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Telfer P, Anie KA, Kotsiopoulou S, Aiken L, Hibbs S, Burt C, Stuart-Smith S, Lugthart S. The acute pain crisis in sickle cell disease: What can be done to improve outcomes? Blood Rev 2024; 65:101194. [PMID: 38553339 DOI: 10.1016/j.blre.2024.101194] [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: 12/04/2023] [Revised: 02/19/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.
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Affiliation(s)
- Paul Telfer
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, UK; Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK.
| | - Kofi A Anie
- Brent Sickle Cell & Thalassaemia Centre, London North West University Healthcare NHS Trust, London, UK
| | | | - Laura Aiken
- Department of Haematology, Royal London Hospital, Bart's Health NHS Trust, London, UK
| | - Stephen Hibbs
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | | | - Sanne Lugthart
- University of Bristol, School of Cellular and Molecular Medicine, Bristol, UK; Department of Haematology, University Hospitals of Bristol, Bristol, UK
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Kenney MO, Knisely MR, McGill LS, Campbell C. Altered pain processing and sensitization in sickle cell disease: a scoping review of quantitative sensory testing findings. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:144-156. [PMID: 37815822 DOI: 10.1093/pm/pnad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVES Over 50% of adults living with sickle cell disease (SCD) have chronic pain, but the underlying mechanisms of chronic pain in this population remain unclear. Quantitative sensory testing is an important measurement tool for understanding pain and sensory processing. This scoping review summarizes quantitative sensory testing methodologies used in sickle cell studies and the evidence for central sensitization in this population. METHODS We conducted a systematic search of PubMed, Embase, and CINAHL to identify studies using quantitative sensory testing in individuals living with sickle cell disease. Search strategies were based on variations of the terms "sickle cell disease," and "quantitative sensory testing." Eligible studies were observational or experimental studies in human participants living with SCD that reported findings and detailed methodology for at least 1 quantitative sensory testing modality. RESULTS Our search yielded a total of 274 records; 27 of which are included in this scoping review. Of the 27 studies, 17 were original studies (with combined total of 516 adult and 298 pediatric participants), and 10 were secondary or subgroup analyses of these prior studies. Significant variation existed in quantitative sensory testing methodologies across studies, including testing locations, type and intensity of stimuli, and interpretation of findings. Of the identified studies, 22% (2/9 studies) reported sensory abnormalities in mechanical sensitivity and thresholds, 22% (2/9 studies) reported abnormal pressure pain thresholds, 46% (6/13 studies) reported sensory abnormalities in thermal pain thresholds and tolerance (cold and warm), and 50% (2/4 studies) reported abnormalities in temporal summation. CONCLUSION Future studies should use standardized quantitative sensory testing protocols with consistent and operationalized definitions of sensitization to provide clear insight about pain processing and central sensitization in sickle cell disease.
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Affiliation(s)
- Martha O Kenney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Duke University, Durham, NC 27710, United States
| | | | - Lakeya S McGill
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
| | - Claudia Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
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Pinto VM, Gianesin B, Sardo S, Mazzi F, Baiardi G, Menotti S, Piras F, Quintino S, Robello G, Mattioli F, Finco G, Forni GL, De Franceschi L. Safety and efficacy of ketorolac continuous infusion for multimodal analgesia of vaso-occlusive crisis in patients with sickle cell disease. Orphanet J Rare Dis 2024; 19:22. [PMID: 38254184 PMCID: PMC10801952 DOI: 10.1186/s13023-023-02998-7] [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: 06/26/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Pain is an hallmark of sickle-cell-related acute clinical manifestations as part of acute vaso-occlusive crisis (VOC). In SCD pain has different origins such as vascular or neuropathic pain, which requires multimodal analgesia. This is based on the administration of drugs with different pharmacological mechanisms of action, maximizing analgesia and minimizing their adverse events and the risk of drug-addition in patients experiencing acute-recurrent pain events as in SCD. Ketorolac is a potent non-narcotic analgesic, being relatively safe and effective during pain-management in children and adults. Up to now, there is a lack of safety information on continuous infusion ketorolac as used to control acute pain in patients with SCD, and the benefits/risks ratio needs to be investigated. Here, we report for the first time the safety profile of ketorolac in the special population of patients with SCD. We confirmed that ketorolac in combination with tramadol, an opioid like molecule, is effective in pain control of adult patients with SCD experiencing acute severe VOCs defined by pain visual analog scale. Our study shows that short term (72 h) continuous infusion of ketorolac plus tramadol is not associated with adverse events such as liver or kidney acute disfunction or abnormalities in coagulation parameters during patients' hospitalization and within 30 days after patients discharge. This is extremely important for patients with SCD, who should have access to multimodal therapy to control recurrent acute pain crisis in order to limit central sensitization a fearsome issue of undertreated recurrent acute pain and of chronic pain.
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Affiliation(s)
- Valeria Maria Pinto
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
| | - Barbara Gianesin
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
- For Anemia Foundation, Genoa, Italy
| | - Salvatore Sardo
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Filippo Mazzi
- Department of Medicine, University of Verona and AOUI Verona, Verona, Italy
| | - Giammarco Baiardi
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
- Clinical Pharmacology Unit, EO Ospedali Galliera, Genoa, Italy
| | - Sofia Menotti
- Department of Medicine, University of Verona and AOUI Verona, Verona, Italy
| | - Fabio Piras
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
| | - Sabrina Quintino
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
| | - Giacomo Robello
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy
| | - Francesca Mattioli
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genoa, Italy
- Clinical Pharmacology Unit, EO Ospedali Galliera, Genoa, Italy
| | - Gabriele Finco
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Gian Luca Forni
- EO Ospedali Galliera, Centro della Microcitemia, delle Anemie Congenite e dei Disordini del Metabolismo del Ferro, Genoa, Italy.
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Kenney MO, Wilson S, Shah N, Bortsov A, Smith WR, Little J, Lanzkron S, Kanter J, Padrino S, Owusu-Ansah A, Cohen A, Desai P, Manwani D, Rehman SSU, Hagar W, Keefe F. Biopsychosocial Factors Associated With Pain and Pain-Related Outcomes in Adults and Children With Sickle Cell Disease: A Multivariable Analysis of the GRNDaD Multicenter Registry. THE JOURNAL OF PAIN 2024; 25:153-164. [PMID: 37544393 DOI: 10.1016/j.jpain.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
Pain is the primary symptomatic manifestation of sickle cell disease (SCD), an inherited hemoglobinopathy. The characteristics that influence pain experiences and outcomes in SCD are not fully understood. The primary objective of this study was to use multivariable modeling to examine associations of biopsychosocial variables with a disease-specific measure of pain interference known as pain impact. We conducted a secondary analysis of data from the Global Research Network for Data and Discovery national SCD registry. A total of 657 children and adults with SCD were included in the analysis. This sample was 60% female with a median age of 34 (interquartile range 26-42 years) and a chronic pain prevalence of 64%. The model accounted for 58% of the variance in pain impact. Low social (P < .001) and emotional (P < .001) functioning, increasing age (P = .004), low income (P < .001), and high acute painful episodes (P = .007) were most strongly associated with high pain impact in our multivariable model. Additionally, multivariable modeling of pain severity and physical function in 2 comparable samples of registry participants revealed that increasing age and low social functioning were also strongly associated with higher pain severity and low physical functioning. Overall, the results suggest that social and emotional functioning are more strongly associated with pain impact in individuals with SCD than previously studied biological modifiers such as SCD genotype, hemoglobin, and percentage fetal hemoglobin. Future research using longitudinally collected data is needed to confirm these findings. PERSPECTIVE: This study reveals that psychosocial (ie, social and emotional functioning) and demographic (ie, age) variables may play an important role in predicting pain and pain-related outcomes in SCD. Our findings can inform future multicenter prospective longitudinal studies aimed at identifying modifiable psychosocial predictors of adverse pain outcomes in SCD.
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Affiliation(s)
- Martha O Kenney
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Duke University, Durham, North Carolina
| | - Samuel Wilson
- Department of Medicine, Division of Hematology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina; UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nirmish Shah
- Departments of Pediatrics & Hematology, Duke University, Durham, North Carolina
| | - Andrey Bortsov
- Center for Translational Pain Medicine, Duke University, Durham, North Carolina
| | - Wally R Smith
- Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Jane Little
- Department of Medicine, Division of Hematology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina; UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sophie Lanzkron
- Department of Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julie Kanter
- Division of Hematology and Oncology, University of Alabama, Birmingham, Alabama
| | - Susan Padrino
- School of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Amma Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Hematology Oncology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Alice Cohen
- Division of Hematology and Oncology, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Payal Desai
- Levin Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore (CHAM), Bronx, New York
| | - Sana Saif Ur Rehman
- Department of Medicine, Division of Hematology, Washington University School of Medicine, St. Louis, Missouri
| | - Ward Hagar
- Department of Pediatrics, UCSF Benioff Children's Hospital, Oakland, California
| | - Francis Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Science, Duke University, Durham, North Carolina
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Smith WR, Valrie CR, Jaja C, Kenney MO. Precision, integrative medicine for pain management in sickle cell disease. FRONTIERS IN PAIN RESEARCH 2023; 4:1279361. [PMID: 38028431 PMCID: PMC10666191 DOI: 10.3389/fpain.2023.1279361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Sickle cell disease (SCD) is a prevalent and complex inherited pain disorder that can manifest as acute vaso-occlusive crises (VOC) and/or chronic pain. Despite their known risks, opioids are often prescribed routinely and indiscriminately in managing SCD pain, because it is so often severe and debilitating. Integrative medicine strategies, particularly non-opioid therapies, hold promise in safe and effective management of SCD pain. However, the lack of evidence-based methods for managing SCD pain hinders the widespread implementation of non-opioid therapies. In this review, we acknowledge that implementing personalized pain treatment strategies in SCD, which is a guideline-recommended strategy, is currently fraught with limitations. The full implementation of pharmacological and biobehavioral pain approaches targeting mechanistic pain pathways faces challenges due to limited knowledge and limited financial and personnel support. We recommend personalized medicine, pharmacogenomics, and integrative medicine as aspirational strategies for improving pain care in SCD. As an organizing model that is a comprehensive framework for classifying pain subphenotypes and mechanisms in SCD, and for guiding selection of specific strategies, we present evidence updating pain research pioneer Richard Melzack's neuromatrix theory of pain. We advocate for using the updated neuromatrix model to subphenotype individuals with SCD, to better select personalized multimodal treatment strategies, and to identify research gaps fruitful for exploration. We present a fairly complete list of currently used pharmacologic and non-pharmacologic SCD pain therapies, classified by their mechanism of action and by their hypothesized targets in the updated neuromatrix model.
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Affiliation(s)
- Wally R. Smith
- Division of General Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Cecelia R. Valrie
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States
| | - Cheedy Jaja
- College of Nursing, University of South Florida School of Nursing, Tampa, FL, United States
| | - Martha O. Kenney
- Department of Anesthesiology, Duke University, Durham, NC, United States
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Pascale A, Sisler I, Smith W, Valrie C. Intraindividual pain variability metrics for youth with sickle cell disease: Relations to health outcomes. Pediatr Blood Cancer 2023; 70:e30194. [PMID: 36605027 PMCID: PMC9974742 DOI: 10.1002/pbc.30194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/18/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND While the majority of pediatric sickle cell disease (SCD) research has used mean pain intensity as the only pain metric, recent evidence suggests this metric alone is inadequate in describing the intraindividual variability in SCD pain experiences and subsequent impact. There is limited information on other intraindividual pain metrics in youth with SCD, or how they relate to health outcomes in this population. The aims of this study were to describe differing patterns of intraindividual pain metrics derived from ecological momentary assessments (EMAs) of youth with SCD and to characterize the unique relationships between these metrics and health outcomes. METHODS Eighty-eight youth with SCD, aged 8-17 (mean age = 11.6), were recruited from three regional pediatric SCD clinics in the United States. At baseline, youth and their guardians reported on demographic and disease information. Then youth completed twice daily EMAs for up to 4 weeks. Pain metrics derived from EMA data were calculated including mean daily pain intensity (DP), SD-DP (standard deviation of DP), proportion of pain days (PPD), and 90th percentile of DP (p90). Pearson correlations were calculated between pain metrics and health outcomes. RESULTS High DP and SD-DP were correlated with more anxiety symptoms, while high SD-DP and p90 were correlated with more depression symptoms. High SD-DP was correlated with low self-esteem, and high DP and PPD were correlated with low sickle cell self-efficacy. For healthcare utilization due to pain, high p90 was correlated with more emergency department visits, while high DP, p90, and PPD were correlated with more healthcare contacts. CONCLUSION There are distinct associations between pain variability metrics beyond DP and health outcomes. Collectively, the patterns of associations suggest the utility of these pain metrics for determining risk in relation to specific health outcomes for youth with SCD.
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Affiliation(s)
- Angela Pascale
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - India Sisler
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Wally Smith
- Department of Internal Medicine, Division of General Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Cecelia Valrie
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
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Koehl JL, Koyfman A, Hayes BD, Long B. High risk and low prevalence diseases: Acute chest syndrome in sickle cell disease. Am J Emerg Med 2022; 58:235-244. [PMID: 35717760 DOI: 10.1016/j.ajem.2022.06.018] [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: 05/19/2022] [Revised: 05/31/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Acute chest syndrome (ACS) in sickle cell disease (SCD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ACS in SCD, including diagnosis and management in the emergency department (ED) based on current evidence. DISCUSSION ACS is defined by respiratory symptoms and/or fever and a new radiodensity on chest imaging in a patient with SCD. There are a variety of inciting causes, including infectious and non-infectious etiologies. Although ACS is more common in those with homozygous SCD, clinicians should consider ACS in all SCD patients, as ACS is a leading cause of death in SCD. Patients typically present with or develop respiratory symptoms including fever, cough, chest pain, and shortness of breath, which can progress to respiratory failure requiring mechanical ventilation in 20% of adult patients. However, the initial presentation can vary. While the first line imaging modality is classically chest radiograph, lung ultrasound has demonstrated promise. Further imaging to include computed tomography may be necessary. Management focuses on analgesia, oxygen supplementation, incentive spirometry, bronchodilators, rehydration, antibiotics, consideration for transfusion, and specialist consultation. Empiric antibiotics that cover atypical pathogens are necessary along with measures to increase oxygen-carrying capacity in those with hypoxemia such as simple transfusion or exchange transfusion. CONCLUSIONS An understanding of ACS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Bryan D Hayes
- Department of Emergency Medicine, Division of Medical Toxicology, Harvard Medical School, Boston, MA, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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