remitting multiple sclerosis (RR-MS) patients. Levels of ACh and pro-inflammatory cytokines IL1-β and IL-17 were measured both in cerebrospinal fluid (CSF) and sera of 22 RR-MS patients in the relapsing phase and in 17 control subjects affected by other non-neurological diseases (OND). We observed higher levels of pro-inflammatory cytokines such as IL-1β and IL-17 in both CSF and serum of RR-MS patients compared to control subjects. Moreover, ACh levels were lower in CSF and serum of RR-MS patients compared to levels of control subjects. Although the relationship between high inflammatory cytokine levels and low ACh levels need to be further investigated in the future, our data suggest that IL-1β, and cytokines induced by it, such as IL-17 and ACh, may be involved in the pathogenesis of MS.
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Obata H, Kimura M, Nakajima K, Tobe M, Nishikawa K, Saito S. Monoamine-Dependent, Opioid-Independent Antihypersensitivity Effects of Intrathecally Administered Milnacipran, a Serotonin Noradrenaline Reuptake Inhibitor, in a Postoperative Pain Model in Rats. J Pharmacol Exp Ther 2010; 334:1059-65. [DOI: 10.1124/jpet.110.168336] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Pan HL, Wu ZZ, Zhou HY, Chen SR, Zhang HM, Li DP. Modulation of pain transmission by G-protein-coupled receptors. Pharmacol Ther 2007; 117:141-61. [PMID: 17959251 DOI: 10.1016/j.pharmthera.2007.09.003] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Accepted: 09/07/2007] [Indexed: 01/17/2023]
Abstract
The heterotrimeric G-protein-coupled receptors (GPCR) represent the largest and most diverse family of cell surface receptors and proteins. GPCR are widely distributed in the peripheral and central nervous systems and are one of the most important therapeutic targets in pain medicine. GPCR are present on the plasma membrane of neurons and their terminals along the nociceptive pathways and are closely associated with the modulation of pain transmission. GPCR that can produce analgesia upon activation include opioid, cannabinoid, alpha2-adrenergic, muscarinic acetylcholine, gamma-aminobutyric acidB (GABAB), groups II and III metabotropic glutamate, and somatostatin receptors. Recent studies have led to a better understanding of the role of these GPCR in the regulation of pain transmission. Here, we review the current knowledge about the cellular and molecular mechanisms that underlie the analgesic actions of GPCR agonists, with a focus on their effects on ion channels expressed on nociceptive sensory neurons and on synaptic transmission at the spinal cord level.
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Affiliation(s)
- Hui-Lin Pan
- Department of Anesthesiology and Pain Medicine, The University of Texas M.D. Anderson Cancer Center, Program in Neuroscience, The University of Texas Graduate School of Biomedical Sciences, Houston, TX 77225, United States.
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Takasu K, Honda M, Ono H, Tanabe M. Spinal alpha(2)-adrenergic and muscarinic receptors and the NO release cascade mediate supraspinally produced effectiveness of gabapentin at decreasing mechanical hypersensitivity in mice after partial nerve injury. Br J Pharmacol 2006; 148:233-44. [PMID: 16582934 PMCID: PMC1617063 DOI: 10.1038/sj.bjp.0706731] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
After partial nerve injury, the central analgesic effect of systemically administered gabapentin is mediated by both supraspinal and spinal actions. We further evaluate the mechanisms related to the supraspinally mediated analgesic actions of gabapentin involving the descending noradrenergic system. Intracerebroventricularly (i.c.v.) administered gabapentin (100 microg) decreased thermal and mechanical hypersensitivity in a murine chronic pain model that was prepared by partial ligation of the sciatic nerve. These effects were abolished by intrathecal (i.t.) injection of either yohimbine (3 microg) or idazoxan (3 microg), alpha(2)-adrenergic receptor antagonists. Pretreatment with atropine (0.3 mg kg(-1), i.p. or 0.1 microg, i.t.), a muscarinic receptor antagonist, completely suppressed the effect of i.c.v.-injected gabapentin on mechanical hypersensitivity, whereas its effect on thermal hypersensitivity remained unchanged. Similar effects were obtained with pirenzepine (0.1 microg, i.t.), a selective M(1)-muscarinic receptor antagonist, but not with methoctramine (0.1 and 0.3 microg, i.t.), a selective M(2)-muscarinic receptor antagonist. The cholinesterase inhibitor neostigmine (0.3 ng, i.t.) potentiated only the analgesic effect of i.c.v. gabapentin on mechanical hypersensitivity, confirming spinal acetylcholine release downstream of the supraspinal action of gabapentin. Moreover, the effect of i.c.v. gabapentin on mechanical but not thermal hypersensitivity was reduced by i.t. injection of L-NAME (3 microg) or L-NMMA (10 microg), both of which are nitric oxide (NO) synthase inhibitors. Systemically administered naloxone (10 mg kg(-1), i.p.), an opioid receptor antagonist, failed to suppress the analgesic actions of i.c.v. gabapentin, indicating that opioid receptors are not involved in activation of the descending noradrenergic system by gabapentin. Thus, the supraspinally mediated effect of gabapentin on mechanical hypersensitivity involves activation of spinal alpha(2)-adrenergic receptors followed by muscarinic receptors (most likely M(1)) and the NO cascade. In contrast, the effect of supraspinal gabapentin on thermal hypersensitivity is independent of the spinal cholinergic-NO system.
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Affiliation(s)
- Keiko Takasu
- Laboratory of CNS Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1 Tanabe-dori, Mizuho-ku, Nagoya 467-8603, Japan
| | - Motoko Honda
- Laboratory of CNS Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1 Tanabe-dori, Mizuho-ku, Nagoya 467-8603, Japan
| | - Hideki Ono
- Laboratory of CNS Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1 Tanabe-dori, Mizuho-ku, Nagoya 467-8603, Japan
| | - Mitsuo Tanabe
- Laboratory of CNS Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1 Tanabe-dori, Mizuho-ku, Nagoya 467-8603, Japan
- Author for correspondence:
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Ma W, Eisenach JC. Neuronal nitric oxide synthase is upregulated in a subset of primary sensory afferents after nerve injury which are necessary for analgesia from alpha2-adrenoceptor stimulation. Brain Res 2006; 1127:52-8. [PMID: 17113051 PMCID: PMC1831830 DOI: 10.1016/j.brainres.2006.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 09/29/2006] [Accepted: 10/02/2006] [Indexed: 11/21/2022]
Abstract
alpha2-Adrenoceptor (AR) agonists increase in analgesic potency and efficacy after peripheral nerve injury, and their effects are blocked by neuronal nitric oxide synthase (nNOS) inhibitors and M4 muscarinic receptor antagonists only after injury. We tested whether nNOS and M4 muscarinic receptors are co-expressed in the spinal cord, and whether destruction of a subset of sensory afferents which are essential to alpha2-AR analgesia would also destroy nNOS and M4 receptor expression. Male Sprague-Dawley rats underwent left L5 and L6 spinal nerve ligation. Lumbar spinal cord was removed and immunostained for M4 muscarinic receptors and nNOS alone and for co-expression. Others received intrathecal injection of saporin linked to an antibody to the neurotrophin receptor p75(NTR), which eliminates cells expressing this receptor and the analgesic effects of alpha2-AR agonists. nNOS staining of fibers in the superficial dorsal horn was dramatically increased after spinal nerve ligation, and this was abolished by saporin linked anti-p75(NTR) treatment. In contrast, nNOS staining in dorsal horn neurons was unaltered by these manipulations. M4 receptors were present on neurons in the dorsal horn, some of which co-expressed nNOS, but their pattern of expression was not altered by these manipulations. Peripheral nerve injury increases nNOS expression in fibers in the superficial dorsal horn, some of which likely express p75(NTR), and alpha2-AR agonists may reduce injury-induced sensitization by activation of nNOS in these fibers In contrast, changes in nNOS and M4 receptor location on spinal cord neurons are not responsible for increased analgesic potency of alpha2-AR agonists after nerve injury.
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MESH Headings
- Adrenergic alpha-2 Receptor Agonists
- Adrenergic alpha-Agonists/pharmacology
- Animals
- Disease Models, Animal
- Ganglia, Spinal/drug effects
- Ganglia, Spinal/metabolism
- Ganglia, Spinal/physiopathology
- Ligation
- Male
- Neuralgia/drug therapy
- Neuralgia/metabolism
- Neuralgia/physiopathology
- Neurons, Afferent/drug effects
- Neurons, Afferent/metabolism
- Neurotoxins/pharmacology
- Nitric Oxide/metabolism
- Nitric Oxide Synthase Type I/metabolism
- Nociceptors/cytology
- Nociceptors/drug effects
- Nociceptors/metabolism
- Peripheral Nervous System Diseases/drug therapy
- Peripheral Nervous System Diseases/metabolism
- Peripheral Nervous System Diseases/physiopathology
- Posterior Horn Cells/drug effects
- Posterior Horn Cells/metabolism
- Rats
- Rats, Sprague-Dawley
- Receptor, Muscarinic M4/drug effects
- Receptor, Muscarinic M4/metabolism
- Receptor, Nerve Growth Factor/drug effects
- Receptor, Nerve Growth Factor/metabolism
- Receptors, Adrenergic, alpha-2/metabolism
- Spinal Nerve Roots/drug effects
- Spinal Nerve Roots/metabolism
- Spinal Nerve Roots/physiopathology
- Spinal Nerves/injuries
- Spinal Nerves/metabolism
- Spinal Nerves/physiopathology
- Up-Regulation/drug effects
- Up-Regulation/physiology
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Affiliation(s)
- Weiya Ma
- Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1009, USA
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Paradiso KG, Steinbach JH. Nicotine is highly effective at producing desensitization of rat alpha4beta2 neuronal nicotinic receptors. J Physiol 2003; 553:857-71. [PMID: 14555718 PMCID: PMC2343639 DOI: 10.1113/jphysiol.2003.053447] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We examined desensitization by acetylcholine (ACh) and nicotine at the rat alpha4beta2 neuronal nicotinic receptor stably expressed in HEK cells. For both agonists, the decay in response due to desensitization ('onset') was best fitted by the sum of two exponentials with the fast component dominant at concentrations > 1 microM. The time constants for onset were similar for both agonists, and showed little concentration dependence over the range of 0.1-100 microM. Recovery from desensitization also showed two exponential components. In contrast to the similarity in onset, nicotine produced longer lasting desensitization, resulting from an increase in the proportion of receptors in the slowly recovering population and from an increase in the time constant for the slow recovery process. The proportion of receptors in the slowly recovering population increased as the duration of the desensitizing pulse increased. Desensitization was also induced by low concentrations of agonist, with no apparent macroscopic response. A 100 s application of 10 nM nicotine desensitized 70 % of the peak response, while 100 s of 10 nM ACh desensitized only 15 %. At higher concentrations of agonist, which result in a macroscopic response, desensitization in the absence of activation also can occur. Nicotine is a very potent and efficacious desensitizing agent at this neuronal nicotinic receptor.
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Affiliation(s)
- K G Paradiso
- Department of Anesthesiology, Washington University, St Louis, MO 63110, USA
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Abstract
Laboratory data, economic pressures, and the wish for humane treatment have been some of the driving forces behind improvements in paediatric pain management. Within the space of 10 years, there have been dramatic changes in the quality of treatment received by children undergoing surgical operations. Moreover, those receiving medical treatment, for example, sickle cell disease, have also benefited from increased experience in pain management. Children receiving care in specialised centres can now expect to benefit from up-to-date techniques of pain management, such as patient-controlled analgesia, nurse-controlled analgesia, and epidural infusions. They will be managed by ward nurses experienced and trained in paediatric pain relief, they will be attended by nurses whose special interest and training is the management of children's pain, and they will be provided with the techniques of analgesia by competent, trained anaesthetic staff. Improved care, with close attention to pain relief, is not only humane, but improves the patient turnaround by enhancing rapid discharge. Further education is required to spread these benefits to children being managed outside highly specialised centres. Not only education, but investment, is needed also to ensure that all children receive a standard of care second to none.
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Affiliation(s)
- A R Lloyd-Thomas
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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