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Ponzano M, Signori A, Bellavia A, Carbone A, Bovis F, Schiavetti I, Montobbio N, Sormani MP. Race and ethnicity in multiple sclerosis phase 3 clinical trials: A systematic review. Mult Scler 2024; 30:934-967. [PMID: 38849992 DOI: 10.1177/13524585241254283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
BACKGROUND Distinctive differences in multiple sclerosis (MS) have been observed by race and ethnicity. We aim to (1) assess how often race and ethnicity were reported in clinical trials registered on ClinicalTrials.gov, (2) evaluate whether the population was diverse enough, and (3) compare with publications. METHODS We included phase 3 clinical trials registered with results on ClinicalTrials.gov between 2007 and 2023. When race and/or ethnicity were reported, we searched for the corresponding publications. RESULTS Out of the 99 included studies, 56% reported race and/or ethnicity, of which only 26% of those primarily completed before 2017. Studies reporting race or ethnicity contributed to a total of 33,891 participants, mainly enrolled in Eastern Europe. Most were White (93%), and the median percentage of White participants was 93% (interquartile range (IQR) = 86%-98%), compared to 3% for Black (IQR = 1%-12%) and 0.2% for Asian (IQR = 0%-1%). Four trials omitted race and ethnicity in publications and even when information was reported, some discrepancies in terminology were identified and categories with fewer participants were often collapsed. CONCLUSION More efforts should be done to improve transparency, accuracy, and representativeness, in publications and at a design phase, by addressing social determinants of health that historically limit the enrollment of underrepresented population.
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Affiliation(s)
- Marta Ponzano
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Andrea Bellavia
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alessio Carbone
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Irene Schiavetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Noemi Montobbio
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy; Ospedale Policlinico San Martino IRCCS, Genoa, Italy
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Fernández Ó, Sörensen PS, Comi G, Vermersch P, Hartung HP, Leocani L, Berger T, Van Wijmeersch B, Oreja-Guevara C. Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review. Front Immunol 2024; 15:1379538. [PMID: 38646534 PMCID: PMC11032020 DOI: 10.3389/fimmu.2024.1379538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.
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Affiliation(s)
- Óscar Fernández
- Departament of Pharmacology, Faculty of Medicine; Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, Malaga, Spain
- Department of Pharmacology and Pediatry, Faculty of Medicine, University of Malaga, Malaga, Spain
| | - Per Soelberg Sörensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Copenhagen and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Giancarlo Comi
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
| | - Letizia Leocani
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Bart Van Wijmeersch
- University MS Centre, Hasselt-Pelt, Belgium
- Rehabilitation and Multiple Sclerosis (MS), Noorderhart Hospitals, Pelt, Belgium
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico Universitario San Carlos, IdISSC, Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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3
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Shkodina AD, Bardhan M, Chopra H, Anyagwa OE, Pinchuk VA, Hryn KV, Kryvchun AM, Boiko DI, Suresh V, Verma A, Delva MY. Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis. CNS Drugs 2024; 38:205-224. [PMID: 38421578 DOI: 10.1007/s40263-024-01072-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/02/2024]
Abstract
Multiple sclerosis is a chronic inflammatory disease that affects the central nervous system and can cause various types of pain including ongoing extremity pain, Lhermitte's phenomenon, trigeminal neuralgia, and mixed pain. Neuropathic pain is a major concern for individuals with multiple sclerosis as it is directly linked to myelin damage in the central nervous system and the management of neuropathic pain in multiple sclerosis is challenging as the options available have limited efficacy and can cause unpleasant side effects. The literature search was conducted across two databases, PubMed, and Google Scholar. Eligible studies included clinical trials, observational studies, meta-analyses, systematic reviews, and narrative reviews. The objective of this article is to provide an overview of literature on pharmacological and non-pharmacological strategies employed in the management of neuropathic pain in multiple sclerosis. Pharmacological options include cannabinoids, muscle relaxants (tizanidine, baclofen, dantrolene), anticonvulsants (benzodiazepines, gabapentin, phenytoin, carbamazepine, lamotrigine), antidepressants (duloxetine, venlafaxine, tricyclic antidepressants), opioids (naltrexone), and botulinum toxin variants, which have evidence from various clinical trials. Non-pharmacological approaches for trigeminal neuralgia may include neurosurgical methods. Non-invasive methods, physical therapy, and psychotherapy (cognitive behavioral therapy, acceptance and commitment therapy and mindfulness-based stress reduction) may be recommended for patients with neuropathic pain in multiple sclerosis. The choice of treatment depends on the severity and type of pain as well as other factors, such as patient preferences and comorbidities. There is a pressing need for healthcare professionals and researchers to prioritize the development of better strategies for managing multiple sclerosis-induced neuropathic pain.
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Affiliation(s)
- Anastasiia D Shkodina
- Department of Neurological diseases, Poltava State Medical University, Poltava, Ukraine
| | - Mainak Bardhan
- Neuro Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, 8900 N. Kendall Drive, Miami, FL, 33176, USA.
| | - Hitesh Chopra
- Department of Biosciences, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Chennai, 602105, Tamil Nadu, India
| | | | - Viktoriia A Pinchuk
- Department of Neurological diseases, Poltava State Medical University, Poltava, Ukraine
| | - Kateryna V Hryn
- Department of Neurological diseases, Poltava State Medical University, Poltava, Ukraine
| | - Anzhelina M Kryvchun
- Department of Neurological diseases, Poltava State Medical University, Poltava, Ukraine
| | - Dmytro I Boiko
- Department of Psychiatry, Narcology and Medical Psychology, Poltava State Medical University, Poltava, Ukraine
| | - Vinay Suresh
- King George's Medical University, Lucknow, India
| | - Amogh Verma
- Rama Medical College Hospital and Research Centre, Hapur, India
| | - Mykhailo Yu Delva
- Department of Neurological diseases, Poltava State Medical University, Poltava, Ukraine
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Rosner J, de Andrade DC, Davis KD, Gustin SM, Kramer JLK, Seal RP, Finnerup NB. Central neuropathic pain. Nat Rev Dis Primers 2023; 9:73. [PMID: 38129427 PMCID: PMC11329872 DOI: 10.1038/s41572-023-00484-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Central neuropathic pain arises from a lesion or disease of the central somatosensory nervous system such as brain injury, spinal cord injury, stroke, multiple sclerosis or related neuroinflammatory conditions. The incidence of central neuropathic pain differs based on its underlying cause. Individuals with spinal cord injury are at the highest risk; however, central post-stroke pain is the most prevalent form of central neuropathic pain worldwide. The mechanisms that underlie central neuropathic pain are not fully understood, but the pathophysiology likely involves intricate interactions and maladaptive plasticity within spinal circuits and brain circuits associated with nociception and antinociception coupled with neuronal hyperexcitability. Modulation of neuronal activity, neuron-glia and neuro-immune interactions and targeting pain-related alterations in brain connectivity, represent potential therapeutic approaches. Current evidence-based pharmacological treatments include antidepressants and gabapentinoids as first-line options. Non-pharmacological pain management options include self-management strategies, exercise and neuromodulation. A comprehensive pain history and clinical examination form the foundation of central neuropathic pain classification, identification of potential risk factors and stratification of patients for clinical trials. Advanced neurophysiological and neuroimaging techniques hold promise to improve the understanding of mechanisms that underlie central neuropathic pain and as predictive biomarkers of treatment outcome.
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Affiliation(s)
- Jan Rosner
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Daniel C de Andrade
- Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Karen D Davis
- Division of Brain, Imaging and Behaviour, Krembil Brain Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Surgery and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia M Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - John L K Kramer
- International Collaboration on Repair Discoveries, ICORD, University of British Columbia, Vancouver, Canada
- Department of Anaesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rebecca P Seal
- Pittsburgh Center for Pain Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Departments of Neurobiology and Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.
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5
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Doneddu PE, Pensato U, Iorfida A, Alberti C, Nobile-Orazio E, Fabbri A, Voza A. Neuropathic Pain in the Emergency Setting: Diagnosis and Management. J Clin Med 2023; 12:6028. [PMID: 37762968 PMCID: PMC10531819 DOI: 10.3390/jcm12186028] [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: 07/21/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Neuropathic pain, traditionally considered a chronic condition, is increasingly encountered in the emergency department (ED), accounting for approximately 20% of patients presenting with pain. Understanding the physiology and key clinical presentations of neuropathic pain is crucial for ED physicians to provide optimal treatment. While diagnosing neuropathic pain can be challenging, emphasis should be placed on obtaining a comprehensive medical history and conducting a thorough clinical examination. Patients often describe neuropathic pain as a burning or shock-like sensation, leading them to seek care in the ED after ineffective relief from common analgesics such as paracetamol and NSAIDs. Collaboration between emergency medicine specialists, neurologists, and pain management experts can contribute to the development of evidence-based guidelines specifically tailored for the emergency department setting. This article provides a concise overview of the common clinical manifestations of neuropathic pain that may prompt patients to seek emergency care.
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Affiliation(s)
- Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
| | - Umberto Pensato
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Alessandra Iorfida
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Claudia Alberti
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, 20133 Milano, MI, Italy
| | - Andrea Fabbri
- Emergency Department AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, FC, Italy
| | - Antonio Voza
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
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6
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Birkinshaw H, Friedrich CM, Cole P, Eccleston C, Serfaty M, Stewart G, White S, Moore RA, Phillippo D, Pincus T. Antidepressants for pain management in adults with chronic pain: a network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD014682. [PMID: 37160297 PMCID: PMC10169288 DOI: 10.1002/14651858.cd014682.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well-being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients' global impression of change for certain chronic pain conditions. However, there has not been a network meta-analysis (NMA) examining all antidepressants across all chronic pain conditions. OBJECTIVES To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. SELECTION CRITERIA We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double-blind. We included RCTs with active comparators that were unable to be double-blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow-up was less than two weeks and those with fewer than 10 participants in each arm. DATA COLLECTION AND ANALYSIS: Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta-analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta-Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB-MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. MAIN RESULTS This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo-controlled (83), and parallel-armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate-certainty evidence) and continuous pain intensity (standardised mean difference (SMD) -0.31, 95% CI -0.39 to -0.24; 18 studies, 4959 participants; moderate-certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD -0.22, 95% CI -0.39 to 0.06; 4 studies, 1866 participants; moderate-certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD -0.5, 95% CI -0.78 to -0.22; 1 study, 406 participants; low-certainty evidence), while duloxetine showed a small effect (SMD -0.16, 95% CI -0.22 to -0.1; 26 studies, 7952 participants; moderate-certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest-ranked antidepressants with moderate-certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low-certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. AUTHORS' CONCLUSIONS Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point.
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Affiliation(s)
- Hollie Birkinshaw
- Department of Psychology, University of Southampton, Southampton, UK
| | | | - Peter Cole
- Oxford Pain Relief Unit, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | | | | | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | | | | | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, UK
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Fung S, Kang C. Management of central neuropathic pain involves many drugs but few have proven efficacy. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00965-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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8
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Ri S. The Management of Poststroke Thalamic Pain: Update in Clinical Practice. Diagnostics (Basel) 2022; 12:1439. [PMID: 35741249 PMCID: PMC9222201 DOI: 10.3390/diagnostics12061439] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/29/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022] Open
Abstract
Poststroke thalamic pain (PS-TP), a type of central poststroke pain, has been challenged to improve the rehabilitation outcomes and quality of life after a stroke. It has been shown in 2.7-25% of stroke survivors; however, the treatment of PS-TP remains difficult, and in majority of them it often failed to manage the pain and hypersensitivity effectively, despite the different pharmacotherapies as well as invasive interventions. Central imbalance, central disinhibition, central sensitization, other thalamic adaptative changes, and local inflammatory responses have been considered as its possible pathogenesis. Allodynia and hyperalgesia, as well as the chronic sensitization of pain, are mainly targeted in the management of PS-TP. Commonly recommended first- and second-lines of pharmacological therapies, including traditional medications, e.g., antidepressants, anticonvulsants, opioid analgesics, and lamotrigine, were more effective than others. Nonpharmacological interventions, such as transcranial magnetic or direct current brain stimulations, vestibular caloric stimulation, epidural motor cortex stimulation, and deep brain stimulation, were effective in some cases/small-sized studies and can be recommended in the management of therapy-resistant PS-TP. Interestingly, the stimulation to other areas, e.g., the motor cortex, periventricular/periaqueductal gray matter, and thalamus/internal capsule, showed more effect than the stimulation to the thalamus alone. Further studies on brain or spinal stimulation are required for evidence.
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Affiliation(s)
- Songjin Ri
- Department for Neurology, Meoclinic, Berlin, Friedrichstraße 71, 10117 Berlin, Germany;
- Department of Neurology, Charité University Hospital (CBS), 12203 Berlin, Germany
- Outpatient Clinic for Neurology, Manfred-von-Richthofen-Straße 15, 12101 Berlin, Germany
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9
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Symptom-based pharmacotherapy for neuropathic pain related to spinal disorders: results from a patient-based assessment. Sci Rep 2022; 12:7192. [PMID: 35504949 PMCID: PMC9064937 DOI: 10.1038/s41598-022-11345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/21/2022] [Indexed: 11/09/2022] Open
Abstract
Existing guidelines advocate an updated therapeutic algorithm for chronic neuropathic pain (NeP), but pharmacotherapeutic management should be individualized to pain phenotypes to achieve higher efficacy. This study was aimed to evaluate the efficacy of medications, based on NeP phenotypes, and to propose symptom-based pharmacotherapy. This retrospective study was enrolled 265 outpatients with chronic NeP related to spinal disorders. The patients were classified into three groups: spinal cord-related pain, radicular pain, and cauda equina syndrome. Data were obtained from patient-based questionnaires using Neuropathic Pain Symptom Inventory (NPSI) and the Brief Scale for Psychiatric Problems in Orthopaedic Patients, and from clinical information. The proportions of patients with ≥ 30% and ≥ 50% reduction in NPSI score for each pain subtype (spontaneous pain, paroxysmal pain, evoked pain, and paresthesia/dysesthesia) and drugs were evaluated. The pain reduction rate was significantly lower in patients with spinal cord-related pain, especially for paresthesia/dysesthesia. For spinal cord-related pain, duloxetine and neurotropin had insufficient analgesic effects, whereas mirogabalin was the most effective. Pregabalin or mirogabalin for radicular pain and duloxetine for cauda equina syndrome are recommended in cases of insufficient analgesic effects with neurotropin. The findings could contribute to better strategies for symptom-based pharmacotherapeutic management.
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10
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Central Neuropathic Pain Syndromes: Current and Emerging Pharmacological Strategies. CNS Drugs 2022; 36:483-516. [PMID: 35513603 DOI: 10.1007/s40263-022-00914-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/31/2022]
Abstract
Central neuropathic pain is caused by a disease or lesion of the brain or spinal cord. It is difficult to predict which patients will develop central pain syndromes after a central nervous system injury, but depending on the etiology, lifetime prevalence may be greater than 50%. The resulting pain is often highly distressing and difficult to treat, with no specific treatment guidelines currently available. This narrative review discusses mechanisms contributing to central neuropathic pain, and focuses on pharmacological approaches for managing common central neuropathic pain conditions such as central post-stroke pain, spinal cord injury-related pain, and multiple sclerosis-related neuropathic pain. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids have some evidence for efficacy in central neuropathic pain. Medications from other pharmacologic classes may also provide pain relief, but current evidence is limited. Certain non-pharmacologic approaches, neuromodulation in particular, may be helpful in refractory cases. Emerging data suggest that modulating the primary afferent input may open new horizons for the treatment of central neuropathic pain. For most patients, effective treatment will likely require a multimodal therapy approach.
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Abboud H, Salazar-Camelo A, George N, Planchon SM, Matiello M, Mealy MA, Goodman A. Symptomatic and restorative therapies in neuromyelitis optica spectrum disorders. J Neurol 2021; 269:1786-1801. [PMID: 34482456 PMCID: PMC8940781 DOI: 10.1007/s00415-021-10783-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 02/06/2023]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are a group of autoimmune inflammatory conditions that primarily target the optic nerves, spinal cord, brainstem, and occasionally the cerebrum. NMOSD is characterized by recurrent attacks of visual, motor, and/or sensory dysfunction that often result in severe neurological deficits. In recent years, there has been a significant progress in relapse treatment and prevention but the residual disability per attack remains high. Although symptomatic and restorative research has been limited in NMOSD, some therapeutic approaches can be inferred from published case series and evidence from multiple sclerosis literature. In this review, we will discuss established and emerging therapeutic options for symptomatic treatment and restoration of function in NMOSD. We highlight NMOSD-specific considerations and identify potential areas for future research. The review covers pharmacologic, non-pharmacologic, and neuromodulatory approaches to neuropathic pain, tonic spasms, muscle tone abnormalities, sphincter dysfunction, motor and visual impairment, fatigue, sleep disorders, and neuropsychological symptoms. In addition, we briefly discuss remyelinating agents and mesenchymal stem cell transplantation in NMOSD.
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Affiliation(s)
- Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, Parkinson's and Movement Disorders Center, University Hospitals of Cleveland, Case Western Reserve University, Bolwell, 5th floor, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Andrea Salazar-Camelo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Naveen George
- Multiple Sclerosis and Neuroimmunology Program, Parkinson's and Movement Disorders Center, University Hospitals of Cleveland, Case Western Reserve University, Bolwell, 5th floor, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sarah M Planchon
- The Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Marcelo Matiello
- Neurology Department, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maureen A Mealy
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Horizon Therapeutics Plc, Deerfield, IL, USA
| | - Andrew Goodman
- Neuroimmunology Division, Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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12
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Tosti G, Attal N. Trattamento farmacologico dei dolori neuropatici. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Stamoula E, Siafis S, Dardalas I, Ainatzoglou A, Matsas A, Athanasiadis T, Sardeli C, Stamoulas K, Papazisis G. Antidepressants on Multiple Sclerosis: A Review of In Vitro and In Vivo Models. Front Immunol 2021; 12:677879. [PMID: 34093579 PMCID: PMC8173210 DOI: 10.3389/fimmu.2021.677879] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/06/2021] [Indexed: 01/03/2023] Open
Abstract
Background Increased prevalence of depression has been observed among patients with multiple sclerosis (MS) and correlated with the elevated levels of proinflammatory cytokines and the overall deregulation of monoaminergic neurotransmitters that these patients exhibit. Antidepressants have proved effective not only in treating depression comorbid to MS, but also in alleviating numerous MS symptoms and even minimizing stress-related relapses. Therefore, these agents could prospectively prove beneficial as a complementary MS therapy. Objective This review aims at illustrating the underlying mechanisms involved in the beneficial clinical effects of antidepressants observed in MS patients. Methods Through a literature search we screened and comparatively assessed papers on the effects of antidepressant use both in vitro and in vivo MS models, taking into account a number of inclusion and exclusion criteria. Results In vitro studies indicated that antidepressants promote neural and glial cell viability and differentiation, reduce proinflammatory cytokines and exert neuroprotective activity by eliminating axonal loss. In vivo studies confirmed that antidepressants delayed disease onset and alleviated symptoms in Experimental Autoimmune Encephalomyelitis (EAE), the most prevalent animal model of MS. Further, antidepressant agents suppressed inflammation and restrained demyelination by decreasing immune cell infiltration of the CNS. Conclusion Antidepressants were efficient in tackling numerous aspects of disease pathophysiology both in vitro and in vivo models. Given that several antidepressants have already proved effective in clinical trials on MS patients, the inclusion of such agents in the therapeutic arsenal of MS should be seriously considered, following an individualized approach to minimize the adverse events of antidepressants in MS patients.
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Affiliation(s)
- Eleni Stamoula
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyridon Siafis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Dardalas
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Ainatzoglou
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alkis Matsas
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Chrysanthi Sardeli
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Georgios Papazisis
- Department of Clinical Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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14
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Oliveira RAAD, Baptista AF, Sá KN, Barbosa LM, Nascimento OJMD, Listik C, Moisset X, Teixeira MJ, Andrade DCD. Pharmacological treatment of central neuropathic pain: consensus of the Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:741-752. [DOI: 10.1590/0004-282x20200166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022]
Abstract
ABSTRACT Background: Central neuropathic pain (CNP) is often refractory to available therapeutic strategies and there are few evidence-based treatment options. Many patients with neuropathic pain are not diagnosed or treated properly. Thus, consensus-based recommendations, adapted to the available drugs in the country, are necessary to guide clinical decisions. Objective: To develop recommendations for the treatment of CNP in Brazil. Methods: Systematic review, meta-analysis, and specialists opinions considering efficacy, adverse events profile, cost, and drug availability in public health. Results: Forty-four studies on CNP treatment were found, 20 were included in the qualitative analysis, and 15 in the quantitative analysis. Medications were classified as first-, second-, and third-line treatment based on systematic review, meta-analysis, and expert opinion. As first-line treatment, gabapentin, duloxetine, and tricyclic antidepressants were included. As second-line, venlafaxine, pregabalin for CND secondary to spinal cord injury, lamotrigine for CNP after stroke, and, in association with first-line drugs, weak opioids, in particular tramadol. For refractory patients, strong opioids (methadone and oxycodone), cannabidiol/delta-9-tetrahydrocannabinol, were classified as third-line of treatment, in combination with first or second-line drugs and, for central nervous system (CNS) in multiple sclerosis, dronabinol. Conclusions: Studies that address the treatment of CNS are scarce and heterogeneous, and a significant part of the recommendations is based on experts opinions. The CNP approach must be individualized, taking into account the availability of medication, the profile of adverse effects, including addiction risk, and patients' comorbidities.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Daniel Ciampi de Andrade
- Universidade de São Paulo, Brazil; Academia Brasileira de Neurologia, Brazil; Universidade de São Paulo, Brazil
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15
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Beyond pain: can antidepressants improve depressive symptoms and quality of life in patients with neuropathic pain? A systematic review and meta-analysis. Pain 2020; 160:2186-2198. [PMID: 31145210 DOI: 10.1097/j.pain.0000000000001622] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Neuropathic pain can be a predictor of severe emotional distress, up to full-blown depressive states. In these patients, it is important to move beyond the sole treatment of pain, to recognize depressive symptoms, and to ultimately improve the quality of life. We systematically searched for published and unpublished clinical trials assessing the efficacy and tolerability of antidepressants vs placebo on depression, anxiety and quality of life in patients with neuropathic pain, and pooled data in a meta-analysis. A total of 37 studies fulfilled eligibility criteria and 32 provided data for meta-analysis. Antidepressants were more effective than placebo in improving depressive symptoms (standardized mean difference -0.11; 95% confidence interval -0.20 to -0.02), although the magnitude of effect was small, with a number needed to treat of 24. No significant difference emerged between antidepressants and placebo in reducing anxiety. Quality of life seemed improved in patients on antidepressants, as did pain. Acceptability and tolerability were higher in patients on placebo. To the best of our knowledge, this is the first meta-analysis specifically focusing on the effect of antidepressants on psychiatric symptoms and quality of life in patients with neuropathic pain. Our findings suggest that despite their potential benefit in patients with neuropathic pain, antidepressants should be prescribed with particular care because they might be less tolerable in such a fragile population. However, our findings warrant further research to explore how a correct use of antidepressants can help patients to cope with the consequences of neuropathic pain on their psychosocial health and quality of life.
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16
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Abstract
Pain is a major matter for patients with multiple sclerosis; treatment response is frequently inadequate, with a significant impact on quality of life. The estimated prevalence of pain in multiple sclerosis ranges widely (26-86%), and different subtypes of pain, mediated by specific pathophysiological mechanisms, are described. The aim of this narrative review, performed using a systematic search methodology, was to provide current, evidence-based, knowledge about the pharmacological treatment of the different kinds of pain in multiple sclerosis. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov), considering publications up to November 2019. Two authors independently selected studies for inclusion, data extraction, and bias assessment. A total of 27 randomized controlled trials were identified, but in only a few cases, patients with different pain qualities were stratified. Following a mechanism-based approach, treatment of paroxysmal pain and painful tonic spasms should be based on sodium-channel blockers, whereas treatment of ongoing extremity pain should be based on gabapentinoids and antidepressants.
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17
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Park K, Kim S, Ko YJ, Park BJ. Duloxetine and cardiovascular adverse events: A systematic review and meta-analysis. J Psychiatr Res 2020; 124:109-114. [PMID: 32135389 DOI: 10.1016/j.jpsychires.2020.02.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 02/08/2023]
Abstract
Duloxetine has been increasingly administered, but the associated cardiovascular adverse event risk is not clearly understood. Therefore, we identified the association between duloxetine and cardiovascular adverse events through an analysis of heart rate and blood pressure change. We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and psycINFO in June 2019. The title, abstract, and full text were checked in order to obtain articles. A meta-analysis was conducted with random effect model and quality of articles was evaluated using Cochrane Risk of Bias 2.0. The manuscript has been written according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) harm checklist. A total of 4009 studies were screened by the title and abstract. After reviewing 186 full texts, 17 studies were finally selected for the meta-analysis. Nine of the 17 studied duloxetine given for mood disorders and 8 for pain control. The duration of 14 studies was under 13 weeks. Cardiovascular adverse events (hypertension, myocardial infarction, transient ischemic attack, tachycardia atrial fibrillation, and cerebrovascular accident) were reported. The meta-analysis demonstrated that duloxetine increased heart rate by 2.22 beats/min (95% confidence intervals [CIs]: 1.53, 2.91) and diastolic blood pressure by 0.82 mmHg (95% CI: 0.17, 1.47). Our findings may be the signal for the safety of cardiovascular disease for short-term use of duloxetine. Well-designed pharmaco-epidemiological studies evaluating the causal relationship between long-term use of duloxetine and cardiovascular disease is still necessary.
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Affiliation(s)
- Kyounghoon Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, South Korea.
| | - Seonji Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, South Korea.
| | - Young-Jin Ko
- Department of Preventive Medicine, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, South Korea.
| | - Byung-Joo Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, South Korea.
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18
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Chisari CG, Sgarlata E, Arena S, D’Amico E, Toscano S, Patti F. An update on the pharmacological management of pain in patients with multiple sclerosis. Expert Opin Pharmacother 2020; 21:2249-2263. [DOI: 10.1080/14656566.2020.1757649] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Clara G. Chisari
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Eleonora Sgarlata
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
- Stroke Unit, Department of Medicine, Umberto I Hospital, Siracusa, Italy
| | - Sebastiano Arena
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Emanuele D’Amico
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia”, Section of Neurosciences, University of Catania, Catania, Italy
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19
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Moisset X, Bouhassira D, Avez Couturier J, Alchaar H, Conradi S, Delmotte MH, Lanteri-Minet M, Lefaucheur JP, Mick G, Piano V, Pickering G, Piquet E, Regis C, Salvat E, Attal N. Pharmacological and non-pharmacological treatments for neuropathic pain: Systematic review and French recommendations. Rev Neurol (Paris) 2020; 176:325-352. [PMID: 32276788 DOI: 10.1016/j.neurol.2020.01.361] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/07/2020] [Indexed: 02/08/2023]
Abstract
Neuropathic pain remains a significant unmet medical need. Several recommendations have recently been proposed concerning pharmacotherapy, neurostimulation techniques and interventional management, but no comprehensive guideline encompassing all these treatments has yet been issued. We performed a systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018. The main inclusion criteria were chronic neuropathic pain for at least three months, a randomized controlled methodology, at least three weeks of follow-up, at least 10 patients per group, and a double-blind design for drug therapy. Based on the GRADE system, we provide weak-to-strong recommendations for use and proposal as a first-line treatment for SNRIs (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants and, for topical lidocaine and transcutaneous electrical nerve stimulation specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a second-line treatment for pregabalin, tramadol, combination therapy (antidepressant combined with gabapentinoids), and for high-concentration capsaicin patches and botulinum toxin A specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a third-line treatment for high-frequency rTMS of the motor cortex, spinal cord stimulation (failed back surgery syndrome and painful diabetic polyneuropathy) and strong opioids (in the absence of an alternative). Psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies. An algorithm encompassing all the recommended treatments is proposed.
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Affiliation(s)
- X Moisset
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France.
| | - D Bouhassira
- INSERM U987, CETD, Ambroise-Paré Hospital, AP-HP, Boulogne-Billancourt, France; Université Versailles - Saint-Quentin-en-Yvelines, Versailles, France
| | - J Avez Couturier
- Service de Neuropédiatrie, Consultation Douleur Enfant, CIC-IT 1403, CHU de Lille, Lille, France
| | - H Alchaar
- 73, boulevard de Cimiez, Nice, France
| | - S Conradi
- CETD, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - M H Delmotte
- GHU, Paris site Ste-Anne, Structure Douleurs, 1, rue Cabanis, Paris 14, France
| | - M Lanteri-Minet
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; Département d'Évaluation et Traitement de la Douleur, Centre Hospitalier Universitaire (CHU) de Nice, Fédération Hospitalo-Universitaire InovPain, Université Côte d'Azur, Nice, France
| | - J P Lefaucheur
- EA 4391, Faculté de Médecine, Université Paris Est Créteil, Créteil, France; Service de Physiologie, Explorations Fonctionnelles, Hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil, France
| | - G Mick
- Centre d'Évaluation et Traitement de la Douleur du Voironnais, Centre Hospitalier de Voiron, Laboratoire P2S, Université de Lyon, Lyon, France
| | - V Piano
- Centre Hospitalier de Draguignan, Service Algologie 4(e), route de Montferrat, 83007 Draguignan cedex, France
| | - G Pickering
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; Clinical Pharmacology Department, CPC/CIC Inserm 1405, University Hospital CHU, Clermont-Ferrand, France
| | - E Piquet
- Département d'Évaluation et Traitement de la Douleur, Centre Hospitalier Universitaire (CHU) de Nice, Fédération Hospitalo-Universitaire InovPain, Université Côte d'Azur, Nice, France
| | - C Regis
- CETD, CHU Montpellier, Montpellier, France
| | - E Salvat
- Centre d'Évaluation et de Traitement de la Douleur, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
| | - N Attal
- INSERM U987, CETD, Ambroise-Paré Hospital, AP-HP, Boulogne-Billancourt, France; Université Versailles - Saint-Quentin-en-Yvelines, Versailles, France
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20
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Rodrigues-Amorim D, Olivares JM, Spuch C, Rivera-Baltanás T. A Systematic Review of Efficacy, Safety, and Tolerability of Duloxetine. Front Psychiatry 2020; 11:554899. [PMID: 33192668 PMCID: PMC7644852 DOI: 10.3389/fpsyt.2020.554899] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022] Open
Abstract
Duloxetine is a serotonin-norepinephrine reuptake inhibitor approved for the treatment of patients affected by major depressive disorder (MDD), generalized anxiety disorder (GAD), neuropathic pain (NP), fibromyalgia (FMS), and stress incontinence urinary (SUI). These conditions share parallel pathophysiological pathways, and duloxetine treatment might be an effective and safe alternative. Thus, a systematic review was conducted following the 2009 Preferred Reporting Items (PRISMA) recommendations and Joanna Briggs Institute Critical (JBI) Appraisals guidelines. Eighty-five studies focused on efficacy, safety, and tolerability of duloxetine were included in our systematic review. Studies were subdivided by clinical condition and evaluated individually. Thus, 32 studies of MDD, 11 studies of GAD, 19 studies of NP, 9 studies of FMS, and 14 studies of SUI demonstrated that the measured outcomes indicate the suitability of duloxetine in the treatment of these clinical conditions. This systematic review confirms that the dual mechanism of duloxetine benefits the treatment of comorbid clinical conditions, and supports the efficacy, safety, and tolerability of duloxetine in short- and long-term treatments.
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Affiliation(s)
- Daniela Rodrigues-Amorim
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), University of Vigo, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
| | - José Manuel Olivares
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), University of Vigo, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain.,Head of Department of Psychiatry, Health Area of Vigo, Servizo Galego de Saúde (SERGAS), Vigo, Spain.,Director Neuroscience Area, Galicia Sur Health Research Institute (IISGS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
| | - Carlos Spuch
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), University of Vigo, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
| | - Tania Rivera-Baltanás
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
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21
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Aboud T, Schuster NM. Pain Management in Multiple Sclerosis: a Review of Available Treatment Options. Curr Treat Options Neurol 2019; 21:62. [PMID: 31773455 DOI: 10.1007/s11940-019-0601-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Multiple Sclerosis (MS) is a chronic autoimmune disease with no curative treatment available. While recent years have ushered in many effective new disease-modifying therapies for MS, they have not obviated the need for symptomatic treatments for MS-related pain. In this review, we discuss available approaches to control pain, which is one of the most common complaints MS patients have. RECENT FINDINGS The most recent research in this topic is directed towards non-pharmacologic interventions including water exercises, yoga and cannabis. More trials are being conducted on neuromodulation for MS-related neuropathic pain, including transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation (tDCS). Pain control for MS patients is challenging, considering the progressive and relapsing remitting nature of the disease, however, it is a very important aspect of it's management, as it improves mobility, exercise tolerance, concomitant depression and overall quality of life. Future research should focus on the use of neuromodulation in controlling MS pain.
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Affiliation(s)
- Talal Aboud
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nathaniel M Schuster
- Center for Pain Medicine, Department of Anesthesiology, University of California, San Diego, CA, USA
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22
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Mealy MA, Kozachik SL, Levy M. Review of Treatment for Central Spinal Neuropathic Pain and Its Effect on Quality of Life: Implications for Neuromyelitis Optica Spectrum Disorder. Pain Manag Nurs 2019; 20:580-591. [PMID: 31103517 DOI: 10.1016/j.pmn.2019.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 03/10/2019] [Accepted: 03/15/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Neuromyelitis optica spectrum disorder (NMOSD) causes disabling and persistent central neuropathic pain (NP). Because the pain syndrome in NMOSD is severe and often intractable to analgesic treatment, it interferes with quality of life in patients. No interventional trials have been published looking at response to interventions for pain in NMOSD. This is a synthesis of the literature surveying the impact on quality of life of interventions in all mechanisms of central spinal NP. This review has important implications for management of pain in NMOSD. METHODS AND DATA SOURCES A systematic database search was conducted using PubMed, Embase, and CINAHL Plus with keywords including "spinal cord," "quality of life," and "neuropathic pain" in an attempt to identify original research that targeted spinal NP treatment and used quality of life as an outcome measure. Both pharmacologic and nonpharmacologic treatments were sought out. RESULTS Twenty-one studies meeting our eligibility criteria were identified and evaluated, 13 using pharmacologic treatments and 8 using nonpharmacologic interventions. Overall, sample sizes were modest, and effects on decreasing pain and/or improving quality of life were suboptimal. CONCLUSIONS This review provides researchers with a foundation from which to start a more thorough and thoughtful investigation into the management of NP in NMOSD and underscores the importance of including quality of life as a clinically meaningful outcome measure.
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Affiliation(s)
- Maureen A Mealy
- Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, Maryland; Johns Hopkins University, School of Nursing, Baltimore, Maryland.
| | | | - Michael Levy
- Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, Maryland
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Torres-Moreno MC, Papaseit E, Torrens M, Farré M. Assessment of Efficacy and Tolerability of Medicinal Cannabinoids in Patients With Multiple Sclerosis: A Systematic Review and Meta-analysis. JAMA Netw Open 2018; 1:e183485. [PMID: 30646241 PMCID: PMC6324456 DOI: 10.1001/jamanetworkopen.2018.3485] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Cannabinoids have antispastic and analgesic effects; however, their role in the treatment of multiple sclerosis (MS) symptoms is not well defined. OBJECTIVE To conduct a systematic review and meta-analysis to assess the efficacy and tolerability of medicinal cannabinoids compared with placebo in the symptomatic treatment of patients with MS. DATA SOURCES MEDLINE and the Cochrane Library Plus up to July 26, 2016. No restrictions were applied. The search was completed with information from ClinicalTrials.gov. STUDY SELECTION Randomized, double-blind, and placebo-controlled trials evaluating the effect of medicinal cannabinoids by oral or oromucosal route of administration on the symptoms of spasticity, pain, or bladder dysfunction in adult patients with MS. DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. Effect sizes were calculated as standardized mean difference (SMD) for efficacy, and rate ratio (RR) for tolerability. Within each study, those SMDs evaluating the same outcome were combined before the meta-analysis to obtain a single value per outcome and study. Pooling of the studies was performed on an intention-to-treat basis by means of random-effect meta-analysis. MAIN OUTCOMES AND MEASURES Spasticity (on the Ashworth and Modified Ashworth scales and subjective), pain, bladder dysfunction, adverse events, and withdrawals due to adverse events. RESULTS Seventeen selected trials including 3161 patients were analyzed. Significant findings for the efficacy of cannabinoids vs placebo were SMD = -0.25 SD (95% CI, -0.38 to -0.13 SD) for spasticity (subjective patient assessment data), -0.17 SD (95% CI, -0.31 to -0.03 SD) for pain, and -0.11 SD (95% CI, -0.22 to -0.0008 SD) for bladder dysfunction. Results favored cannabinoids. Findings for tolerability were RR = 1.72 patient-years (95% CI, 1.46-2.02 patient-years) in the total adverse events analysis and 2.95 patient-years (95% CI, 2.14-4.07 patient-years) in withdrawals due to adverse events. Results described a higher risk for cannabinoids. The serious adverse events meta-analysis showed no statistical significance. CONCLUSIONS AND RELEVANCE The results suggest a limited efficacy of cannabinoids for the treatment of spasticity, pain, and bladder dysfunction in patients with MS. Therapy using these drugs can be considered as safe. TRIAL REGISTRATION PROSPERO Identifier: CRD42014015391.
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Affiliation(s)
- Mari Carmen Torres-Moreno
- Universitat Autònoma de Barcelona, Departament de Farmacologia, Terapèutica i Toxicologia, Cerdanyola del Vallès, Spain
- Hospital Universitari Germans Trias i Pujol and Institut de Recerca Germans Trias i Pujol, Servei de Farmacologia Clínica, Badalona, Spain
| | - Esther Papaseit
- Universitat Autònoma de Barcelona, Departament de Farmacologia, Terapèutica i Toxicologia, Cerdanyola del Vallès, Spain
- Hospital Universitari Germans Trias i Pujol and Institut de Recerca Germans Trias i Pujol, Servei de Farmacologia Clínica, Badalona, Spain
| | - Marta Torrens
- Universitat Autònoma de Barcelona, Departament de Psiquiatria i Medicina Legal, Cerdanyola del Vallès, Spain
- Hospital del Mar, Institut de Neuropsiquiatria i Addiccions, Programa Addiccions, Barcelona, Spain
| | - Magí Farré
- Universitat Autònoma de Barcelona, Departament de Farmacologia, Terapèutica i Toxicologia, Cerdanyola del Vallès, Spain
- Hospital Universitari Germans Trias i Pujol and Institut de Recerca Germans Trias i Pujol, Servei de Farmacologia Clínica, Badalona, Spain
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24
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Long-Term Outcomes in the Management of Central Neuropathic Pain Syndromes: A Prospective Observational Cohort Study. Can J Neurol Sci 2018; 45:545-552. [DOI: 10.1017/cjn.2018.55] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractBackground:Central neuropathic pain syndromes are a result of central nervous system injury, most commonly related to stroke, traumatic spinal cord injury, or multiple sclerosis. These syndromes are distinctly less common than peripheral neuropathic pain, and less is known regarding the underlying pathophysiology, appropriate pharmacotherapy, and long-term outcomes. The objective of this study was to determine the long-term clinical effectiveness of the management of central neuropathic pain relative to peripheral neuropathic pain at tertiary pain centers.Methods:Patients diagnosed with central (n=79) and peripheral (n=710) neuropathic pain were identified for analysis from a prospective observational cohort study of patients with chronic neuropathic pain recruited from seven Canadian tertiary pain centers. Data regarding patient characteristics, analgesic use, and patient-reported outcomes were collected at baseline and 12-month follow-up. The primary outcome measure was the composite of a reduction in average pain intensity and pain interference. Secondary outcome measures included assessments of function, mood, quality of life, catastrophizing, and patient satisfaction.Results:At 12-month follow-up, 13.5% (95% confidence interval [CI], 5.6-25.8) of patients with central neuropathic pain and complete data sets (n=52) achieved a ≥30% reduction in pain, whereas 38.5% (95% CI, 25.3-53.0) achieved a reduction of at least 1 point on the Pain Interference Scale. The proportion of patients with central neuropathic pain achieving both these measures, and thus the primary outcome, was 9.6% (95% CI, 3.2-21.0). Patients with peripheral neuropathic pain and complete data sets (n=463) were more likely to achieve this primary outcome at 12 months (25.3% of patients; 95% CI, 21.4-29.5) (p=0.012).Conclusion:Patients with central neuropathic pain syndromes managed in tertiary care centers were less likely to achieve a meaningful improvement in pain and function compared with patients with peripheral neuropathic pain at 12-month follow-up.
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Schimrigk S, Marziniak M, Neubauer C, Kugler EM, Werner G, Abramov-Sommariva D. Dronabinol Is a Safe Long-Term Treatment Option for Neuropathic Pain Patients. Eur Neurol 2017; 78:320-329. [PMID: 29073592 DOI: 10.1159/000481089] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/29/2017] [Indexed: 01/04/2023]
Abstract
Treatment of neuropathic pain (NP) symptoms associated with multiple sclerosis (MS) is frequently insufficient. Yet, cannabis is still rarely offered for treatment of pain. This clinical trial aimed at showing the positive benefit-risk ratio of dronabinol. Two hundred forty MS patients with central NP entered a 16-weeks placebo-controlled phase-III study followed by a 32-weeks open-label period. One hundred patients continued therapy for overall up to 119 weeks. Primary endpoint was change of pain intensity on the 11-point Numerical Rating Scale over a 16-weeks treatment period. Safety was assessed on the basis of adverse reactions (ARs), signs of dependency and abuse. Pain intensity during 16-weeks dronabinol and placebo treatment was reduced by 1.92 and 1.81 points without significant difference in between (p = 0.676). Although the proportion of patients with ARs was higher under dronabinol compared to placebo (50.0 vs. 25.9%), it decreased during long-term use of dronabinol (26%). No signs of drug abuse and only one possible case of dependency occurred. The trial results demonstrate that dronabinol is a safe long-term treatment option.
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Affiliation(s)
- Sebastian Schimrigk
- Märkische Kliniken GmbH, Klinikum Lüdenscheid, Klinik für Neurologie, Lüdenscheid, Germany
| | - Martin Marziniak
- Kbo-Isar-Amper-Klinikum München-Ost, Klinik für Neurologie, Haar, Germany
| | - Christine Neubauer
- Department Clinical Research International, Bionorica SE, Neumarkt, Germany
| | - Eva Maria Kugler
- Department Clinical Research International, Bionorica SE, Neumarkt, Germany
| | - Gudrun Werner
- Department Clinical Research International, Bionorica SE, Neumarkt, Germany
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Nathoo N, Mackie A. Treating depression in multiple sclerosis with antidepressants: A brief review of clinical trials and exploration of clinical symptoms to guide treatment decisions. Mult Scler Relat Disord 2017; 18:177-180. [PMID: 29141805 DOI: 10.1016/j.msard.2017.10.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/06/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022]
Abstract
Depression is a common comorbidity in patients with multiple sclerosis (MS). Those with MS and concurrent depression have poorer quality of life and are also less likely to be compliant with disease-modifying treatment, which may ultimately affect their MS disease course. Treating depression in MS with pharmacological agents can improve not only depression, but may also impact the MS disease course. However, no guidelines exist around treating depression in MS. Few randomized-controlled trials using antidepressants in MS exist. Here, we briefly review trials using antidepressant medications to treat depression in MS. We also propose individualizing treatment of depression in MS, as the depressive symptoms and MS symptoms and disease course differ significantly between patients. We explore the heterogeneity in presentation of depression through different comorbid symptoms in MS, and discuss which antidepressant options would be appropriate in each situation. We propose that future clinical trials should incorporate differences in issues between those with depression (e.g. sexual dysfunction, urinary incontinence) into analysis. As MS is incredibly heterogeneous, treating concurrent depression on a case-by-case basis may enable for improving quality of life and the MS disease course.
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Affiliation(s)
- Nabeela Nathoo
- Department of Radiology & Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Aaron Mackie
- Departments of Psychiatry & Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Kaszuba BC, Walling I, Gee LE, Shin DS, Pilitsis JG. Effects of subthalamic deep brain stimulation with duloxetine on mechanical and thermal thresholds in 6OHDA lesioned rats. Brain Res 2016; 1655:233-241. [PMID: 27984022 DOI: 10.1016/j.brainres.2016.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 10/24/2016] [Accepted: 10/27/2016] [Indexed: 01/31/2023]
Abstract
Chronic pain is the most common non-motor symptom of Parkinson's disease (PD) and is often overlooked. Unilateral 6-hydroxydopamine (6-OHDA) medial forebrain bundle lesioned rats used as models for PD exhibit decreased sensory thresholds in the left hindpaw. Subthalamic deep brain stimulation (STN DBS) increases mechanical thresholds and offers improvements with chronic pain in PD patients. However, individual responses to STN high frequency stimulation (HFS) in parkinsonian rats vary with 58% showing over 100% improvement, 25% showing 30-55% improvement, and 17% showing no improvement. Here we augment STN DBS by supplementing with a serotonin-norepinephrine reuptake inhibitor commonly prescribed for pain, duloxetine. Duloxetine was administered intraperitoneally (30mg/kg) in 15 parkinsonian rats unilaterally implanted with STN stimulating electrodes in the lesioned right hemisphere. Sensory thresholds were tested using von Frey, Randall-Selitto and hot-plate tests with or without duloxetine, and stimulation to the STN at HFS (150Hz), low frequency (LFS, 50Hz), or off stimulation. With HFS or LFS alone (left paw; p=0.016; p=0.024, respectively), animals exhibited a higher mechanical thresholds stable in the three days of testing, but not with duloxetine alone (left paw; p=0.183). Interestingly, the combination of duloxetine and HFS produced significantly higher mechanical thresholds than duloxetine alone (left paw, p=0.002), HFS alone (left paw, p=0.028), or baseline levels (left paw; p<0.001). These findings show that duloxetine paired with STN HFS increases mechanical thresholds in 6-OHDA-lesioned animals more than either treatment alone. It is possible that duloxetine augments STN DBS with a central and peripheral additive effect, though a synergistic mechanism has not been excluded.
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Affiliation(s)
- Brian C Kaszuba
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Ian Walling
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Lucy E Gee
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Damian S Shin
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Julie G Pilitsis
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States.
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Watson JC, Sandroni P. Central Neuropathic Pain Syndromes. Mayo Clin Proc 2016; 91:372-85. [PMID: 26944242 DOI: 10.1016/j.mayocp.2016.01.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/24/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Abstract
Chronic pain is common in patients with neurologic complications of a central nervous system insult such as stroke. The pain is most commonly musculoskeletal or related to obligatory overuse of neurologically unaffected limbs. However, neuropathic pain can result directly from the central nervous system injury. Impaired sensory discrimination can make it challenging to differentiate central neuropathic pain from other pain types or spasticity. Central neuropathic pain may also begin months to years after the injury, further obscuring recognition of its association with a past neurologic injury. This review focuses on unique clinical features that help distinguish central neuropathic pain. The most common clinical central pain syndromes-central poststroke pain, multiple sclerosis-related pain, and spinal cord injury-related pain-are reviewed in detail. Recent progress in understanding of the pathogenesis of central neuropathic pain is reviewed, and pharmacological, surgical, and neuromodulatory treatments of this notoriously difficult to treat pain syndrome are discussed.
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Affiliation(s)
- James C Watson
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
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Shah P. Symptomatic management in multiple sclerosis. Ann Indian Acad Neurol 2015; 18:S35-42. [PMID: 26538847 PMCID: PMC4604696 DOI: 10.4103/0972-2327.164827] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 06/26/2015] [Accepted: 06/15/2015] [Indexed: 02/02/2023] Open
Abstract
Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.
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Affiliation(s)
- Pushkar Shah
- Department of Neurology, Institute of Neurosciences, South Glasgow University Hospital NHS Trust, Glasgow, G51 4TF, United Kingdom
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Brown TR, Slee A. A randomized placebo-controlled trial of duloxetine for central pain in multiple sclerosis. Int J MS Care 2015; 17:83-9. [PMID: 25892978 DOI: 10.7224/1537-2073.2014-001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pain is common in multiple sclerosis (MS). Duloxetine has a potential therapeutic role in treating MS-related pain. METHODS Thirty-eight MS patients were randomized 1:1 to receive duloxetine (n = 18) or matched placebo (n = 20). The dosing regimen was 30 mg daily for 1 week, then 60 mg daily for 5 weeks. The primary outcome measure was change in worst pain for week 6 relative to baseline recorded on a daily pain diary. RESULTS Of 38 randomized patients, 14 (78%) patients randomized to duloxetine and 18 (90%) randomized to placebo completed treatment per protocol. These participants had an average age of 55.5 years, 25% were male, and 66% had relapsing-remitting MS (RRMS). Baseline characteristics were similar. Discontinuations were due primarily to drug intolerance. Among those who completed treatment, worst pain at 6 weeks was reduced by 29% (±20%) for duloxetine versus 12% (±18%) for placebo (P = .016). Average daily pain at 6 weeks was reduced by 39% (±29%) in the duloxetine group compared to 10% (±18.8%) in the placebo group (P = .002). There were no significant changes (week 6 vs. baseline) or between-group differences for subject global impression, Beck Depression Inventory, 36-item Short Form Health Status Survey (SF-36), or sleep quality score. CONCLUSIONS Fewer patients could tolerate duloxetine compared to placebo. Among patients who completed 6 weeks of treatment, there were significant reductions in average and worst daily pain scores with duloxetine compared to placebo. This study suggests that duloxetine has a direct pain-relieving effect in MS.
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Affiliation(s)
- Theodore R Brown
- MS Center at Evergreen, Evergreen Health, Kirkland, WA, USA (TRB); and Axio Research, LLC, Seattle, WA, USA (AS)
| | - April Slee
- MS Center at Evergreen, Evergreen Health, Kirkland, WA, USA (TRB); and Axio Research, LLC, Seattle, WA, USA (AS)
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Arakawa A, Kaneko M, Narukawa M. An Investigation of Factors Contributing to Higher Levels of Placebo Response in Clinical Trials in Neuropathic Pain: A Systematic Review and Meta-Analysis. Clin Drug Investig 2015; 35:67-81. [DOI: 10.1007/s40261-014-0259-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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