1
|
Darbari DS, Sheehan VA, Ballas SK. The vaso-occlusive pain crisis in sickle cell disease: Definition, pathophysiology, and management. Eur J Haematol 2020; 105:237-246. [PMID: 32301178 DOI: 10.1111/ejh.13430] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/11/2022]
Abstract
Early diagnosis, treatment, and prevention of a vaso-occlusive crisis (VOC) are critical to the management of patients with sickle cell disease. It is essential to differentiate between VOC-associated pain and chronic pain, hyperalgesia, neuropathy, and neuropathic pain. The pathophysiology of VOCs includes polymerization of abnormal sickle hemoglobin, inflammation, and adhesion. Hydroxyurea, L-glutamine, crizanlizumab, and voxelotor have been approved by the US Food and Drug Administration for reducing the frequency of VOCs; the European Medicines Agency has approved only hydroxyurea. Other novel treatments are in late-stage clinical development in both the United States and the European Union. The development of agents for prevention and treatment of VOCs should be driven by our understanding of its pathophysiology.
Collapse
Affiliation(s)
- Deepika S Darbari
- Division of Hematology, Children's National Medical Center, Washington, DC, USA
| | - Vivien A Sheehan
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Samir K Ballas
- Cardeza Foundation for Hematologic Research, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
2
|
De Franceschi L, Mura P, Schweiger V, Vencato E, Quaglia FM, Delmonte L, Evangelista M, Polati E, Olivieri O, Finco G. Fentanyl Buccal Tablet: A New Breakthrough Pain Medication in Early Management of Severe Vaso-Occlusive Crisis in Sickle Cell Disease. Pain Pract 2015; 16:680-7. [PMID: 26009799 DOI: 10.1111/papr.12313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/24/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is a worldwide distributed hereditary red cell disorder. The principal clinical manifestations of SCD are the chronic hemolytic anemia and the acute vaso-occlusive crisis (VOCs), which are mainly characterized by ischemic/reperfusion tissue injury. Pain is the main symptom of VOCs, and its management is still a challenge for hematologists, requiring a multidisciplinary approach. METHODS We carried out a crossover study on adult SCD patients, who received two different types of multimodal analgesia during two separate severe VOCs with time interval between VOCs of at least 6 months. The first VOC episode was treated with ketorolac (0.86 mg/kg/day) and tramadol (7.2 mg/kg/day) (TK treatment). In the second VOC episode, fentanyl buccal tablet (FBT; 100 μg) was introduced in a single dose after three hours from the beginning of TK analgesia (TKF treatment). We focused on the first 24 hours of acute pain management. The primary efficacy measure was the time-weighted-sum of pain intensity differences (SPID24). The secondary efficacy measures included the pain intensity difference (PID), the total pain relief (TOTPAR), and the time-wighted sum of anxiety (SAID24). RESULTS SPID24 was significantly higher in TKF than in TK treatment. All the secondary measures were significantly ameliorated in TKF compared to TK treatment, without major opioid side effects. Patients satisfaction was higher with TKF treatment than with TK one. CONCLUSIONS We propose that VOCs might require breakthrough pain drug strategy as vaso-occlusive phenomena and enhanced vasoconstriction promoting acute ischemic pain component exacerbate the continuous pain of VOCs. FBT might be a powerful and feasible tool in early management of acute pain during VOCs in emergency departments.
Collapse
Affiliation(s)
- Lucia De Franceschi
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Paolo Mura
- Department of Medical Science "M. Aresu", Section of Anesthesia, Intensive Care and Pain Therapy, University of Cagliari, Cagliari, Italy
| | - Vittorio Schweiger
- Department of Surgical Science, Anesthesiology, Intensive Care and Pain therapy Center, University of Verona-AOUI-Verona, Verona, Italy
| | - Elisa Vencato
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Francesca Maria Quaglia
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Letizia Delmonte
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Maurizio Evangelista
- Department of Emergency, Institute of Anesthesia, Resuscitation and Pain Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Enrico Polati
- Department of Surgical Science, Anesthesiology, Intensive Care and Pain therapy Center, University of Verona-AOUI-Verona, Verona, Italy
| | - Oliviero Olivieri
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Gabriele Finco
- Department of Medical Science "M. Aresu", Section of Anesthesia, Intensive Care and Pain Therapy, University of Cagliari, Cagliari, Italy
| |
Collapse
|
3
|
Calhoun G, Wang L, Almeida LEF, Kenyon N, Afsar N, Nouraie M, Finkel JC, Quezado ZMN. Dexmedetomidine ameliorates nocifensive behavior in humanized sickle cell mice. Eur J Pharmacol 2015; 754:125-33. [PMID: 25724786 DOI: 10.1016/j.ejphar.2015.02.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 02/11/2015] [Accepted: 02/17/2015] [Indexed: 10/24/2022]
Abstract
Patients with sickle cell disease (SCD) can have recurrent episodes of vaso-occlusive crises, which are associated with severe pain. While opioids are the mainstay of analgesic therapy, in some patients, increasing opioid use results in continued and increasing pain. Many believe that this phenomenon results from opioid-induced tolerance or hyperalgesia or that SCD pain involves non-opioid-responsive mechanisms. Dexmedetomidine, a specific α2-adrenoreceptor agonist, which has sedative and analgesic properties, reduces opioid requirements, and can facilitate opioid withdrawal in clinical settings. We hypothesized that dexmedetomidine would ameliorate the nociception phenotype of SCD mice. Townes and BERK SCD mice, strains known to have altered nociception phenotypes, were used in a crossover preclinical trial that measured nocifensive behavior before and after treatment with dexmedetomidine or vehicle. In a linear dose-effect relationship, over 60-min, dexmedetomidine, compared with vehicle, significantly increased hot plate latency in Townes and BERK mice (P≤0.006). In sickle, but not control mice, dexmedetomidine improved grip force, an indicator of muscle pain (P=0.002). As expected, dexmedetomidine had a sedative effect in sickle and control mice as it decreased wakefulness scores compared with vehicle (all P<0.001). Interestingly, the effects of dexmedetomidine on hot plate latency and wakefulness scores were different in sickle and control mice, i.e., dexmedetomidine-related increases in hotplate latency and decreases in wakefulness scores were significantly smaller in Townes sickle compared to control mice. In conclusion, these findings of beneficial effects of dexmedetomidine on the nociception phenotype in SCD mice might support the conduct of studies of dexmedetomidine in SCD patients.
Collapse
Affiliation(s)
- Gabriela Calhoun
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States
| | - Li Wang
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States
| | - Luis E F Almeida
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States
| | - Nicholas Kenyon
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States
| | - Nina Afsar
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States
| | - Mehdi Nouraie
- Center for Sickle Cell Disease and Department of Internal Medicine, Howard University, Washington, DC 20001, United States
| | - Julia C Finkel
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States
| | - Zenaide M N Quezado
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Division of Pain Medicine, Children׳s National Health System, Children׳s Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC 20010, United States.
| |
Collapse
|
4
|
Nath KA, Katusic ZS. Vasculature and kidney complications in sickle cell disease. J Am Soc Nephrol 2012; 23:781-4. [PMID: 22440903 DOI: 10.1681/asn.2011101019] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Recent developments in sickle cell disease include the concept of a vasculopathic state and the classification of sickle cell disease into a hemolysis-endothelial dysfunction phenotype or a viscosity-vasoocclusion phenotype. The hemolysis-endothelial dysfunction phenotype largely reflects deficiency of or resistance to nitric oxide. In addition to discussing these areas, we suggest that the hemolysis-endothelial dysfunction phenotype also reflects the instability of sickle hemoglobin, the release of heme, and the induction of heme oxygenase-1. From these perspectives the renal complications of sickle cell disease are discussed and classified.
Collapse
Affiliation(s)
- Karl A Nath
- Division of Nephrology and Hypertension, Internal Medicine, Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55905, USA.
| | | |
Collapse
|
5
|
Hebbel RP. Reconstructing sickle cell disease: a data-based analysis of the "hyperhemolysis paradigm" for pulmonary hypertension from the perspective of evidence-based medicine. Am J Hematol 2011; 86:123-54. [PMID: 21264896 DOI: 10.1002/ajh.21952] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The "hyperhemolytic paradigm" (HHP) posits that hemolysis in sickle disease sequentially and causally establishes increased cell-free plasma Hb, consumption of NO, a state of NO biodeficiency, endothelial dysfunction, and a high prevalence of pulmonary hypertension. The basic science underpinning this concept has added an important facet to the complexity of vascular pathobiology in sickle disease, and clinical research has identified worrisome clinical issues. However, this critique identifies and explains a number of significant concerns about the various HHP component tenets. In addressing these issues, this report presents: a very brief history of the HHP, an integrated synthesis of mechanisms underlying sickle hemolysis, a review of the evidentiary value of hemolysis biomarkers, an examination of evidence bearing on existence of a hyperhemolytic subgroup, and a series of questions that should naturally be applied to the HHP if it is examined using critical thinking skills, the fundamental basis of evidence-based medicine. The veracity of different HHP tenets is found to vary from true, to weakly supported, to demonstrably false. The thesis is developed that the HHP has misidentified the mechanism and clinical significance of its findings. The extant research questions identified by these analyses are delineated, and a conservative, evidence-based approach is suggested for application in clinical medicine.
Collapse
Affiliation(s)
- Robert P. Hebbel
- Department of Medicine, Division of Hematology‐Oncology‐Transplantation, Vascular Biology Center, University of Minnesota Medical School, Minneapolis, Minnesota
| |
Collapse
|