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Yaouanq M, Gibson N, Boudoussier A, Edouard L, Pouvreau P, Taleb I, Bouleftour W, Sargos P, Magné N, Benziane-Ouaritini N. Emergency radiation therapy in modern-day practice: Now or never, or never again ? Support Care Cancer 2024; 32:114. [PMID: 38240886 DOI: 10.1007/s00520-024-08322-8] [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] [Received: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
Radiation therapy plays a fundamental role in oncological emergencies such as superior vena cava syndrome (SVCS) and metastatic epidural spinal cord compression (MESCC). These are two examples of critical complications of metastatic cancer in terms of pain and functional impact (respiratory and/or neurological). The aim of this review is to explore the current indications, treatment options and outcomes for emergency radiotherapy regarding to these complications.Regarding SVCS, studies are mostly retrospective and unanimously demonstrated a beneficial effect of radiotherapy on symptom relief. Spinal cord compression remains an indication for urgent radiotherapy, and should be combined with surgery when possible. The innovative stereotactic body radiotherapy (SBRT) showed promising results, however this technique requires small volumes and more time preparation and therefore is often unsuitable for SVCS and MESCC emergencies.This review concluded that radiotherapy has a central role to play within a multimodal approach for SVCS and MESCC treatment. Further prospective studies are needed to confirm the effectiveness of radiation and establish the criteria for selecting patients to benefit from this treatment option.
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Affiliation(s)
- Margaux Yaouanq
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Nyere Gibson
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | | | - Lucas Edouard
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Pierre Pouvreau
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Imed Taleb
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Wafa Bouleftour
- Cancerology and Hematology Institute, Department of Medical Oncology, Saint-Etienne University Hospital, 42055, Saint-Etienne, France.
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Nicolas Magné
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
- Cellular and Molecular Radiobiology Laboratory, Lyon-Sud Medical School, Unité Mixte de Recherche CNRS5822/IP2I, University of Lyon, Lyon, France
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2
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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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Liu H, Lauzadis J, Gunaratna K, Sipple E, Kaczocha M, Puopolo M. Inhibition of T-Type Calcium Channels With TTA-P2 Reduces Chronic Neuropathic Pain Following Spinal Cord Injury in Rats. THE JOURNAL OF PAIN 2023; 24:1681-1695. [PMID: 37169156 DOI: 10.1016/j.jpain.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/03/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
Spinal cord injury (SCI)-induced neuropathic pain (SCI-NP) develops in up to 60 to 70% of people affected by traumatic SCI, leading to a major decline in quality of life and increased risk for depression, anxiety, and addiction. Gabapentin and pregabalin, together with antidepressant drugs, are commonly prescribed to treat SCI-NP, but their efficacy is unsatisfactory. The limited efficacy of current pharmacological treatments for SCI-NP likely reflects our limited knowledge of the underlying mechanism(s) responsible for driving the maintenance of SCI-NP. The leading hypothesis in the field supports a major role for spontaneously active injured nociceptors in driving the maintenance of SCI-NP. Recent data from our laboratory provided additional support for this hypothesis and identified the T-type calcium channels as key players in driving the spontaneous activity of SCI-nociceptors, thus providing a rational pharmacological target to treat SCI-NP. To test whether T-type calcium channels contribute to the maintenance of SCI-NP, male and female SCI and sham rats were treated with TTA-P2 (a blocker of T-type calcium channels) to determine its effects on mechanical hypersensitivity (as measured with the von Frey filaments) and spontaneous ongoing pain (as measured with the conditioned place preference paradigm), and compared them to the effects of gabapentin, a blocker of high voltage-activated calcium channels. We found that both TTA-P2 and gabapentin reduced mechanical hypersensitivity in male and females SCI rats, but surprisingly only TTA-P2 reduced spontaneous ongoing pain in male SCI rats. PERSPECTIVES: SCI-induced neuropathic pain, and in particular the spontaneous ongoing pain component, is notoriously very difficult to treat. Our data provide evidence that inhibition of T-type calcium channels reduces spontaneous ongoing pain in SCI rats, supporting a clinically relevant role for T-type channels in the maintenance of SCI-induced neuropathic pain.
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Affiliation(s)
- Huilin Liu
- Department of Anesthesiology, Stony Brook Pain and Analgesia Research Center (SPARC), Health Sciences Center L4-072, Stony Brook Renaissance School of Medicine, Stony Brook, New York
| | - Justas Lauzadis
- Department of Anesthesiology, Stony Brook Pain and Analgesia Research Center (SPARC), Health Sciences Center L4-072, Stony Brook Renaissance School of Medicine, Stony Brook, New York
| | - Kavindu Gunaratna
- Department of Anesthesiology, Stony Brook Pain and Analgesia Research Center (SPARC), Health Sciences Center L4-072, Stony Brook Renaissance School of Medicine, Stony Brook, New York
| | - Erin Sipple
- Department of Anesthesiology, Stony Brook Pain and Analgesia Research Center (SPARC), Health Sciences Center L4-072, Stony Brook Renaissance School of Medicine, Stony Brook, New York
| | - Martin Kaczocha
- Department of Anesthesiology, Stony Brook Pain and Analgesia Research Center (SPARC), Health Sciences Center L4-072, Stony Brook Renaissance School of Medicine, Stony Brook, New York
| | - Michelino Puopolo
- Department of Anesthesiology, Stony Brook Pain and Analgesia Research Center (SPARC), Health Sciences Center L4-072, Stony Brook Renaissance School of Medicine, Stony Brook, New York.
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Koukoulithras I, Alkhazi A, Gkampenis A, Stamouli A, Plexousakis M, Drousia G, Xanthi E, Roussos C, Kolokotsios S. A Systematic Review of the Interventions for Management of Pain in Patients After Spinal Cord Injury. Cureus 2023; 15:e42657. [PMID: 37644939 PMCID: PMC10461890 DOI: 10.7759/cureus.42657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/31/2023] Open
Abstract
Chronic pain is a very common problem in patients with spinal cord injury (SCI) as it affects 80% of these patients, which negatively affects their quality of life. Despite many advantages that exist in the management of any type of pain (neuropathic, nociceptive, mixed) in these patients, there is no cure, and the analgesic effect of some treatments is inadequate. This study aims to conduct an evidence-based systematic review regarding the various interventions used for the management of pain after SCI. The PubMed, Physiotherapy Evidence Database (PEDro), and Cochrane Library databases were searched from 1969 to 2023. The risk of bias was assessed using the PEDro scoring system. A total of 57 studies met the inclusion criteria and were included in this systematic review. Among the different interventions at present, 18 studies examined the role of oral medications, 11 studies examined the role of minimally invasive methods (injection and infusion), 16 studies investigated physiotherapy and alternative treatments, and 12 studies examined the role of repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), and cranial electrotherapy stimulation (CES) in the management of pain in patients after SCI. Gabapentin and pregabalin are very effective in managing chronic neuropathic pain after SCI, and pregabalin also seems to reduce anxiety and sleep disturbances in the patients. It is noteworthy that lamotrigine, valproate, and carbamazepine do not have an analgesic effect, but mirogabalin is a novel and promising drug. Antidepressants (selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors) did not reduce the pain of the patients, although some studies showed an efficacy of amitriptyline especially in depressed patients and tramadol should be considered short-term with caution. Also, tDCS and rTMS reduced pain. Moreover, botulinum toxin type A, lidocaine, ketamine, and intrathecal baclofen significantly reduced pain intensity, although the sample of the studies was small. Physiotherapy and alternative treatments seem to relieve pain, and transcutaneous electrical nerve stimulation had the greatest reduction of pain intensity. In conclusion, several pharmaceutical and non-pharmaceutical methods exist, which can reduce pain in patients after SCI. The type of intervention can be considered by the physician depending on the patients' preference, age, medical history, type of pain, and associated symptoms. However, more studies with greater samples and with better methodological quality should be conducted.
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Affiliation(s)
- Ioannis Koukoulithras
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, GRC
- Faculty of Medicine, University of Ioannina, Ioannina, GRC
| | - Abdulaziz Alkhazi
- Department of Neurosurgery, Mater Dei Hospital, Msida, MLT
- Faculty of Medicine, University of Malta, Imsida, MLT
| | - Athanasios Gkampenis
- Department of Neurosurgery, University Hospital of Ioannina, Ioannina, GRC
- Faculty of Medicine, University of Ioannina, Ioannina, GRC
| | - Alexandra Stamouli
- Department of Physical Therapy, University Hospital, University of West Attica, Athens, GRC
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| | - Minas Plexousakis
- Department of Physical Therapy, University Hospital, University of West Attica, Athens, GRC
| | - Gianna Drousia
- Department of Physical Therapy, University Hospital, University of West Attica, Athens, GRC
| | - Eleana Xanthi
- Department of Physical Therapy, University Hospital, University of West Attica, Athens, GRC
| | - Charis Roussos
- Department of Physical Medicine and Rehabilitation, Mitera Hospital, Athens, GRC
| | - Spyridon Kolokotsios
- Department of Physical Therapy, University Hospital, University of West Attica, Athens, GRC
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Widerström-Noga E. Neuropathic Pain and Spinal Cord Injury: Management, Phenotypes, and Biomarkers. Drugs 2023:10.1007/s40265-023-01903-7. [PMID: 37326804 DOI: 10.1007/s40265-023-01903-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/17/2023]
Abstract
Chronic neuropathic pain after a spinal cord injury (SCI) continues to be a complex condition that is difficult to manage due to multiple underlying pathophysiological mechanisms and the association with psychosocial factors. Determining the individual contribution of each of these factors is currently not a realistic goal; however, focusing on the primary mechanisms may be more feasible. One approach used to uncover underlying mechanisms includes phenotyping using pain symptoms and somatosensory function. However, this approach does not consider cognitive and psychosocial mechanisms that may also significantly contribute to the pain experience and impact treatment outcomes. Indeed, clinical experience supports that a combination of self-management, non-pharmacological, and pharmacological approaches is needed to optimally manage pain in this population. This article will provide a broad updated summary integrating the clinical aspects of SCI-related neuropathic pain, potential pain mechanisms, evidence-based treatment recommendations, neuropathic pain phenotypes and brain biomarkers, psychosocial factors, and progress regarding how defining neuropathic pain phenotypes and other surrogate measures in the neuropathic pain field may lead to targeted treatments for neuropathic pain after SCI.
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Affiliation(s)
- Eva Widerström-Noga
- The Miami Project to Cure Paralysis, University of Miami, 1611 NW 12th Avenue, Miami, FL, 33136, USA.
- Department of Neurological Surgery, University of Miami, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
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Ushida T, Katayama Y, Hiasa Y, Nishihara M, Tajima F, Katoh S, Tanaka H, Maeda T, Furusawa K, Richardson M, Kakehi Y, Kikumori K, Kuroha M. Mirogabalin for Central Neuropathic Pain After Spinal Cord Injury: A Randomized, Double-Blind, Placebo-Controlled, Phase 3 Study in Asia. Neurology 2023; 100:e1193-e1206. [PMID: 36517235 PMCID: PMC10074464 DOI: 10.1212/wnl.0000000000201709] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/07/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with spinal cord injury (SCI) commonly experience central neuropathic pain (CNeP), which is challenging to treat. Mirogabalin is effective for peripheral neuropathic pain, but evidence for CNeP is lacking. METHODS This randomized, double-blind, placebo-controlled, phase 3 study investigated mirogabalin efficacy and safety for the treatment of CNeP in patients with traumatic SCI. Adult patients from 120 sites throughout Japan, Korea, and Taiwan were randomized (1:1) to receive placebo or mirogabalin (5 mg twice daily [BID] for 1 week, 10 mg BID for 1 week, and 10 or 15 mg BID for 12 weeks). Patients with moderate renal impairment received half the dosage. The primary efficacy endpoint was change from baseline in the weekly average daily pain score (ADPS) at week 14. The secondary endpoints included ADPS responder rates, the Short-Form McGill Pain Questionnaire (SF-MPQ), average daily sleep interference score (ADSIS), and Neuropathic Pain Symptom Inventory (NPSI). Adverse events were monitored for safety. RESULTS Each treatment group comprised 150 patients. Mirogabalin elicited a statistical and clinically relevant improvement in change from baseline in the weekly ADPS at week 14 (least-squares mean difference [95% CI] vs placebo -0.71 [-1.08 to -0.34], p = 0.0001). Responder rates at week 14 were higher for mirogabalin than those for placebo (odds ratio [95% CI] 1.91 [1.11-3.27] for the ≥30% responder rate; 2.52 [1.11-5.71] for the ≥50% responder rate). Statistical improvements (i.e., least-squares mean difference [95% CI] vs placebo) were also observed in the SF-MPQ (-2.4 [-3.8 to -1.1]), ADSIS -0.71 (-1.04 to -0.38), and NPSI -7.7 (-11.1 to -4.4) scores. Most treatment-emergent adverse events were mild; no serious adverse drug reactions were reported. DISCUSSION Mirogabalin elicited clinically relevant decreases in pain and was well tolerated, suggesting that mirogabalin is a promising treatment for patients with CNeP due to SCI. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov (NCT03901352); first submitted April 3, 2019; first patient enrolled March 14, 2019; available at clinicaltrials.gov/ct2/show/NCT03901352. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in adult patients with CNeP due to traumatic SCI, mirogabalin, 10 or 15 mg BID, effectively improves weekly ADPS at week 14.
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Affiliation(s)
- Takahiro Ushida
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Yoichi Katayama
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Yoichi Hiasa
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Makoto Nishihara
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Fumihiro Tajima
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Shinsuke Katoh
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Hirotaka Tanaka
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Takeshi Maeda
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Kazunari Furusawa
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Mary Richardson
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Yoshihiro Kakehi
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Kunika Kikumori
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan
| | - Masanori Kuroha
- From the Multidisciplinary Pain Center (T.U., M.N.), Aichi Medical University, Nagakute; Department of Neurological Surgery (Y. Katayama), Nihon University School of Medicine, Itabashi, Tokyo; Center for Brain and Health Sciences (Y. Katayama), Aomori University; Department of Gastroenterology and Metabology (Y.H.), Ehime University Graduate School of Medicine, Toon, Ehime; Department of Rehabilitation Medicine (F.T.), Wakayama Medical University; Red Cross Tokushima Hinomine Rehabilitation Center for People with Disabilities (S.K.), Komatsushima; Department of Rehabilitation (H.T.), Chubu Rosai Hospital, Nagoya, Aichi; Spinal Injuries Center (T.M.), Iizuka, Fukuoka; Kibikogen Rehabilitation Center for Employment Injuries (K.F.), Kaga, Okayama; Edanz Japan (M.R.), Chuo-ku, Fukuoka; Clinical Development Department III (Y. Kakehi, M.K.), Daiichi Sankyo Co., Ltd.; and Data Intelligence Department (K.K.), Daiichi Sankyo Co., Ltd., Shinagawa, Tokyo, Japan.
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7
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Meaadi J, Obara I, Eldabe S, Nazar H. The safety and efficacy of gabapentinoids in the management of neuropathic pain: a systematic review with meta-analysis of randomised controlled trials. Int J Clin Pharm 2023:10.1007/s11096-022-01528-y. [PMID: 36848024 DOI: 10.1007/s11096-022-01528-y] [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: 08/12/2022] [Accepted: 12/01/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND There are increasing concerns regarding the abusive potential of gabapentinoids putting at risk patients with neuropathic pain requiring long-term pain management. The evidence to support this is rather inconcusive. AIM This systematic review aimed to evaluate the safety and efficacy of gabapentinoids in the management of neuropathic pain with a focus on randomised controlled trials (RCTs) and categorising the side effects according to the body systems they were affecting. METHOD Searches were conducted in MEDLINE (PubMed), EMBASE, Web of Science, PsycoINFO, and CINAHL (EBSCO), and included RCTs to identify and critically appraise studies investigating safety and therapeutic effects of gabapentionoids in adults with neuropathic pain. Data extraction was conducted using an established Cochrane form and the risk-of-bias tool was used in the assessment of quality. RESULTS 50 studies (12,398 participants) were included. The majority of adverse events pertained to the nervous system (7 effects) or psychiatric (3 effects) disorders. There were more adverse effects reported with pregabalin (36 effects) than with gabapentin (22 effects). Six pregabalin studies reported euphoria as a side effect, while no studies reported euphoria with gabapentin. This was the only side effect that may correlate with addictive potential. Gabapentioids were reported to significantly reduce pain compared to placebo. CONCLUSION Despite RCTs documenting the adverse events of gabapentionoids on the nervous system, there was no evidence of gabapentinoid use leading to addiction, suggesting an urgent need to design studies investigating their abusive potential.
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Affiliation(s)
- Jawza Meaadi
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle-Upon-Tyne, NE1 7RU, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK.,King Saud Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Ilona Obara
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle-Upon-Tyne, NE1 7RU, UK. .,Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK.
| | - Sam Eldabe
- Department of Pain and Anaesthesia, James Cook Hospital, Middlesbrough, UK
| | - Hamde Nazar
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle-Upon-Tyne, NE1 7RU, UK.,Population Health Sciences Institute, Newcastle University, Newcastle-Upon-Tyne, UK
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8
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Nazish S. Obesity and metabolic syndrome in patients with epilepsy, their relation with epilepsy control. Ann Afr Med 2023; 22:136-144. [PMID: 37026193 DOI: 10.4103/aam.aam_139_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Obesity and metabolic syndrome (MetS) are commonly observed in patients with epilepsy (PWE). Obesity and MetS are not only affecting the physical fitness and quality of life of these patients, rather antiepileptic drugs (AEDs) compliance and seizure control have also been affected. The objective of this review is to search the published literature regarding the prevalence of obesity and MetS in PWE and their relation to the response to AEDs. A comprehensive search using PubMed, Cochrane Databases, and Google Scholar was performed. A supplementary citation search was also conducted by analyzing the reference lists of identified sources. The initial search revealed 364 articles of potential relevance. The studies were analyzed in detail to obtain clinical information relevant to the objectives of the review. Many observational, case control studies, randomized control trials and few review articles were included for critical appraisal and review writing. Epilepsy is associated with MetS and obesity in all age groups. AEDs and lack of exercise are the chief causes while metabolic disturbances such as adiponectin, mitochondrial dysfunction, valproic acid (VPA)-associated insulin resistance, leptin deficiency, and endocrine dysfunction are also addressable factors. Although the risk of drug-resistant epilepsy (DRE) is also higher among obese PWE, the interaction between, MetS, and its components with DRE remain to be fully investigated. Further research is required to elucidate their interplay. Appropriate and careful selection of AEDs without compromising therapeutic efficacy supplemented by lifestyle counseling for exercise and diet should be practiced to avoid weight gain and potential DRE.
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9
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Williams CD, Al-Jammali Z, Herink MC. Gabapentinoids for Pain: A Review of Published Comparative Effectiveness Trials and Data Submitted to the FDA for Approval. Drugs 2023; 83:37-53. [PMID: 36529848 DOI: 10.1007/s40265-022-01810-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 12/23/2022]
Abstract
Use of the gabapentinoids for pain continues to increase. In 2018, the US Food and Drug Administration (FDA) strengthened the warnings for both gabapentin and pregabalin to emphasize the central nervous system side effects and the risk of respiratory depression, especially when combined with other centrally acting drugs. We reviewed the published comparative effectiveness literature for gabapentinoids for pain as well as all trials (published and unpublished) used by the FDA for the approval of the five pain indications for these agents (one for gabapentin, four for pregabalin). Among the findings of interest are the fact that the FDA rejected the application for gabapentin for diabetic peripheral neuropathy based on the risk versus benefit profile of that drug in the clinical trials that were submitted by the manufacturer. Additionally, both the comparative effectiveness trials as well as the studies used by the FDA tend to be short in duration and show only modest pain benefits for the gabapentinoids. The placebo response in these trials was frequently one-third to one-half as great as the pain benefit demonstrated by the gabapentinoid. Based on the available clinical trial evidence, we feel prescribers should be cautious when using gabapentinoids for pain, particularly when using these agents for a prolonged period or when combined with other, centrally acting agents.
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Affiliation(s)
- C D Williams
- Oregon State University College of Pharmacy, 2730 SW Moody Ave., CL5CP, Portland, OR, USA.
| | - Z Al-Jammali
- Oregon State University College of Pharmacy, 2730 SW Moody Ave., CL5CP, Portland, OR, USA
| | - M C Herink
- Oregon State University College of Pharmacy, 2730 SW Moody Ave., CL5CP, Portland, OR, USA
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10
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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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11
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Ghusn W, Bouchard C, Frye MA, Acosta A. Weight-centric treatment of depression and chronic pain. OBESITY PILLARS (ONLINE) 2022; 3:100025. [PMID: 37990725 PMCID: PMC10661995 DOI: 10.1016/j.obpill.2022.100025] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2023]
Abstract
Background Depression and chronic pain are two major chronic non-communicable diseases (CNCD). Considering the bidirectional relationship between obesity and CNCD, it is of the utmost importance to understand the effect of medications utilized to treat these diseases on body weight. Methods This is a clinical review on the effect of medications for depression and chronic pain on body weight. We searched PubMed, Scopus, MEDLINE, and Google Scholar databases for studies on the topic from January 1, 1950 to April 1, 2022 in English language. Additionally, we present expert opinions in the fields of obesity, depression and chronic pain, providing a weight-centric approach to treat depression and chronic pain. Results Several antidepressant and chronic pain medications are associated with weight gain. Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidases, mirtazapine and trazodone are common antidepressants that can increase body weight while bupropion is significantly associated with weight loss. Gabapentin and pregabalin are common chronic pain medications that are linked to weight gain. On the other hand, topiramate is associated with significant weight loss. Obesity, depression and chronic pain experts recommend avoiding medications that can increase body weight if another effective alternative is available. Conclusion By shifting prescribing practices toward a weight-conscious approach (i.e., switching from weight gain medications to weight loss/neutral), it is possible to mitigate the incidence of drug-induced weight gain.
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Affiliation(s)
- Wissam Ghusn
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Mark A. Frye
- Department of Psychiatry, Mayo Clinic, Rochester, MN, USA
| | - Andres Acosta
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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12
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Vouri SM, Morris EJ, Wang GHM, Hashim Jaber Bilal A, Hallas J, Henriksen DP. Association between gabapentinoids and oedema treated with loop-diuretics: a pooled sequence symmetry analysis from the United States and Denmark. Br J Clin Pharmacol 2022; 88:5269-5294. [PMID: 35748326 DOI: 10.1111/bcp.15447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/25/2022] [Accepted: 06/02/2022] [Indexed: 11/28/2022] Open
Abstract
AIMS To assess the gabapentinoid-oedema-loop diuretic prescribing cascade in adults using large administrative health care databases from the US and Denmark. METHODS This study used a sequence symmetry analysis to assess loop diuretic initiation before and after the initiation of gabapentinoids among patients aged 20 years or older without heart failure or chronic kidney disease. Data from MarketScan Commercial and Medicare Supplemental Claims databases (2005 to 2019) and Danish National Prescription Register (2005 to 2018) were analyzed. Use of loop diuretics associated with initiation of selective norepinephrine reuptake inhibitors (SNRI) was used as a negative control. We assessed the pooled temporality of loop diuretic initiation relative to gabapentinoid or SNRI initiation across the two countries. Secular trend-adjusted sequence ratios (aSRs) with 95% Cis were calculated using data from 90 days before and after initiation of gabapentinoids. Pooled ratio of aSRs were calculated by comparing gabapentinoids to SNRIs. RESULTS Among the 1,511,493 gabapentinoid initiators (Denmark [n=338,941]; United States [n=1,172,552]), 20,139 patients had a new loop diuretic prescription 90 days before or after gabapentinoid initiation, resulting in a pooled aSR of 1.33 (95% CI 1.06-1.67). The pooled aSR for the negative control (i.e., SNRI) was 0.84 (95% CI 0.75-0.94), which resulted in a pooled ratio of aSRs of 1.58 (95% CI 1.23-2.04). Pooled estimated incidence of the gabapentinoid-loop diuretic prescribing cascade was 8.14 (95% CI, 1.92-34.49) events per 1000 patient years. CONCLUSION We identified evidence of the gabapentinoid-oedema-loop diuretic prescribing cascade in two countries.
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Affiliation(s)
- Scott Martin Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States.,Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, United States
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States
| | - Grace Hsin-Min Wang
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States
| | | | - Jesper Hallas
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Daniel Pilsgaard Henriksen
- Department of Clinical Pharmacology, Odense University Hospital, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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13
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Future Treatment of Neuropathic Pain in Spinal Cord Injury: The Challenges of Nanomedicine, Supplements or Opportunities? Biomedicines 2022; 10:biomedicines10061373. [PMID: 35740395 PMCID: PMC9219608 DOI: 10.3390/biomedicines10061373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/28/2022] [Accepted: 06/08/2022] [Indexed: 12/12/2022] Open
Abstract
Neuropathic pain (NP) is a common chronic condition that severely affects patients with spinal cord injuries (SCI). It impairs the overall quality of life and is considered difficult to treat. Currently, clinical management of NP is often limited to drug therapy, primarily with opioid analgesics that have limited therapeutic efficacy. The persistence and intractability of NP following SCI and the potential health risks associated with opioids necessitate improved treatment approaches. Nanomedicine has gained increasing attention in recent years for its potential to improve therapeutic efficacy while minimizing toxicity by providing sensitive and targeted treatments that overcome the limitations of conventional pain medications. The current perspective begins with a brief discussion of the pathophysiological mechanisms underlying NP and the current pain treatment for SCI. We discuss the most frequently used nanomaterials in pain diagnosis and treatment as well as recent and ongoing efforts to effectively treat pain by proactively mediating pain signals following SCI. Although nanomedicine is a rapidly growing field, its application to NP in SCI is still limited. Therefore, additional work is required to improve the current treatment of NP following SCI.
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14
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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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15
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Campo AR, Pacichana-Quinayáz SG, Bonilla-Escobar FJ, Leiva-Pemberthy LM, Tovar-Sánchez MA, Hernández-Orobio OM, Arango-Hoyos GP, Mujanovic A. Effectiveness of Hydrotherapy on Neuropathic Pain and Pain Catastrophization in Patients With Spinal Cord Injury: Protocol for a Pilot Trial Study. JMIR Res Protoc 2022; 11:e37255. [PMID: 35486436 PMCID: PMC9107053 DOI: 10.2196/37255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/22/2022] Open
Abstract
Background Neuropathic pain (NP) is one of the most frequent spinal cord injury (SCI) complications. Pain, quality of life, and functionality are associated and can lead to pain catastrophization. Pharmacological management of patients with NP secondary to SCI is widely known and there is increasing evidence in the area. Nevertheless, nonpharmacological management is not fully elucidated since its efficacy is inconclusive. Objective We hypothesize that (1) hydrotherapy is effective in reducing NP secondary to SCI. Additionally, our secondary hypotheses are that (2) hydrotherapy decreases the catastrophization of NP, and that (3) hydrotherapy improves life quality and minimizes the degree of disability, when compared to physical therapy. Methods A sample of approximately 20 participants will be randomly assigned to either the intervention (hydrotherapy) or control group (standard physical therapy). Both interventions will be administered twice a week over a 9-week period (18 sessions in total). Primary outcomes are changes in neuropathic pain perception and pain catastrophization. Secondary outcomes are changes in disability and quality of life scores. They will be assessed at baseline and follow-up at 4 weeks after discharge. Validated Spanish language scales that will be used are the following: Numerical Pain Rating Scale, Pain Catastrophization, Health-related Quality of life, and the World Health Organization’s Disability Assessment Schedule 2.0. Generalized mixed linear models will be used for comparing baseline and postintervention means of each group and their differences, together with 95% CIs and P values. A P value of less than .05 will be considered significant. Results Recruitment began in April 2019, and we recruited the last participants by December 2019, with 10 individuals assigned to hydrotherapy and 8 to physical therapy (control). Results from this study will be disseminated via scientific publication, in ClinicalTrials.gov, and in national and international conferences in the latter half of 2022. Conclusions This trial will explore the effects of hydrotherapy on neuropathic pain, together with functionality and quality of life, in patients with SCI. Furthermore, this study aims to evaluate these therapeutic modalities, including perception variables, and mental processes, which may affect the clinical condition and rehabilitation outcomes in these patients. Hydrotherapy is likely to be a safe, efficient, and cost-effective alternative to the current standard of care for NP secondary to SCI, with comparable results between the two. Trial Registration ClinicalTrials.gov NCT04164810; https://clinicaltrials.gov/ct2/show/NCT04164810 International Registered Report Identifier (IRRID) DERR1-10.2196/37255
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Affiliation(s)
- Andrés Reyes Campo
- Departamento de Medicina Física y Rehabilitación, Grupo de Investigación en Rehabilitación de la Universidad del Valle, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Sara Gabriela Pacichana-Quinayáz
- Departamento de Medicina Física y Rehabilitación, Grupo de Investigación en Rehabilitación de la Universidad del Valle, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia.,Fundación Somos Ciencia al Servicio de la Comunidad, Fundación SCISCO/Science to Serve the Community Foundation, SCISCO Foundation, Cali, Colombia
| | - Francisco Javier Bonilla-Escobar
- Departamento de Medicina Física y Rehabilitación, Grupo de Investigación en Rehabilitación de la Universidad del Valle, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia.,Fundación Somos Ciencia al Servicio de la Comunidad, Fundación SCISCO/Science to Serve the Community Foundation, SCISCO Foundation, Cali, Colombia.,Institute for Clinical Research Education, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Luz Miriam Leiva-Pemberthy
- Departamento de Medicina Física y Rehabilitación, Grupo de Investigación en Rehabilitación de la Universidad del Valle, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Maria Ana Tovar-Sánchez
- Departamento de Medicina Física y Rehabilitación, Grupo de Investigación en Rehabilitación de la Universidad del Valle, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Olga Marina Hernández-Orobio
- Departamento de Medicina Física y Rehabilitación, Grupo de Investigación en Rehabilitación de la Universidad del Valle, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | | | - Adnan Mujanovic
- Fundación Somos Ciencia al Servicio de la Comunidad, Fundación SCISCO/Science to Serve the Community Foundation, SCISCO Foundation, Cali, Colombia.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, Bern, Switzerland
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16
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Efficacy and safety of different drug treatments in patients with spinal-cord injury-related neuropathic pain: a network meta-analysis. Spinal Cord 2022; 60:943-953. [DOI: 10.1038/s41393-022-00804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022]
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17
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Ling HQ, Chen ZH, He L, Feng F, Weng CG, Cheng SJ, Rong LM, Xie PG. Comparative Efficacy and Safety of 11 Drugs as Therapies for Adults With Neuropathic Pain After Spinal Cord Injury: A Bayesian Network Analysis Based on 20 Randomized Controlled Trials. Front Neurol 2022; 13:818522. [PMID: 35386408 PMCID: PMC8977449 DOI: 10.3389/fneur.2022.818522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/07/2022] [Indexed: 12/13/2022] Open
Abstract
Objective To provide an updated analysis of the efficacy and safety of drugs for the management of neuropathic pain (NP) after spinal cord injury (SCI) based on Bayesian network analysis. Methods A Bayesian network meta-analysis of literature searches within PubMed, Cochrane Library, Embase, and Web of Science databases from their inception to February 21 2021 was conducted without language restrictions. Paired and network meta-analyses of random effects were used to estimate the total standardized mean deviations (SMDs) and odds ratios (ORs). Results A total of 1,133 citations were identified and 20 RCTs (including 1,198 patients) involving 11 drugs and placebos for post-SCI NP selected. The 5 outcomes from all 11 drugs and placebos had no inconsistencies after Bayesian network analysis. BTX-A gave the most effective pain relief for the 4 weeks, following a primary outcome. No significant differences were found among drugs with regard to adverse events of the primary outcome. Gabapentin, BTX-A, and pregabalin were found to be the most helpful in relieving secondary outcomes of mental or sleep-related symptoms with differences in SMDs, ranging from −0.63 to −0.86. Tramadol triggered more serious adverse events than any of the other drugs with differences in ORs ranging from 0.09 to 0.11. Conclusion BTX-A, gabapentin, pregabalin, amitriptyline, ketamine, lamotrigine, and duloxetine were all effective for NP management following SCI. Lamotrigine and gabapentin caused fewer side effects and had better efficacy in relieving mental or sleep-related symptoms caused by SCI-related NP. Tramadol, levetiracetam, carbamazepine, and cannabinoids could not be recommended due to inferior safety or efficacy. Systematic Review Registration [https://inplasy.com/inplasy-2020-7-0061/], identifier [INPLASY202070061].
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Affiliation(s)
- Hai-Qian Ling
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China.,Department of Orthopedics, Longgang Orthopedics Hospital of Shenzhen, Shenzhen, China
| | - Zi-Hao Chen
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Lei He
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Feng Feng
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Chuang-Gui Weng
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Si-Jin Cheng
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Li-Min Rong
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Pei-Gen Xie
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, China.,Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
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Tamburella F, Lorusso M, Tramontano M, Fadlun S, Masciullo M, Scivoletto G. Overground robotic training effects on walking and secondary health conditions in individuals with spinal cord injury: systematic review. J Neuroeng Rehabil 2022; 19:27. [PMID: 35292044 PMCID: PMC8922901 DOI: 10.1186/s12984-022-01003-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 02/14/2022] [Indexed: 12/12/2022] Open
Abstract
Overground powered lower limb exoskeletons (EXOs) have proven to be valid devices in gait rehabilitation in individuals with spinal cord injury (SCI). Although several articles have reported the effects of EXOs in these individuals, the few reviews available focused on specific domains, mainly walking. The aim of this systematic review is to provide a general overview of the effects of commercial EXOs (i.e. not EXOs used in military and industry applications) for medical purposes in individuals with SCI. This systematic review was conducted following the PRISMA guidelines and it referred to MED-LINE, EMBASE, SCOPUS, Web of Science and Cochrane library databases. The studies included were Randomized Clinical Trials (RCTs) and non-RCT based on EXOs intervention on individuals with SCI. Out of 1296 studies screened, 41 met inclusion criteria. Among all the EXO studies, the Ekso device was the most discussed, followed by ReWalk, Indego, HAL and Rex devices. Since 14 different domains were considered, the outcome measures were heterogeneous. The most investigated domain was walking, followed by cardiorespiratory/metabolic responses, spasticity, balance, quality of life, human–robot interaction, robot data, bowel functionality, strength, daily living activity, neurophysiology, sensory function, bladder functionality and body composition/bone density domains. There were no reports of negative effects due to EXOs trainings and most of the significant positive effects were noted in the walking domain for Ekso, ReWalk, HAL and Indego devices. Ekso studies reported significant effects due to training in almost all domains, while this was not the case with the Rex device. Not a single study carried out on sensory functions or bladder functionality reached significance for any EXO. It is not possible to draw general conclusions about the effects of EXOs usage due to the lack of high-quality studies as addressed by the Downs and Black tool, the heterogeneity of the outcome measures, of the protocols and of the SCI epidemiological/neurological features. However, the strengths and weaknesses of EXOs are starting to be defined, even considering the different types of adverse events that EXO training brought about. EXO training showed to bring significant improvements over time, but whether its effectiveness is greater or less than conventional therapy or other treatments is still mostly unknown. High-quality RCTs are necessary to better define the pros and cons of the EXOs available today. Studies of this kind could help clinicians to better choose the appropriate training for individuals with SCI.
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Affiliation(s)
- Federica Tamburella
- I.R.C.C.S. Santa Lucia Foundation (FSL), Via Ardeatina, 306, 00179, Rome, Italy.
| | - Matteo Lorusso
- I.R.C.C.S. Santa Lucia Foundation (FSL), Via Ardeatina, 306, 00179, Rome, Italy
| | - Marco Tramontano
- I.R.C.C.S. Santa Lucia Foundation (FSL), Via Ardeatina, 306, 00179, Rome, Italy
| | - Silvia Fadlun
- I.R.C.C.S. Santa Lucia Foundation (FSL), Via Ardeatina, 306, 00179, Rome, Italy
| | - Marcella Masciullo
- I.R.C.C.S. Santa Lucia Foundation (FSL), Via Ardeatina, 306, 00179, Rome, Italy
| | - Giorgio Scivoletto
- I.R.C.C.S. Santa Lucia Foundation (FSL), Via Ardeatina, 306, 00179, Rome, Italy
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19
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Abstract
Purpose: Spinal cord injury-related pain is often a severe debilitating condition that adversely affects the patient's physical health, psychological wellbeing and quality of life. Opioid medications have historically been prescribed to this population with great frequency. As opioid abuse disorder becomes an ever-worsening public health issue, more attention must be placed upon non-opioid options. This paper reviews non-opioid medications to be considered when treating spinal cord injury-related pain. The pertinent literature is reviewed, and the advantages and pitfalls of various medication options are discussed in the complicated context of the individual with a spinal cord injury.Methods: Peer-reviewed journal articles and medication package insert data are reviewed.Results:. The non-opioid medications with the greatest evidence for efficacy in the treatment of chronic spinal cord injury-related pain are drawn from the antiepileptic drug and antidepressant categories though the specific selection must be nuanced to the particular individual patient. More research is required to understand the role of calcitonin, lithium, and marijuana in treating spinal cord injury-related pain.Conclusions: The complex clinical situation of each individual patient must be weighed against the risks and benefits of each medication, as reviewed in this paper, to determine the ideal treatment strategy for chronic spinal cord injury-related pain.
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Affiliation(s)
- Mendel Kupfer
- Rehabilitation Medicine, Magee Rehabilitation Hospital/Thomas Jefferson University, Philadelphia, Pennsylvania, USA,Correspondence to: Mendel Kupfer, Rehabilitation Medicine, Magee Rehabilitation Hospital/Thomas Jefferson University, 1513 Race St., Philadelphia, Pennsylvania19102, USA.
| | - Christopher S. Formal
- Rehabilitation Medicine, Magee Rehabilitation Hospital/Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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20
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The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update. Spinal Cord 2022; 60:548-566. [PMID: 35124700 PMCID: PMC9209331 DOI: 10.1038/s41393-021-00744-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 12/23/2022]
Abstract
STUDY DESIGN Clinical practice guidelines. OBJECTIVES The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI). SETTING The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada. METHODS The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations. RESULTS The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made. CONCLUSIONS The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice.
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21
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Tong C, Zhengyao Z, Mei L, Dongpo S, Qian H, Fengqun M. Pregabalin and Gabapentin in Patients with Spinal Cord Injury-Related Neuropathic Pain: A Network Meta-Analysis. Pain Ther 2021; 10:1497-1509. [PMID: 34491542 PMCID: PMC8586377 DOI: 10.1007/s40122-021-00302-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 08/04/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION This study was performed to explore the efficacy and safety of pregabalin and gabapentin in patients with spinal cord injury (SCI)-induced neuropathic pain to determine which treatment is most suitable for such patients. METHODS We searched the PubMed, MEDLINE, Embase, and Cochrane Library databases from database inception to August 31, 2020. The quality of the included studies was assessed. We selected the average pain intensity after treatment and the proportion of patients who discontinued treatment because of adverse effects as the outcome indicators for efficacy and safety, respectively. Statistical analyses were performed using Stata, v16.0, and RevMan, v5.3, software. RESULTS We included eight randomized controlled trials that examined four interventions (pregabalin, gabapentin, carbamazepine, and amitriptyline). Based on the average pain intensity after treatment, the efficacy order from highest to lowest was pregabalin, gabapentin, amitriptyline, carbamazepine, and placebo. Based on the proportion of patients who discontinued treatment because of adverse effects, the order from highest to lowest was pregabalin, amitriptyline, carbamazepine, gabapentin, and placebo. In addition, five studies reported the overall incidence of treatment-related adverse effects for two interventions (pregabalin and gabapentin). According to the pooled analysis of these studies, the order for the overall incidence of treatment-related adverse effects from highest to lowest was pregabalin, gabapentin, and placebo. CONCLUSIONS This study revealed that for patients with SCI-related neuropathic pain, pregabalin was the most effective for relieving pain, whereas gabapentin performed better in aspects associated with drug therapy-related safety.
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Affiliation(s)
- Chen Tong
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China.
| | - Zuo Zhengyao
- grid.470203.2Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000 Hebei China
| | - Li Mei
- grid.470203.2Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000 Hebei China
| | - Su Dongpo
- grid.470203.2Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000 Hebei China
| | - Han Qian
- grid.470203.2Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000 Hebei China
| | - Mu Fengqun
- Department of Neurology, Gongren Hospital, Tangshan, 063000 Hebei China
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22
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Development of Physiologically Based Pharmacokinetic Model for Pregabalin to Predict the Pharmacokinetics in Pediatric Patients with Renal Impairment and Adjust Dosage Regimens: PBPK Model of Pregabalin in Pediatric Patients with Renal Impairment. J Pharm Sci 2021; 111:542-551. [PMID: 34706283 DOI: 10.1016/j.xphs.2021.10.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 12/17/2022]
Abstract
Pregabalin (PGB) is widely used clinically; however, its pharmacokinetics (PK) has not been studied in pediatric patients with renal impairment (RI). To design optimized PGB regimens for pediatric patients with varying degrees of RI and predict exposure to PGB, physiologically based pharmacokinetic (PBPK) models of PGB were developed and verified, and its disposition was simulated in the healthy population and adults with RI. The simulated results from the PBPK models after single-dose and multi-dose administrations of PGB were consistent with the corresponding observed data based on the fold error values of less than 2. The area under curve ratios were 1.23 ± 0.06, 2.02 ± 0.10, 3.86 ± 0.21, and 9.92 ± 0.79 in pediatric patients with mild, moderate, severe, and end-stage RI, respectively. Based on the predictions for pediatric patients with moderate, severe, and end-stage RI, the maximum dose should not exceed 7, 3.5, and 1.4 mg/kg/day, respectively, among those weighing < 30 kg, and it should not exceed 5, 2.5, and 1 mg/kg/day, respectively, among those weighing > 30 kg. In conclusion, the developed PBPK model is a valuable tool for predicting PGB dosage for pediatric patients with RI.
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23
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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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24
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Elmoheen A, Nazal AF, Zubaidi O, Siddiqui UA, Alhatou M. Expert review and recommendations for the management of acute, chronic, and neuropathic pain in Qatar. Qatar Med J 2021; 2021:19. [PMID: 34285886 DOI: 10.5339/qmj.2021.19] [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: 11/18/2020] [Accepted: 02/24/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pain management is an evolving area of expertise in Qatar. Gaps in knowledge, inadequate training for physicians and nurses, and the absence of policies/guidelines are the main barriers to effective pain management in Qatar. In addition, the use of certain pain medication, especially opioids, is highly regulated, limiting their availability in outpatient pain management. These factors are responsible for the undertreatment of pain in Qatar. This study aimed to standardize evidence-based local recommendations for pharmacological treatment of pain in Qatar. METHODS An expert panel of physicians from different disciplines, with experience in diagnosis and treatment of the three pain types (i.e., acute, chronic, and neuropathic), was convened for two face-to-face meetings in Doha, Qatar, on November 29, 2019, and on February 22, 2020, with subsequent virtual meetings. A literature search was performed on Medline and Google Scholar databases from inception till December 2019, and all relevant articles were selected. Based on these articles and repeated feedback from the authors, the final pain treatment protocols were developed. RESULTS Recommendations for the treatment of acute pain, based on pain severity, followed three approaches: acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain and moderate pain and referral to a pain specialist for severe pain. Acetaminophen/paracetamol or NSAIDs is recommended for chronic pain, and the use of opioids was strongly discouraged because of its long-term side effects. For neuropathic pain, tricyclic antidepressants or gabapentin or pregabalin or serotonin-norepinephrine reuptake inhibitors were recommended first-line agents. Non-responders must be referred to neurologists or a pain specialist. CONCLUSION The expert panel provides recommendations for the management of acute, chronic, and neuropathic pain based on international guidelines adapted to local practice and treatment availability in Qatar. More importantly, the panel has recommended taking extreme caution in the use of opioids for long-term management of chronic pain and to refer the patient to a pain specialist clinician as required.
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Affiliation(s)
- Amr Elmoheen
- Emergency Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdullah F Nazal
- Pain Management Section, Department of Anesthesiology, ICU and Perioperative Medicine, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Osman Zubaidi
- Research, Development and Medical, Upjohn-A Division of Pfizer, Doha, Qatar
| | - Urooj A Siddiqui
- Research, Development and Medical, Upjohn-A Division of Pfizer, Dubai, UAE
| | - Mohammed Alhatou
- Neuromuscular Division, Hamad Medical Corporation, Doha, Qatar; Neurology Division, Department of Medicine, Al Khor Hospital, Doha, Qatar
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25
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Basheer C. Extraction of Pregabalin in Urine Samples Using a Sulfonated Poly(ether ether ketone) Membrane. Int J Anal Chem 2021; 2021:3439242. [PMID: 34158813 PMCID: PMC8187039 DOI: 10.1155/2021/3439242] [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: 04/14/2021] [Revised: 05/06/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
In this work, a simple polymer-assisted microextraction technique was developed to determine pregabalin (an anticonvulsant drug) in the urine sample. A sulfonated poly(ether ether ketone) membrane was used as a sorbent for pregabalin extraction, and the extraction performance was compared with that of the conventional polydimethylsiloxane membrane. The extraction device is free moving and tumbles continuously throughout the stirred sample solution during extraction to enhance the extraction efficiency. The electrostatic interactions between the sulfonic-acid-functionalized polymeric membrane and the amine group in the pregabalin molecule facilitate higher preconcentration factor at a shorter extraction time. Optimizing conditions of the extraction method were investigated to obtain higher extraction efficiency. The developed method exhibited good linearity in the range of 0.05 to 2 µg/mL with a correlation of determination (r 2) 0.9998, acceptable limits of detection, limits of quantification, and preconcentration factor of 105-fold. The within-day and between-day precisions of pregabalin were lower than 7% relative standard deviations. Pregabalin was extracted from urine samples with recoveries of >92%, and no significant matrix effects were observed.
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Affiliation(s)
- Chanbasha Basheer
- Department of Chemistry, King Fahd University of Petroleum and Minerals, Dhahran 31261, Saudi Arabia
- Membranes and Water Security, Interdisciplinary Research Center, KFUPM, Dhahran 31261, Saudi Arabia
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26
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Fakhri S, Abbaszadeh F, Jorjani M. On the therapeutic targets and pharmacological treatments for pain relief following spinal cord injury: A mechanistic review. Biomed Pharmacother 2021; 139:111563. [PMID: 33873146 DOI: 10.1016/j.biopha.2021.111563] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/11/2022] Open
Abstract
Spinal cord injury (SCI) is globally considered as one of the most debilitating disorders, which interferes with daily activities and life of the affected patients. Despite many developments in related recognizing and treating procedures, post-SCI neuropathic pain (NP) is still a clinical challenge for clinicians with no distinct treatments. Accordingly, a comprehensive search was conducted in PubMed, Medline, Scopus, Web of Science, and national database (SID and Irandoc). The relevant articles regarding signaling pathways, therapeutic targets and pharmacotherapy of post-SCI pain were also reviewed. Data were collected with no time limitation until November 2020. The present study provides the findings on molecular mechanisms and therapeutic targets, as well as developing the critical signaling pathways to introduce novel neuroprotective treatments of post-SCI pain. From the pathophysiological mechanistic point of view, post-SCI inflammation activates the innate immune system, in which the immune cells elicit secondary injuries. So, targeting the critical signaling pathways for pain management in the SCI population has significant importance in providing new treatments. Indeed, several receptors, ion channels, excitatory neurotransmitters, enzymes, and key signaling pathways could be used as therapeutic targets, with a pivotal role of n-methyl-D-aspartate, gamma-aminobutyric acid, and inflammatory mediators. The current review focuses on conventional therapies, as well as crucial signaling pathways and promising therapeutic targets for post-SCI pain to provide new insights into the clinical treatment of post-SCI pain. The need to develop innovative delivery systems to treat SCI is also considered.
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Affiliation(s)
- Sajad Fakhri
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fatemeh Abbaszadeh
- Neurobiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Masoumeh Jorjani
- Neurobiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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27
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Canavan C, Inoue T, McMahon S, Doody C, Blake C, Fullen BM. The Efficacy, Adverse Events & Withdrawal Rates of the Pharmacological Management of Chronic Spinal Cord Injury Pain: A Systematic Review & Meta-Analysis. PAIN MEDICINE 2021; 23:375-395. [PMID: 33844010 DOI: 10.1093/pm/pnab140] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To establish the efficacy of medications, incidence of adverse events (AE) and withdrawal rates (WR) of the pharmacological management of chronic spinal cord injury (SCI) pain. METHODOLOGY PubMed, MEDLINE, Embase, CINAHL, Web of Science, CENTRAL and PsycINFO were searched (November 2017) and updated (January 2020). Two independent review authors screened and identified papers for inclusion. RESULTS Twenty-one studies met inclusion for efficacy analysis and 17 for AEs and WR analysis; no additional paper were included from the up dated 2020 search. Treatments were divided into 6 categories: anticonvulsants (n = 6), antidepressants (n = 3), analgesics (n = 8), anti-spasticity (n = 2), cannabinoids (n = 1) and other (n = 2). Trials of anticonvulsants, antidepressants, and cannabinoids included long-term follow-up trials (2 weeks- 4 months), and analgesics, anti-spasticity, among others were short term trials (0-2 days). Effectiveness for NP was found for Pregabalin (3/3 studies) and Lidocaine (2/3 studies). Studies using Ketamine also reported effectiveness (2/2) but the quality of these papers was rated as poor. Most frequently reported AEs included dizziness, dry mouth, nausea and constipation. Pregabalin had a higher risk of somnolence (RR 3.15, 95% CI 2.00-4.98) and dizziness (RR 2.9, 95% CI 1.58-5.30). Ketamine had a higher risk of reduced vision (RR 9.00, 95% CI 0.05-146.11), dizziness (RR 8.33, 95% CI 1.73-40.10) and somnolence (RR 7.00, 95% CI 1.73-40.1). WRs ranged from: 18.4% (antidepressants), 0-30% (anticonvulsants), 0-10% (anti-spasticity), 0-48% (analgesics), 28.6% (cannabinoids) and 0-22.2% (other). CONCLUSION Pregabalin was found to be effective for NP versus placebo. Cannabinoids was ineffective for NP. AEs are a common cause for withdrawal. The nature of AEs was poorly reported and should be improved in future RCT's.
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Affiliation(s)
- Clare Canavan
- UCD Centre for Translational Pain Research, University College Dublin, Belfield Campus, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science
| | - Takayoshi Inoue
- UCD Centre for Translational Pain Research, University College Dublin, Belfield Campus, Dublin, Ireland
| | - Sinead McMahon
- School of Public Health, Physiotherapy and Sports Science
| | - Catherine Doody
- UCD Centre for Translational Pain Research, University College Dublin, Belfield Campus, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science
| | - Catherine Blake
- UCD Centre for Translational Pain Research, University College Dublin, Belfield Campus, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science
| | - Brona M Fullen
- UCD Centre for Translational Pain Research, University College Dublin, Belfield Campus, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science
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Abstract
Central post-stroke pain is a chronic neuropathic pain syndrome following a cerebrovascular accident. The development of central post-stroke pain is estimated to occur in 8 to 55% of stroke patients and is described as constant or intermittent neuropathic pain accompanied by dysesthesia of temperature and/or pressure sensations. These pain and sensory deficits are within the area of the body corresponding to the stroke lesion. The onset of pain is usually gradual, though it can develop either immediately after stroke or years after. Given the diversity in its clinical presentation, central post-stroke pain is a challenging diagnosis of exclusion. Furthermore, central post-stroke pain is often resistant to pharmacological treatment options and a clear therapeutic algorithm has not been established. Based on current evidence, amitriptyline, lamotrigine, and gabapentinoids should be used as first-line pharmacotherapy options when central post-stroke pain is suspected. Other drugs, such as fluvoxamine, steroids, and Intravenous infusions of lidocaine, ketamine, or even propofol, can be considered in intractable cases. In addition, interventional therapies such as motor cortex stimulation or transcranial magnetic stimulation have been shown to provide relief in difficult-to-treat patients.
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Affiliation(s)
- Hanwool Ryan Choi
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Adem Aktas
- Division of Neurorehabilitation, Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Michael M Bottros
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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29
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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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30
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Shen Z, Li Z, Ke J, He C, Liu Z, Zhang D, Zhang Z, Li A, Yang S, Li X, Li R, Zhao K, Ruan Q, Du H, Guo L, Yin F. Effect of non-invasive brain stimulation on neuropathic pain following spinal cord injury: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21507. [PMID: 32846761 PMCID: PMC7447445 DOI: 10.1097/md.0000000000021507] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In recent years, some studies indicated that repetitive transcranial magnetic stimulation (rTMS) could relieve neuropathic pain (NP) following a spinal cord injury (SCI), whereas some studies showed no pain relief effect. In addition, some studies showed the analgesic effect of transcranial direct current stimulation (tDCS) on NP post SCI, whereas other studies showed no effect. METHODS We systematically searched on the PubMed, Web of Science, EMBASE, Medline, Google Scholar for studies exploring the analgesic effect of rTMS or tDCS on NP post SCI until November 2019. Meta-analysis was conducted to summarize results of these studies. RESULTS The present quantitative meta-analysis indicated no significant difference in the effect of treatment on NP following SCI between rTMS and sham rTMS over the motor cortex at about 1 week after the end of the rTMS period (standardized mean difference (SMD) = 2.89, 95% confidence interval (CI) = -0.27 to 6.04). However, the study indicated that rTMS showed significantly better pain relief of treatment compared with sham rTMS between 2 and 6 weeks after the end of the rTMS period (SMD = 3.81, 95%CI: 0.80-7.52). However, no sufficient evidence could be provided to make a meta-analysis for the analgesic effect of tDCS on NP following SCI over the primary motor area (M1). CONCLUSIONS In conclusion, the present meta-analysis suggested that rTMS did not show early analgesic effect on NP after SCI, but showed better middle-term analgesic effect, compared with sham rTMS. More large scale, blinded randomized controlled trials (RCTs) were needed to explore the analgesic effect of rTMS and tDCS on NP following SCI.
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Affiliation(s)
- Zhubin Shen
- Department of Orthopaedic, China–Japan Union Hospital
| | - Zhongrun Li
- Department of Toxicology, School of Public Health, Jilin University, Changchun, China
| | - Junran Ke
- Department of Orthopaedic, China–Japan Union Hospital
| | - Changhao He
- Department of Toxicology, School of Public Health, Jilin University, Changchun, China
| | - Zhiming Liu
- Department of Orthopaedic, China–Japan Union Hospital
| | - Din Zhang
- Department of Orthopaedic, China–Japan Union Hospital
| | - Zhili Zhang
- Department of Toxicology, School of Public Health, Jilin University, Changchun, China
| | - Anpei Li
- Department of Toxicology, School of Public Health, Jilin University, Changchun, China
| | - Shuang Yang
- Department of Orthopaedic, China–Japan Union Hospital
| | - Xiaolong Li
- Department of Orthopaedic, China–Japan Union Hospital
| | - Ran Li
- Department of Orthopaedic, China–Japan Union Hospital
| | - Kunchi Zhao
- Department of Orthopaedic, China–Japan Union Hospital
| | - Qing Ruan
- Department of Orthopaedic, China–Japan Union Hospital
| | - Haiying Du
- Department of Toxicology, School of Public Health, Jilin University, Changchun, China
| | - Li Guo
- Department of Toxicology, School of Public Health, Jilin University, Changchun, China
| | - Fei Yin
- Department of Orthopaedic, China–Japan Union Hospital
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31
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Stabingas K, Bergman J, Patterson M, Tomycz ND. Peripheral subcutaneous field stimulation for the treatment of spinal cord injury at-level pain: case report, literature review, and 5-year follow-up. Heliyon 2020; 6:e04515. [PMID: 32743101 PMCID: PMC7385456 DOI: 10.1016/j.heliyon.2020.e04515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/28/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022] Open
Abstract
Spinal cord injury (SCI) frequently engenders chronic pain which may be classified as occurring above, at, or below the level of injury. Since patients with SCI may have a complex combination of nociceptive and neuropathic pain, pharmacological interventions often fail. Peripheral subcutaneous field stimulation (PSFS) is a novel neuromodulation surgery for pain in which subcutaneous electrodes designed for spinal cord stimulation are placed subcutaneously in a region of pain. We report the case of a 26-year-old man who was an unrestrained driver in a motor vehicle accident and suffered a complete ASIA A spinal cord injury with paraplegia due to a T4 three-column burst fracture. He underwent successful surgical fixation of the fracture (7/27/12) and developed severe at-level SCI-associated pain which failed all conservative measures. After a successful trial, two octrode leads (Abbott Medical, Plano, TX, USA) were placed for PSFS under general anesthesia and were connected to a right flank rechargeable pulse generator (11/6/13). At 60 months postoperative, the patient continues to use the peripheral field stimulation system on a daily basis and reports near complete relief of his at-level spinal cord injury pain. He noted instantaneous relief of his pain once ideal stimulation programming was achieved and has tolerated complete cessation of all narcotic use. His current programming settings are: Frequency of 50 Hz (Hz), Pulse Width of 350 μs (μsec), Amplitude of 0.00 miliamps (mA), Comf of 7.70 mA, and Perc of 4.50 mA. Chronic pain is a challenging and expensive sequela to manage in SCI patients and newer therapies are needed. Our case suggests that SCI at-level pain may respond durably to PSFS and provides the longest published follow-up on a case of PSFS. Peripheral subcutaneous field stimulation remains an investigational treatment for chronic pain syndrome and larger, long-term follow up studies are needed for the FDA and payers to approve this modality.
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Affiliation(s)
- Kristen Stabingas
- Department of Neurosurgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Jeffrey Bergman
- Department of Neurosurgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Michael Patterson
- Center for Pain Relief, Allegheny Health Network, 161 Waterdam Road, McMurray, PA 15317, USA
| | - Nestor D Tomycz
- Department of Neurosurgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
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32
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Allison DJ, Agudelo AR, Chan BCF, Ditor DS, Loh E. Cannabinoids and an anti-inflammatory diet for the treatment of neuropathic pain after spinal cord injury (The CATNP Study): study protocol for a randomized controlled trial. Spinal Cord 2020; 59:112-122. [PMID: 32612213 DOI: 10.1038/s41393-020-0508-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN Multicenter, randomized, double-blind, placebo controlled, clinical trial. OBJECTIVE The objective of this paper is to evaluate the effectiveness of cannabinoids and an anti-inflammatory diet, alone and in combination, for the management of neuropathic pain (NP) after spinal cord injury (SCI). SETTING Two Canadian SCI rehabilitation centers. METHODS A sample of 144 individuals with SCI will receive either an anti-inflammatory diet, cannabinoids or a placebo for 6 weeks. Following this, a combined effect of these treatments will be evaluated for a further 6 weeks. The primary outcome measure will be the change in NP as assessed by the numeric rating scale (NRS). Secondary outcomes will include changes in inflammation, mood, sleep, spasticity, cost-effectiveness, and function. CONCLUSION This study will assess the efficacy of an anti-inflammatory diet and cannabinoids (individually and in combination) for the treatment of NP following SCI. Results may reveal a cost-effective, side-effect free intervention strategy which could be utilized for the long-term management of NP following SCI.
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Affiliation(s)
- David J Allison
- Lawson Health Research Institute, London, ON, Canada. .,Department of Kinesiology, McMaster University, Hamilton, ON, Canada. .,Parkwood Institute, London, ON, Canada. .,Western University, London, ON, Canada.
| | - Alexandria Roa Agudelo
- Lawson Health Research Institute, London, ON, Canada.,Parkwood Institute, London, ON, Canada.,Western University, London, ON, Canada
| | - Brian C F Chan
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David S Ditor
- Department of Kinesiology, Brock University, St. Catharines, ON, Canada
| | - Eldon Loh
- Lawson Health Research Institute, London, ON, Canada.,Parkwood Institute, London, ON, Canada.,Western University, London, ON, Canada
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33
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Cragg JJ, Jutzeler CR, Grassner L, Ramer M, Bradke F, Kramer JLK. Beneficial "Pharmaceutical Pleiotropy" of Gabapentinoids in Spinal Cord Injury: A Case for Refining Standard-of-Care. Neurorehabil Neural Repair 2020; 34:686-689. [PMID: 32508248 DOI: 10.1177/1545968320931516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spinal cord injury results in devastating neurological deficits accompanied by lifelong disability and significant economic burden. While the development of novel compounds or cell-based interventions for spinal cord injury is unquestionably worthwhile, a complementary approach examines current standards of care and the degree to which these can be optimized to benefit long-term neurological function. Numerous classes of drugs, already in use in the acute phase of spinal cord injury, are intriguing because they (1) readily cross the blood-spinal cord barrier to modulate activity in the central nervous system and (2) are administered during a window of time in which neuroprotection, and even some repair, are feasible. Here, we review a rare case of convergent lines of evidence from both preclinical and human studies to support the early administration of a class of drug (ie, gabapentinoids) to both foster motor recovery and reduce the severity of neuropathic pain.
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Affiliation(s)
- Jacquelyn J Cragg
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Lukas Grassner
- Paracelsus Medical University, Salzburg, Austria.,Medical University Innsbruck, Innsbruck, Austria
| | - Matt Ramer
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
| | - Frank Bradke
- German Centre for Neurodegenerative Disease (DZNE), Bonn, Germany
| | - John L K Kramer
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada
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Comparison of the use of opioids only and pregabalin add-on for the treatment of neuropathic pain in cervical myelopathy patients: a pilot trial. Sci Rep 2020; 10:8120. [PMID: 32415211 PMCID: PMC7229110 DOI: 10.1038/s41598-020-65108-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/15/2020] [Indexed: 01/24/2023] Open
Abstract
Among patients with cervical myelopathy who were diagnosed with neuropathic pain (NP) by the LANSS test, the study participants were randomly assigned to one of the two study groups. The participants in one study group received opioids only, while those in the other group received opioids and pregabalin. Thirty-nine patients were analyzed in the study (20 patients in the opioid-only group and 19 in the pregabalin add-on group). The LANSS, neck pain, and arm pain scores in the pregabalin add-on group improved significantly compared with those in the opioid-only group after the first 4 weeks (p = 0.005, 0.001 and 0.035, respectively), but there was no significant difference between the two groups during the next 4 weeks (p = 0.615, 0.377 and 0.716, respectively). There was no significant difference in the neck disability index and EuroQol-5Dimension scores after four weeks and eight weeks of follow-up. Adverse events were reported by four patients (20.0%) in the opioid-only group and five patients (26.3%) in the pregabalin add-on group (p = 0.716). However, over time, the occurrence of side effects and dropouts increased in the pregabalin add-on group. This exploratory pilot study suggests that pregabalin add-on treatment is more efficient than the use of opioids alone at the beginning of NP treatment in cervical myelopathy patients. However, prescribing pregabalin add-on treatment for more than four weeks should be done cautiously.
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35
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Alles SRA, Cain SM, Snutch TP. Pregabalin as a Pain Therapeutic: Beyond Calcium Channels. Front Cell Neurosci 2020; 14:83. [PMID: 32351366 PMCID: PMC7174704 DOI: 10.3389/fncel.2020.00083] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/20/2020] [Indexed: 12/12/2022] Open
Abstract
Initially developed to generate new treatments for epilepsy, gabapentin, and pregabalin (“gabapentinoids”) were engineered to mimic the action of GABA and to modulate GABA metabolism. Rather than their intended pharmacological action on GABA neurotransmission, instead, they exhibit a high affinity for the α2δ-1 and α2δ-2 subunits of voltage-activated calcium channels, wherein binding of gabapentinoids inhibits cellular calcium influx and attenuates neurotransmission. Despite a lack of activity on GABA levels, gabapentin and pregabalin are effective at suppressing seizures and subsequently approved as a new class of antiepileptic therapy for partial-onset epilepsy. Through the same hypothesized molecular mechanism and by controlling neuronal hyperexcitability, gabapentinoids demonstrate clear efficacy in pain management, which has arguably been their most extensively prescribed application to date. In this review, we focus on pregabalin as a second-generation gabapentinoid widely employed in the treatment of a variety of pain conditions. We also discuss the wider functional roles of α2δ subunits and the contributions that pregabalin might play in affecting physiological and pathophysiological processes.
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Affiliation(s)
- Sascha R A Alles
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Stuart M Cain
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Terrance P Snutch
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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36
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Wang JL, Ren CH, Feng J, Ou CH, Liu L. Oleanolic acid inhibits mouse spinal cord injury through suppressing inflammation and apoptosis via the blockage of p38 and JNK MAPKs. Biomed Pharmacother 2020; 123:109752. [PMID: 31924596 DOI: 10.1016/j.biopha.2019.109752] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/07/2019] [Accepted: 11/29/2019] [Indexed: 12/22/2022] Open
Abstract
Spinal cord injury (SCI) is reported as a devastating disease, leading to tissue loss and neurologic dysfunction. However, there is no effective therapeutic strategy for SCI treatment. Oleanolic acid (OA), as a triterpenoid, has anti-oxidant, anti-inflammatory, and anti-apoptotic activities. However, its regulatory effects on SCI have little to be elucidated, as well as the underlying molecular mechanisms. In this study, we attempted to explore the role of OA in SCI progression. Behavior tests suggested that OA treatments markedly alleviated motor function in SCI mice. Evans blue contents up-regulated in spinal cords of SCI mice were significantly reduced by OA in a dose-dependent manner, demonstrating the improved blood-spinal cord barrier. Moreover, we found that OA treatments significantly reduced the apoptotic cell death in spinal cord samples of SCI mice through decreasing the expression of cleaved Caspase-3. In addition, pro-inflammatory response in SCI mice was significantly attenuated by OA treatments. Furthermore, SCI mice exhibited higher activation of mitogen-activated protein kinases (MAPKs) and nuclear factor-κB (NF-κB) signaling pathways, but these effects were clearly blocked in SCI mice with OA treatments, as evidenced by the down-regulated phosphorylation of p38, c-Jun-NH 2 terminal kinase (JNK), IκB kinase α (IKKα), inhibitor of nuclear factor κB-α (IκBα) and NF-κB. The protective effects of OA against SCI were confirmed in lipopolysaccharide (LPS)-stimulated mouse neurons mainly through the suppression of apoptosis and inflammatory response, which were tightly associated with the blockage of p38 and JNK activation. Together, our data demonstrated that OA treatments could dose-dependently ameliorate spinal cord damage through impeding p38- and JNK-regulated apoptosis and inflammation, and therefore OA might be served as an effective therapeutic agent for SCI treatment.
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Affiliation(s)
- Jiang-Lin Wang
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou City, Sichuan Province, 646000, China
| | - Chang-He Ren
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou City, Sichuan Province, 646000, China
| | - Jian Feng
- Department of Cardiology, The Affiliated Hospital of Southwest Medical University, Luzhou City, Sichuan Province, 646000, China
| | - Ce-Hua Ou
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou City, Sichuan Province, 646000, China.
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou City, Sichuan Province, 646000, China.
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37
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Dombovy-Johnson ML, Hunt CL, Morrow MM, Lamer TJ, Pittelkow TP. Current Evidence Lacking to Guide Clinical Practice for Spinal Cord Stimulation in the Treatment of Neuropathic Pain in Spinal Cord Injury: A Review of the Literature and a Proposal for Future Study. Pain Pract 2020; 20:325-335. [PMID: 31691496 DOI: 10.1111/papr.12855] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/25/2019] [Accepted: 10/31/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND/OBJECTIVE Chronic pain is commonly reported in individuals with spinal cord injuries (SCIs), with recent prevalence reported as high as 80%. Uncontrolled pain is known to decrease quality of life, attenuate mood, and impact sleep. Spinal cord stimulation (SCS) for the treatment of refractory pain was first used in the SCI population in 1972. To date there have been no randomized controlled trials examining the effect of SCS on neuropathic pain post-SCI. A literature review in 2009 identified 27 studies, the majority prior to 2000, that included at least 1 patient with SCI. Given the significant advancements in the field of SCS, this review examines the updated evidence of SCS for the treatment of neuropathic pain in individuals with SCI and provides guidance on future investigations. METHODS MEDLINE and EMBASE databases were searched. All published reports, case series, and clinical trials reviewing SCS for neuropathic pain that included at least 1 individual with SCI were included. RESULTS The initial search identified 376 reports, of which 22 met inclusion criteria, for a total of 69 patients. All reports were of very low quality. A majority of the reported patients were male, underwent tonic stimulation, and reportedly experienced improvement in pain and spasticity, with decreased use of pain medication. CONCLUSIONS The synthesized findings from primarily case studies support the safety of SCS in SCI with the suggestion of potential pain relief benefit; however, data from low-quality studies are insufficient for informing clinical practice. A well-designed, prospective clinical trial is proposed to further investigate this indication.
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Affiliation(s)
| | - Christine L Hunt
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Melissa M Morrow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Thomas P Pittelkow
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Davari M, Amani B, Amani B, Khanijahani A, Akbarzadeh A, Shabestan R. Pregabalin and gabapentin in neuropathic pain management after spinal cord injury: a systematic review and meta-analysis. Korean J Pain 2020; 33:3-12. [PMID: 31888312 PMCID: PMC6944364 DOI: 10.3344/kjp.2020.33.1.3] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/10/2019] [Accepted: 12/10/2019] [Indexed: 01/07/2023] Open
Abstract
Neuropathic pain after spinal cord injury (SCI) has a significant negative impact on the patients’ quality of life. The objective of this systematic review is to examine the safety and efficacy of pregabalin (PGB) and gabapentin (GBP) in the treatment of neuropathic pain due to SCI. PubMed, the Cochrane Library, Embase, Scopus, and the Web of Science were searched up to December 2018. The reference lists of key and review studies were reviewed for additional citations. The quality of the studies was evaluated using the Cochrane Collaboration’s tools for assessing the risk of bias. A meta-analysis was performed for primary and secondary outcomes. Eight studies were eligible for inclusion. Meta-analysis of PGB vs. placebo showed that PGB was effective for neuropathic pain (standardized mean difference [SMD] = −0.40; 95% confidence interval [CI]: −0.78, −0.01), anxiety (MD = −0.68; 95% CI: −0.77, −0.59), depression (mean difference [MD] = −0.99; 95% CI: −1.08, −0.89), and sleep interference (MD = −1.08; 95% CI: −1.13, −1.02). Also, GBP was more effective than a placebo for reducing pain. No significant difference was observed between the efficacy of the two drugs (MD = −0.37; 95% CI: −1.67, 0.93). There was no significant difference between the two drugs for discontinuation due to adverse events (risk ratio = 3.00; 95% CI: 0.81, 11.15). PGB and GBP were effective vs. placebos in decreasing neuropathic pain after SCI. Also, there was no significant difference between the two drugs for decreasing pain and adverse events.
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Affiliation(s)
- Majid Davari
- Department of Pharmacoeconomics and Pharmaceutical Administration, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahman Amani
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Amani
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Khanijahani
- Department of Health Administration and Public Health, John G. Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA, USA
| | - Arash Akbarzadeh
- Department of Biostatistics and Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Rouhollah Shabestan
- Department of Biostatistics and Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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39
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Haller J, Krecsak L, Zámbori J. Double-blind placebo controlled trial of the anxiolytic effects of a standardized Echinacea extract. Phytother Res 2019; 34:660-668. [PMID: 31876052 DOI: 10.1002/ptr.6558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/30/2019] [Accepted: 11/08/2019] [Indexed: 01/12/2023]
Abstract
Earlier studies suggested that specific Echinacea preparations might decrease anxiety. To further study the issue, we performed a double blind, placebo controlled trial with a standardized Echinacea angustifolia root extract. Participants were volunteers scoring above 45 points on the state or on the trait subscale of the State Trait Anxiety Inventory (STAI). They were treated with 40 mg Echinacea or with placebo tablets twice daily for 7 days followed by a 3 week-long washout period. Participants were also administered the Beck Depression Inventory (BDI) and the Perceived Stress Scale (PSS). In the Echinacea group, state anxiety scores decreased by approximately 11 points by the end of the treatment period, whereas the decrease was around 3-points in the placebo group (p< 0.01). The effect maintained over the washout period. The difference from placebo was significant from the 7th day of treatment throughout. Changes were less robust with trait anxiety scores, but the preparation performed better than placebo in patients with high baseline anxiety. Neither BDI nor PSS scores were affected by the treatments. Adverse effects were rare and mild, and all were observed in the placebo group. These findings suggest that particular Echinacea preparations have significant beneficial effects on anxiety in humans.
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Affiliation(s)
- József Haller
- Institute of Experimental Medicine, Budapest, Hungary.,University of Public Service, Budapest, Hungary
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40
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Khan AS, Livingstone DC, Hurd CL, Duchcherer J, Misiaszek JE, Gorassini MA, Manns PJ, Yang JF. Retraining walking over ground in a powered exoskeleton after spinal cord injury: a prospective cohort study to examine functional gains and neuroplasticity. J Neuroeng Rehabil 2019; 16:145. [PMID: 31752911 PMCID: PMC6868817 DOI: 10.1186/s12984-019-0585-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background Powered exoskeletons provide a way to stand and walk for people with severe spinal cord injury. Here, we used the ReWalk exoskeleton to determine the training dosage required for walking proficiency, the sensory and motor changes in the nervous system with training, and the functionality of the device in a home-like environment. Methods Participants with chronic (> 1 yr) motor complete or incomplete spinal cord injury, who were primarily wheelchair users, were trained to walk in the ReWalk for 12 weeks. Measures were taken before, during, immediately after, and 2–3 months after training. Measures included walking progression, sitting balance, skin sensation, spasticity, and strength of the corticospinal tracts. Results Twelve participants were enrolled with 10 completing training. Training progression and walking ability: The progression in training indicated about 45 sessions to reach 80% of final performance in training. By the end of training, participants walked at speeds of 0.28–0.60 m/s, and distances of 0.74–1.97 km in 1 h. The effort of walking was about 3.3 times that for manual wheelchair propulsion. One non-walker with an incomplete injury became a walker without the ReWalk after training. Sensory and motor measures: Sitting balance was improved in some, as seen from the limits of stability and sway speed. Neuropathic pain showed no long term changes. Change in spasticity was mixed with suggestion of differences between those with high versus low spasticity prior to training. The strength of motor pathways from the brain to back extensor muscles remained unchanged. Adverse events: Minor adverse events were encountered by the participants and trainer (skin abrasions, non-injurious falls). Field testing: The majority of participants could walk on uneven surfaces outdoors. Some limitations were encountered in home-like environments. Conclusion For individuals with severe SCI, walking proficiency in the ReWalk requires about 45 sessions of training. The training was accompanied by functional improvements in some, especially in people with incomplete injuries. Trial registration NCT02322125 Registered 22 December 2014. Electronic supplementary material The online version of this article (10.1186/s12984-019-0585-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Atif S Khan
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Donna C Livingstone
- Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada
| | - Caitlin L Hurd
- Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada
| | | | - John E Misiaszek
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.,Occupational Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Monica A Gorassini
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.,Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia J Manns
- Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada
| | - Jaynie F Yang
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada. .,Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada.
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41
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Parsons B, Freynhagen R, Schug S, Whalen E, Ortiz M, Bhadra Brown P, Knapp L. The relationship between the reporting of euphoria events and early treatment responses to pregabalin: an exploratory post-hoc analysis. J Pain Res 2019; 12:2577-2587. [PMID: 31686899 PMCID: PMC6709807 DOI: 10.2147/jpr.s199203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 07/02/2019] [Indexed: 12/12/2022] Open
Abstract
Background Euphoria is a complex, multifactorial problem that is reported as an adverse event in clinical trials of analgesics including pregabalin. The relationship between the reporting of euphoria events and pregabalin early treatment responses was examined in this exploratory post-hoc analysis. Methods Data were from patients with neuropathic or non-neuropathic chronic pain enrolled in 40 randomized clinical trials, who received pregabalin (75–600 mg/day) or placebo. Reports of treatment-emergent euphoria events were based on the Medical Dictionary of Regulatory Activities preferred term “euphoric mood”. Prevalence rates of euphoria events overall and by indication were assessed. Post-treatment endpoints included ≥30% improvements in pain and sleep scores up to 3 weeks as well as a ≥1-point improvement in daily pain score up to 11 days after treatment. Results 13,252 patients were analyzed; 8,501 (64.1%) and 4,751 (35.9%) received pregabalin and placebo, respectively. Overall, 1.7% (n=222) of patients reported euphoria events. Among pregabalin-treated patients, a larger proportion who reported euphoria events achieved an early pain response compared with those who did not report euphoria (30% pain responders in week 1 with euphoria events [43.0%], without euphoria events [24.2%]). Results were similar for weeks 2 and 3. For Days 2–11, a larger proportion of pregabalin-treated patients with (relative to without) euphoria events were 1-point pain responders. Findings were similar in pregabalin-treated patients for sleep endpoints (30% sleep responders in week 1 with euphoria events [50.7%], without euphoria events [36.1%]). Similar results were found for weeks 2 and 3. Patients who received placebo showed similar patterns, although the overall number of them who reported euphoria events was small (n=13). Conclusion In patients who received pregabalin for neuropathic or non-neuropathic chronic pain, those who experienced euphoria events may have better early treatment responses than those who did not report euphoria events.
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Affiliation(s)
| | - Rainer Freynhagen
- Department of Anesthesiology, Critical Care Medicine, Pain Therapy & Palliative Care, Pain Center Lake Starnberg, Benedictus Hospital, Tutzing, Germany.,Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stephan Schug
- Discipline of Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, WA, Australia.,Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, WA, Australia
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Franz S, Schulz B, Wang H, Gottschalk S, Grüter F, Friedrich J, Glaesener JJ, Bock F, Schott C, Müller R, Schultes K, Landmann G, Gerner HJ, Dietz V, Treede RD, Weidner N. Management of pain in individuals with spinal cord injury: Guideline of the German-Speaking Medical Society for Spinal Cord Injury. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2019; 17:Doc05. [PMID: 31354397 PMCID: PMC6637293 DOI: 10.3205/000271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Indexed: 12/19/2022]
Abstract
Introduction: Pain is a prominent complication in spinal cord injury (SCI). It can either occur as a direct or as an indirect consequence of SCI and it often heavily influences the quality of life of affected individuals. In SCI, nociceptive and neuropathic pain can equally emerge at the same time above or below the level of injury. Thus, classification and grading of pain is frequently difficult. Effective treatment of SCI-related pain in general and of neuropathic pain in particular is challenging. Current treatment options are sparse and their evidence is considered to be limited. Considering these aspects, a clinical practice guideline was developed as basis for an optimized, comprehensive and standardized pain management in SCI-related pain. Methods: The German-Speaking Medical Society for Spinal Cord Injury (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie – DMGP) developed a clinical practice guideline that received consensus from seven further German-speaking medical societies and one patient organization. The evidence base from clinical trials and meta-analyses was summarized and subjected to a structured consensus-process in accordance with the regulations of the Association of Scientific Medical Societies in Germany (AWMF) and the methodological requirements of the “German instrument for methodological guideline appraisal”. Results: This consensus-based guideline (S2k classification according to the AWMF guidance manual and rules) resulted in seven on-topic statements and 17 specific recommendations relevant to the classification, assessment and therapy of pain directly or indirectly caused by SCI. Recommended therapeutic approaches comprise pharmacological (e.g. nonsteroidal anti-inflammatory drugs or anticonvulsants) and non-pharmacological (e.g. physical activity or psychotherapeutic techniques) strategies for both nociceptive and neuropathic pain. Discussion: Assessment of SCI-related pain is standardized and respective methods in terms of examination, classification and grading of pain are already in use and validated in German language. In contrast, valid, evidence-based and efficient therapeutic options are limited and ask for further clinical studies, ideally randomized controlled trials and meta-analyses.
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Affiliation(s)
- Steffen Franz
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Barbara Schulz
- BG Klinikum Bergmannstrost, Abteilung Medizinische Psychologie, Spezielle Traumatherapie (DeGPT), Hypnotherapie und Hypnose (DGH), Halle, Germany
| | - Haili Wang
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Gottschalk
- Zentralklinik Bad Berka GmbH, Querschnittgelähmten-Zentrum/Klinik für Paraplegiologie und Neuro-Urologie, Bad Berka, Germany
| | - Florian Grüter
- Kliniken Beelitz GmbH, Neurologische Rehabilitationsklinik, Beelitz-Heilstätten, Germany
| | | | | | | | - Cordelia Schott
- Orthopädische Privatpraxis Schott (OPS), Im Medizinischen Zentrum Essen, Germany
| | | | - Kevin Schultes
- Fördergemeinschaft der Querschnittgelähmten in Deutschland e.V., Lobbach, Germany
| | - Gunther Landmann
- Center for Pain Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Hans Jürgen Gerner
- Fördergemeinschaft der Querschnittgelähmten in Deutschland e.V., Lobbach, Germany
| | - Volker Dietz
- Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland
| | - Rolf-Detlef Treede
- Chair of Neurophysiology, Centre of Biomedicine and Medical Technology Mannheim, Heidelberg University, Mannheim, Germany
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
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Bates D, Schultheis BC, Hanes MC, Jolly SM, Chakravarthy KV, Deer TR, Levy RM, Hunter CW. A Comprehensive Algorithm for Management of Neuropathic Pain. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:S2-S12. [PMID: 31152178 PMCID: PMC6544553 DOI: 10.1093/pm/pnz075] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians. The algorithm covers assessment, multidisciplinary conservative care, nonopioid pharmacological management, interventional therapies, neurostimulation, low-dose opioid treatment, and targeted drug delivery therapy. METHODS Available literature was identified through a search of the US National Library of Medicine's Medline database, PubMed.gov. References from identified published articles also were reviewed for relevant citations. RESULTS The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Clear indicators for progression of therapy from firstline to sixth-line are provided. Multidisciplinary conservative care and nonopioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as firstline therapy; combination therapy (firstline medications) and tramadol and tapentadol are recommended as secondline; serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists and interventional therapies as third-line; neurostimulation as a fourth-line treatment; low-dose opioids (no greater than 90 morphine equivalent units) are fifth-line; and finally, targeted drug delivery is the last-line therapy for patients with refractory pain. CONCLUSIONS The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations. It defines the benefits and limitations of the current treatments at our disposal. Additionally, it provides an easy-to-follow visual guide of the recommended steps in the algorithm for primary care and family practitioners to utilize.
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Affiliation(s)
| | - B Carsten Schultheis
- Muskuloskelettales Zentrum - Interventionelle Schmerztherapie, Krankenhaus Neuwerk “Maria von den Aposteln,” Mönchengladbach, Germany
| | | | - Suneil M Jolly
- Louisiana Pain Specialists, New Orleans, Louisiana
- New Orleans East Hospital, New Orleans, Louisiana
| | - Krishnan V Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, La Jolla, California
- Veterans Administration San Diego Healthcare System, San Diego, California
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | | | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York, USA
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Parsons B, Fujii K, Nozawa K, Yoshiyama T, Ortiz M, Whalen E. The efficacy of pregabalin for the treatment of neuropathic pain in Japanese subjects with moderate or severe baseline pain. J Pain Res 2019; 12:1061-1068. [PMID: 30962707 PMCID: PMC6434920 DOI: 10.2147/jpr.s181729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose Although analyses of pooled clinical trial data have reported how international populations respond to pregabalin by baseline neuropathic pain (NeP) severity, no studies have evaluated this specifically in patients from Japan. Thus, this post hoc pooled analysis evaluated the efficacy of pregabalin in Japanese subjects for treating moderate or severe baseline NeP. Patients and methods Data were pooled from three placebo-controlled trials enrolling Japanese subjects with postherpetic neuralgia (PHN), diabetic peripheral neuropathy (DPN), and spinal cord injury (SCI). The efficacy of pregabalin was evaluated by baseline pain severity (moderate or severe NeP). The trials on PHN and DPN included a 1-week titration of pregabalin from 150 mg/day to 300 or 600 mg/day; the SCI trial included a 4-week dose optimization phase (150 mg/day, titrated up to 600 mg/day). Treatment durations were 13–16 weeks (excluding 1-week taper periods), and pregabalin was administered in two divided doses per day. Results Mean baseline pain scores and demographic characteristics were comparable between treatment cohorts. Pregabalin treatment significantly reduced pain scores from baseline to endpoint compared with placebo in subjects with both moderate (P<0.001) and severe (P<0.05) baseline pain. Significant improvements in mean sleep scores from baseline to endpoint were associated with pregabalin compared with placebo in subjects with both moderate and severe baseline pain (both P<0.0001). A greater proportion of subjects in both pain cohorts achieved a ≥30% reduction in pain from baseline with pregabalin vs placebo (P<0.05). Higher proportions of pregabalin-treated vs placebo-treated subjects shifted to a less severe pain category at endpoint. Consistent with the known safety profile of pregabalin, common adverse events included dizziness, somnolence, weight gain, and peripheral edema. Conclusion Pregabalin demonstrated efficacy for pain relief and sleep improvement with a consistent safety profile in Japanese subjects with either moderate or severe baseline pain severity. ClinicalTrials.gov identifiers NCT0039490130, NCT0055347522, NCT0040774524
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Affiliation(s)
- Bruce Parsons
- Global Medical Product Evaluation, Pfizer Inc, New York, NY, USA,
| | - Koichi Fujii
- Medical Affairs, Pfizer Japan Inc, Shibuya-ku, Tokyo, Japan
| | | | | | - Marie Ortiz
- Global Statistics, Pfizer Inc, New York, NY, USA
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Castany S, Codony X, Zamanillo D, Merlos M, Verdú E, Boadas-Vaello P. Repeated Sigma-1 Receptor Antagonist MR309 Administration Modulates Central Neuropathic Pain Development After Spinal Cord Injury in Mice. Front Pharmacol 2019; 10:222. [PMID: 30967775 PMCID: PMC6439356 DOI: 10.3389/fphar.2019.00222] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/22/2019] [Indexed: 12/19/2022] Open
Abstract
Up to two-thirds of patients affected by spinal cord injury (SCI) develop central neuropathic pain (CNP), which has a high impact on their quality of life. Most of the patients are largely refractory to current treatments, and new pharmacological strategies are needed. Recently, it has been shown that the acute administration of the σ1R antagonist MR309 (previously developed as E-52862) at 28 days after spinal cord contusion results in a dose-dependent suppression of both mechanical allodynia and thermal hyperalgesia in wild-type CD-1 Swiss female mice. The present work was addressed to determine whether MR309 might exert preventive effects on CNP development by repeated administration during the first week after SCI in mice. To this end, the MR309 (16 or 32 mg/kg i.p.) modulation on both thermal hyperalgesia and mechanical allodynia development were evaluated weekly up to 28 days post-injury. In addition, changes in pro-inflammatory cytokine (TNF-α, IL-1β) expression and both the expression and activation (phosphorylation) of the N-methyl-D-aspartate receptor subunit 2B (NR2B-NMDA) and extracellular signal-regulated kinases (ERK1/2) were analyzed. The repeated treatment of SCI-mice with MR309 resulted in significant pain behavior attenuation beyond the end of the administration period, accompanied by reduced expression of central sensitization-related mechanistic correlates, including extracellular mediators (TNF-α and IL-1β), membrane receptors/channels (NR2B-NMDA) and intracellular signaling cascades (ERK/pERK). These findings suggest that repeated MR309 treatment after SCI may be a suitable pharmacologic strategy to modulate SCI-induced CNP development.
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Affiliation(s)
- Sílvia Castany
- Research Group of Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, Universitat de Girona, Girona, Spain
| | - Xavier Codony
- Esteve Pharmaceuticals, Drug Discovery and Preclinical Development, Parc Científic de Barcelona, Barcelona, Spain
| | - Daniel Zamanillo
- Esteve Pharmaceuticals, Drug Discovery and Preclinical Development, Parc Científic de Barcelona, Barcelona, Spain
| | - Manuel Merlos
- Esteve Pharmaceuticals, Drug Discovery and Preclinical Development, Parc Científic de Barcelona, Barcelona, Spain
| | - Enrique Verdú
- Research Group of Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, Universitat de Girona, Girona, Spain
| | - Pere Boadas-Vaello
- Research Group of Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, Universitat de Girona, Girona, Spain
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Gensel JC, Donahue RR, Bailey WM, Taylor BK. Sexual Dimorphism of Pain Control: Analgesic Effects of Pioglitazone and Azithromycin in Chronic Spinal Cord Injury. J Neurotrauma 2019; 36:2372-2376. [PMID: 30618345 PMCID: PMC6648167 DOI: 10.1089/neu.2018.6207] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Central neuropathic pain develops in greater than 75% of individuals suffering a spinal cord injury (SCI). Increasingly, sex is recognized as an important biological variable in the development and treatment of peripheral neuropathic pain, but much less is known about the role of sex in central neuropathic pain and its pharmacological inhibition. To test the hypothesis that efficacy of analgesic therapies differs between males and females in SCI, we used a mouse model of SCI pain to determine the analgesic efficacy of pioglitazone (PIO), U.S. Food and Drug Administration–approved drug for the treatment of diabetes, and azithromycin (AZM), a commonly prescribed macrolide antibiotic with immunomodulatory properties. Male and female mice received moderate-severe T9 contusion SCI (75-kdyn). A robust heat hyperalgesia developed similarly between male and female mice by 4 weeks post-injury and lasted throughout the duration of the study (14 weeks). Three months after SCI, mice were treated with PIO (10 mg/kg, intraperitoneal) or AZM (160 mg/kg, oral). We observed a sex-specific effect of PIO with significant antihyperalgesic effects in females, but not males. In contrast, AZM was effective in both sexes. Our data support the use of PIO and AZM as novel therapies for SCI pain and highlight the importance of considering sex as a biological variable in clinical and experimental SCI pain research.
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Affiliation(s)
- John C Gensel
- 1Spinal Cord and Brain Injury Research Center and Department of Physiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Renée R Donahue
- 1Spinal Cord and Brain Injury Research Center and Department of Physiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - William M Bailey
- 1Spinal Cord and Brain Injury Research Center and Department of Physiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Bradley K Taylor
- 2Department of Anesthesia and Perioperative Medicine, the Pittsburgh Center for Pain Research, and the Opioid Research Center at the University of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Abstract
BACKGROUND This review updates part of an earlier Cochrane Review titled "Pregabalin for acute and chronic pain in adults", and considers only neuropathic pain (pain from damage to nervous tissue). Antiepileptic drugs have long been used in pain management. Pregabalin is an antiepileptic drug used in management of chronic pain conditions. OBJECTIVES To assess the analgesic efficacy and adverse effects of pregabalin for chronic neuropathic pain in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase for randomised controlled trials from January 2009 to April 2018, online clinical trials registries, and reference lists. SELECTION CRITERIA We included randomised, double-blind trials of two weeks' duration or longer, comparing pregabalin (any route of administration) with placebo or another active treatment for neuropathic pain, with participant-reported pain assessment. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality and biases. Primary outcomes were: at least 30% pain intensity reduction over baseline; much or very much improved on the Patient Global Impression of Change (PGIC) Scale (moderate benefit); at least 50% pain intensity reduction; or very much improved on PGIC (substantial benefit). We calculated risk ratio (RR) and number needed to treat for an additional beneficial (NNTB) or harmful outcome (NNTH). We assessed the quality of the evidence using GRADE. MAIN RESULTS We included 45 studies lasting 2 to 16 weeks, with 11,906 participants - 68% from 31 new studies. Oral pregabalin doses of 150 mg, 300 mg, and 600 mg daily were compared with placebo. Postherpetic neuralgia, painful diabetic neuropathy, and mixed neuropathic pain predominated (85% of participants). High risk of bias was due mainly to small study size (nine studies), but many studies had unclear risk of bias, mainly due to incomplete outcome data, size, and allocation concealment.Postherpetic neuralgia: More participants had at least 30% pain intensity reduction with pregabalin 300 mg than with placebo (50% vs 25%; RR 2.1 (95% confidence interval (CI) 1.6 to 2.6); NNTB 3.9 (3.0 to 5.6); 3 studies, 589 participants, moderate-quality evidence), and more had at least 50% pain intensity reduction (32% vs 13%; RR 2.5 (95% CI 1.9 to 3.4); NNTB 5.3 (3.9 to 8.1); 4 studies, 713 participants, moderate-quality evidence). More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (62% vs 24%; RR 2.5 (95% CI 2.0 to 3.2); NNTB 2.7 (2.2 to 3.7); 3 studies, 537 participants, moderate-quality evidence), and more had at least 50% pain intensity reduction (41% vs 15%; RR 2.7 (95% CI 2.0 to 3.5); NNTB 3.9 (3.1 to 5.5); 4 studies, 732 participants, moderate-quality evidence). Somnolence and dizziness were more common with pregabalin than with placebo (moderate-quality evidence): somnolence 300 mg 16% versus 5.5%, 600 mg 25% versus 5.8%; dizziness 300 mg 29% versus 8.1%, 600 mg 35% versus 8.8%.Painful diabetic neuropathy: More participants had at least 30% pain intensity reduction with pregabalin 300 mg than with placebo (47% vs 42%; RR 1.1 (95% CI 1.01 to 1.2); NNTB 22 (12 to 200); 8 studies, 2320 participants, moderate-quality evidence), more had at least 50% pain intensity reduction (31% vs 24%; RR 1.3 (95% CI 1.2 to 1.5); NNTB 22 (12 to 200); 11 studies, 2931 participants, moderate-quality evidence), and more had PGIC much or very much improved (51% vs 30%; RR 1.8 (95% CI 1.5 to 2.0); NNTB 4.9 (3.8 to 6.9); 5 studies, 1050 participants, moderate-quality evidence). More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (63% vs 52%; RR 1.2 (95% CI 1.04 to 1.4); NNTB 9.6 (5.5 to 41); 2 studies, 611 participants, low-quality evidence), and more had at least 50% pain intensity reduction (41% vs 28%; RR 1.4 (95% CI 1.2 to 1.7); NNTB 7.8 (5.4 to 14); 5 studies, 1015 participants, low-quality evidence). Somnolence and dizziness were more common with pregabalin than with placebo (moderate-quality evidence): somnolence 300 mg 11% versus 3.1%, 600 mg 15% versus 4.5%; dizziness 300 mg 13% versus 3.8%, 600 mg 22% versus 4.4%.Mixed or unclassified post-traumatic neuropathic pain: More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (48% vs 36%; RR 1.2 (1.1 to 1.4); NNTB 8.2 (5.7 to 15); 4 studies, 1367 participants, low-quality evidence), and more had at least 50% pain intensity reduction (34% vs 20%; RR 1.5 (1.2 to 1.9); NNTB 7.2 (5.4 to 11); 4 studies, 1367 participants, moderate-quality evidence). Somnolence (12% vs 3.9%) and dizziness (23% vs 6.2%) were more common with pregabalin.Central neuropathic pain: More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (44% vs 28%; RR 1.6 (1.3 to 2.0); NNTB 5.9 (4.1 to 11); 3 studies, 562 participants, low-quality evidence) and at least 50% pain intensity reduction (26% vs 15%; RR 1.7 (1.2 to 2.3); NNTB 9.8 (6.0 to 28); 3 studies, 562 participants, low-quality evidence). Somnolence (32% vs 11%) and dizziness (23% vs 8.6%) were more common with pregabalin.Other neuropathic pain conditions: Studies show no evidence of benefit for 600 mg pregabalin in HIV neuropathy (2 studies, 674 participants, moderate-quality evidence) and limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy.Serious adverse events, all conditions: Serious adverse events were no more common with placebo than with pregabalin 300 mg (3.1% vs 2.6%; RR 1.2 (95% CI 0.8 to 1.7); 17 studies, 4112 participants, high-quality evidence) or pregabalin 600 mg (3.4% vs 3.4%; RR 1.1 (95% CI 0.8 to 1.5); 16 studies, 3995 participants, high-quality evidence). AUTHORS' CONCLUSIONS Evidence shows efficacy of pregabalin in postherpetic neuralgia, painful diabetic neuralgia, and mixed or unclassified post-traumatic neuropathic pain, and absence of efficacy in HIV neuropathy; evidence of efficacy in central neuropathic pain is inadequate. Some people will derive substantial benefit with pregabalin; more will have moderate benefit, but many will have no benefit or will discontinue treatment. There were no substantial changes since the 2009 review.
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Affiliation(s)
| | - Rae Frances Bell
- Haukeland University HospitalRegional Centre of Excellence in Palliative CareBergenNorway
| | - Sebastian Straube
- University of AlbertaDepartment of Medicine, Division of Preventive Medicine5‐30 University Terrace8303‐112 StreetEdmontonCanadaT6G 2T4
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Onakpoya IJ, Thomas ET, Lee JJ, Goldacre B, Heneghan CJ. Benefits and harms of pregabalin in the management of neuropathic pain: a rapid review and meta-analysis of randomised clinical trials. BMJ Open 2019; 9:e023600. [PMID: 30670513 PMCID: PMC6347863 DOI: 10.1136/bmjopen-2018-023600] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To assess the benefits and harms of pregabalin in the management of neuropathic pain. DESIGN Rapid review and meta-analysis of phase III, randomised, placebo-controlled trials. PARTICIPANTS Adults aged 18 years and above with neuropathic pain defined according to the International Association for the Study of Pain criteria. INTERVENTIONS Pregabalin or placebo. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary outcomes were pain (as measured using validated scales) and adverse events. Our secondary outcomes were sleep disturbance, quality of life, Patient Global Impression of Change, Clinician Global Impression scale, anxiety and depression scores, overall discontinuations and discontinuations because of adverse events. RESULTS We included 28 trials comprising 6087 participants. The neuropathic pain conditions studied were diabetic peripheral neuropathy, postherpetic neuralgia, herpes zoster, sciatica (radicular pain), poststroke pain and spinal cord injury-related pain. Patients who took pregabalin reported significant reductions in pain (numerical rating scale (NRS)) compared with placebo (standardised mean difference (SMD) -0.49 (95% CI -0.66 to -0.32, p<0.00001), very low quality evidence). Pregabalin significantly reduced sleep interference scores (NRS) compared with placebo (SMD -0.38 (95% CI -0.50 to -0.26, p<0.00001), moderate quality evidence. Pregabalin significantly increased the risk of adverse events compared with placebo (RR 1.33 (95% CI 1.23 to 1.44, p<0.00001, low quality evidence)). The risks of experiencing weight gain, somnolence, dizziness, peripheral oedema, fatigue, visual disturbances, ataxia, non-peripheral oedema, vertigo and euphoria were significantly increased with pregabalin. Pregabalin was significantly more likely than placebo to lead to discontinuation of the drug because of adverse events (RR 1.91 (95% CI 1.54 to 2.37, p<0.00001), low quality evidence). CONCLUSION Pregabalin has beneficial effects on some symptoms of neuropathic pain. However, its use significantly increases the risk of a number of adverse events and discontinuation due to adverse events. The quality of the evidence from journal publications is low.
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Affiliation(s)
- Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Elizabeth T Thomas
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Ben Goldacre
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
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Lawton AJ, Lee KA, Cheville AL, Ferrone ML, Rades D, Balboni TA, Abrahm JL. Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review. J Clin Oncol 2019; 37:61-71. [DOI: 10.1200/jco.2018.78.1211] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC. Methods This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach. Results Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs. Conclusion Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.
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Affiliation(s)
- Andrew J. Lawton
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Kathleen A. Lee
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Marco L. Ferrone
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Dirk Rades
- University Hospital of Lübeck, Lübeck, Germany
| | - Tracy A. Balboni
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Janet L. Abrahm
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| |
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