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Hincker A, Frey K, Rao L, Wagner-Johnston N, Ben Abdallah A, Tan B, Amin M, Wildes T, Shah R, Karlsson P, Bakos K, Kosicka K, Kagan L, Haroutounian S. Somatosensory predictors of response to pregabalin in painful chemotherapy-induced peripheral neuropathy: a randomized, placebo-controlled, crossover study. Pain 2019; 160:1835-1846. [PMID: 31335651 PMCID: PMC6687437 DOI: 10.1097/j.pain.0000000000001577] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/25/2019] [Accepted: 03/29/2019] [Indexed: 01/22/2023]
Abstract
Painful chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and treatment-resistant sequela of many chemotherapeutic medications. Ligands of α2δ subunits of voltage-gated Ca channels, such as pregabalin, have shown efficacy in reducing mechanical sensitivity in animal models of neuropathic pain. In addition, some data suggest that pregabalin may be more efficacious in relieving neuropathic pain in subjects with increased sensitivity to pinprick. We hypothesized that greater mechanical sensitivity, as quantified by decreased mechanical pain threshold at the feet, would be predictive of a greater reduction in average daily pain in response to pregabalin vs placebo. In a prospective, randomized, double-blinded study, 26 patients with painful CIPN from oxaliplatin, docetaxel, or paclitaxel received 28-day treatment with pregabalin (titrated to maximum dose 600 mg per day) and placebo in crossover design. Twenty-three participants were eligible for efficacy analysis. Mechanical pain threshold was not significantly correlated with reduction in average pain (P = 0.97) or worst pain (P = 0.60) in response to pregabalin. There was no significant difference between pregabalin and placebo in reducing average daily pain (22.5% vs 10.7%, P = 0.23) or worst pain (29.2% vs 16.0%, P = 0.13) from baseline. Post hoc analysis of patients with CIPN caused by oxaliplatin (n = 18) demonstrated a larger reduction in worst pain with pregabalin than with placebo (35.4% vs 14.6%, P = 0.04). In summary, baseline mechanical pain threshold tested on dorsal feet did not meaningfully predict the analgesic response to pregabalin in painful CIPN.
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Affiliation(s)
- Alexander Hincker
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
- Washington University Pain Center, Washington University School of Medicine, St Louis, MO, United States
| | - Karen Frey
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
| | - Lesley Rao
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
- Washington University Pain Center, Washington University School of Medicine, St Louis, MO, United States
| | - Nina Wagner-Johnston
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
| | - Benjamin Tan
- Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Manik Amin
- Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Tanya Wildes
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
- Department of Medicine, Washington University School of Medicine, St Louis, MO, United States
| | - Rajiv Shah
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
- Washington University Pain Center, Washington University School of Medicine, St Louis, MO, United States
| | - Pall Karlsson
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
- Section for Stereology and Microscopy, Core Centre for Molecular Morphology, Aarhus University, Aarhus, Denmark
| | - Kristopher Bakos
- Investigation Drug Service, Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, United States
| | - Katarzyna Kosicka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznan, Poland
| | - Leonid Kagan
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, United States
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
- Washington University Pain Center, Washington University School of Medicine, St Louis, MO, United States
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Liu XY, Ginosar Y, Yazdi J, Hincker A, Chen ZF. Cross-talk between Human Spinal Cord μ-opioid Receptor 1Y Isoform and Gastrin-releasing Peptide Receptor Mediates Opioid-induced Scratching Behavior. Anesthesiology 2019; 131:381-391. [PMID: 31314749 PMCID: PMC7098053 DOI: 10.1097/aln.0000000000002776] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although spinal opioids are safe and effective, pruritus is common and distressing. The authors previously demonstrated in mouse spinal cord that interactions between μ-opioid receptor isoform 1D and gastrin releasing peptide receptor mediate morphine-induced scratch. The C-terminal of 1D inhibits morphine-induced scratch without affecting analgesia. The authors hypothesize that human spinal cord also contains itch-specific μ-opioid receptor isoforms which interact with gastrin releasing peptide receptor. METHODS Reverse transcription polymerase chain reaction was performed on human spinal cord complimentary DNA from two human cadavers. Calcium responses to morphine (1 μM) were examined using calcium imaging microscopy on human cells (HEK293) coexpressing gastrin releasing peptide receptor and different human μ-opioid receptor isoforms. The authors assessed morphine-induced scratching behavior and thermal analgesia in mice following intrathecal injection of morphine (0.3 nmol) and a transactivator of transcription peptide designed from C-terminal sequences of 1Y isoform (0, 0.1, and 0.4 nmol). RESULTS The authors demonstrated 1Y expression in the spinal cord dorsal horn. Morphine administration evoked a calcium response (mean ± SD) (57 ± 13 nM) in cells coexpressing both gastrin releasing peptide receptor and the 1Y isomer. This was blocked by 10 μM naltrexone (0.7 ± 0.4 nM; P < 0.0001), 1 μM gastrin-releasing peptide receptor antagonist (3 ± 2 nM; P < 0.0001), or 200 μM 1Y-peptide (2 + 2 nM; P < 0.0001). In mice, 0.4 nmol 1Y-peptide significantly attenuated morphine-induced scratching behaviors (scratching bouts, vehicle vs. 1Y-peptide) (92 ± 31 vs. 38 ± 29; P = 0.011; n = 6 to 7 mice per group), without affecting morphine antinociception in warm water tail immersion test (% of maximum possible effect) (70 ± 21 vs. 67 ± 22; P = 0.80; n = 6 mice per group). CONCLUSIONS Human μ-opioid receptor 1Y isomer is a C-terminal splicing variant of Oprm1 gene identified in human spinal cord. Cross-talk between 1Y and gastrin releasing peptide receptor is required for mediating opioid-induced pruritus. Disrupting the cross talk may have implications for therapeutic uncoupling of desired analgesic effects from side effects of opioids.
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Affiliation(s)
- Xian-Yu Liu
- From the Center for the Study of Itch, Departments of Anesthesiology, Psychiatry and Developmental Biology (X.-Y.L., Z.-F.C.) the Division of Obstetric Anesthesiology, Department of Anesthesiology, Barnes Jewish Hospital (Y.G., A.H.), Washington University School of Medicine, St. Louis, Missouri the Mother and Child Anesthesia Unit, Department of Anesthesiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel (Y.G.) SpineMore Surgical Associates, St. Louis, Missouri (J.Y.)
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Lockhart EM, Hincker A, Klumpner TT, Hofer J, Cahill AG, Palanisamy A, Boyle W, Ginosar Y. Consultation, Surveillance, Monitoring, and Intensive Care (COSMIC): A Novel 4-Tier Program to Identify and Monitor High-Risk Obstetric Patients From the Clinic to Critical Care. Anesth Analg 2019; 128:1354-1360. [PMID: 31094812 DOI: 10.1213/ane.0000000000004141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ellen M Lockhart
- From the Department of Anesthesiology, Barnes Jewish Hospital, Washington University, St Louis, Missouri
| | - Alexander Hincker
- From the Department of Anesthesiology, Barnes Jewish Hospital, Washington University, St Louis, Missouri
| | - Thomas T Klumpner
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jennifer Hofer
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, Illinois
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Barnes Jewish Hospital, Washington University, St Louis, Missouri
| | - Arvind Palanisamy
- From the Department of Anesthesiology, Barnes Jewish Hospital, Washington University, St Louis, Missouri
| | - Walter Boyle
- From the Department of Anesthesiology, Barnes Jewish Hospital, Washington University, St Louis, Missouri
| | - Yehuda Ginosar
- From the Department of Anesthesiology, Barnes Jewish Hospital, Washington University, St Louis, Missouri
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Hincker A, Feit J, Sladen RN, Wagener G. Rotational thromboelastometry predicts thromboembolic complications after major non-cardiac surgery. Crit Care 2014; 18:549. [PMID: 25292221 PMCID: PMC4200117 DOI: 10.1186/s13054-014-0549-2] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 09/18/2014] [Indexed: 01/15/2023]
Abstract
Introduction Thromboembolic complications contribute substantially to perioperative morbidity and mortality. Routine laboratory tests do not detect patients with acquired or congenital hypercoagulability who may be at increased risk of perioperative thromboembolism. Rotational thromboelastometry (ROTEM) is a digitized modification of conventional thromboelastography that is stable and technically easy to use. We designed a prospective observational study to evaluate whether preoperative ROTEM can identify patients at increased risk for postoperative thromboembolic complications after major non-cardiac surgery. Methods Preoperative ROTEM analysis using extrinsic rotational thromboelastometry (EXTEM), intrinsic rotational thromboelastometry (INTEM), and fibrinogen rotational thromboelastometry (FIBTEM) activators was performed on 313 patients undergoing major non-cardiac surgery. Patients’ medical records were reviewed after discharge for results of standard coagulation studies - partial thromboplastin time (PTT), international normalized ratio (INR), platelet count - and evidence of thromboembolic complications during their hospital stay. A thromboembolic complication was defined as a new arterial or deep venous thrombosis, catheter thrombosis, or pulmonary embolism diagnosed by ultrasound or spiral chest computed tomography. Results Ten patients developed postoperative thromboembolic complications, of whom 9 had received standard prophylaxis with subcutaneous enoxaparin or heparin. There was no indication of by PTT, INR, or platelet count. Preoperative EXTEM and INTEM activators that assess fibrin clot formation and platelet interaction indicated that these patients had significantly lower clot formation time (CFT) and significantly higher alpha angle (α) and maximum clot firmness (MCF), compared to patients without thromboembolic complications. There was no significant difference for any parameter using FIBTEM activator, which excludes platelet interaction. Receiver operating characteristic (ROC) curves were constructed for these variables. INTEM clot firmness at 10 min (A10) was the best predictor of thromboembolic complications, with an ROC area under the curve of 0.751. Conclusions Our results indicate that preoperative ROTEM assays that include fibrin clot and platelet interaction may detect patients at increased risk for postoperative thromboembolic complications after major non-cardiac surgery. Future studies need to evaluate the clinical utility and cost effectiveness of preoperative ROTEM and better define the association between ROTEM values and specific hypercoagulable conditions.
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