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de Andrade DC, Jacobsen Teixeira M, Galhardoni R, Ferreira KSL, Braz Mileno P, Scisci N, Zandonai A, Teixeira WGJ, Saragiotto DF, Silva V, Raicher I, Cury RG, Macarenco R, Otto Heise C, Wilson Iervolino Brotto M, Andrade de Mello A, Zini Megale M, Henrique Curti Dourado L, Mendes Bahia L, Lilian Rodrigues A, Parravano D, Tizue Fukushima J, Lefaucheur JP, Bouhassira D, Sobroza E, Riechelmann RP, Hoff PM, Valério da Silva F, Chile T, Dale CS, Nebuloni D, Senna L, Brentani H, Pagano RL, de Souza ÂM. Pregabalin for the Prevention of Oxaliplatin-Induced Painful Neuropathy: A Randomized, Double-Blind Trial. Oncologist 2017; 22:1154-e105. [PMID: 28652279 PMCID: PMC5634769 DOI: 10.1634/theoncologist.2017-0235] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/14/2017] [Indexed: 11/17/2022] Open
Abstract
Lessons Learned. Pregabalin is a medication that can decrease neuronal hyperexcitability, relieve neuropathic pain, and reach stable plasma levels after a titration period of only a few days. Its use during oxaliplatin infusions was not able to decrease the incidence of chronic, oxalipaltin‐related neuropathic pain, compared with placebo.
Background. Patients with colorectal cancer (CRC) receiving oxaliplatin (OXA) develop acute and chronic painful oxaliplatin‐induced peripheral neuropathy (OXAIPN). Acute and chronic OXA‐related neuropathies have different pathophysiological bases, but both lead to a common phenomenon: central sensitization (CS) of nociceptive neuronal networks, leading to increased sensitivity (hyperlgesia, allodynia) in the somatosensory system, the common ground of chronic neuropathic pain. Because CS is related to increased risk of painful OXAIPN, we hypothesized that preemptive use of the anti‐hyperalgesic drug pregabaline (known to decrease CS) during OXA infusions would decrease the incidence of chronic OXAIPN. Methods. Pain‐free, chemotherapy‐naïve CRC patients receiving at least one cycle of modified‐FLOX [5‐FU(500 mg/m2)+leucovorin(20 mg/m2)/week for] 6 weeks+oxaliplatin(85 mg/m2) at weeks 1‐3‐5 every 8 weeks] were randomized (1:1) into the study. Patients received either pregabalin or placebo for 3 days before and 3 days after each OXA infusion and were followed for up to 6 months. Clinical assessments were performed at baseline, at the end of chemotherapy, and after the follow‐up period. The main outcome was average pain at the last visit assessed by the visual analogic scale (0–10) item of the Brief Pain Inventory (BPI). Secondary endpoints were presence of neuropathic pain according to the Douleur Neuropathique‐4 (DN‐4), pain dimensions (short‐ form McGill Pain Questionnaire [MPQ]), Neuropathic Pain Symptom Inventory (NPSI), and changes in nerve conduction studies (NCS) and side effect profile. Results. One hundred ninety‐nine patients (57.0 ± 10.7 years old, 98 female, 101 male) were randomized. Data from 56 patients were not included in the analyses (as they did not receive at least one full cycle of modified FLOX). Data from 78 patients in the pregabalin group and 65 patients in the placebo group were retained for analyses. At the last visit, pain intensity in the pregabalin group was 1.03 (95% confidence interval [CI] = 0.79–1.26), and 0.85 (95% CI = 0.64–1.06) in the placebo group, which did not reach significance. Scores from the BPI, MPQ, DN‐4, NPSI, and NCS and side‐effect profiles and incidence of death did not differ between groups. Quality of life (QoL) score did not differ between groups (placebo = 76.9 ± 23.1, pregabalin group 79.4 ± 20.6). Mood scores were not significantly different between groups (placebo 9.7 [8.1–11.2]; pregabalin 6.8 [5.6–8.0]). Conclusion. The preemptive use of pregabalin during OXA infusions was safe, but did not decrease the incidence of chronic pain related to OXAIPN.
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Affiliation(s)
- Daniel Ciampi de Andrade
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Centro de Dor, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ricardo Galhardoni
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Medical School of University of City of São Paulo (UNICID), São Paulo, Brazil
| | - Karine S L Ferreira
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Paula Braz Mileno
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Centro de Dor, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | - Nathalia Scisci
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexandra Zandonai
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - William G J Teixeira
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Daniel F Saragiotto
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Valquíria Silva
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Irina Raicher
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Centro de Dor, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | - Rubens Gisbert Cury
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ricardo Macarenco
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | | | - Luciana Mendes Bahia
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
- Centro de Dor, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | | | - Daniella Parravano
- Centro de Dor, Departamento de Neurologia, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Julia Tizue Fukushima
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jean-Pascal Lefaucheur
- Clinical Neurophysiology Unit, Department of Physiology, Henri Mondor University Hospital, AP-HP, Créteil, France
| | - Didier Bouhassira
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, Boulogne, France
| | - Evandro Sobroza
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rachel P Riechelmann
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Paulo M Hoff
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Thais Chile
- LIM 23, Instituto de Psiquiatria, Universidade de Sao Paulo, Brazil
| | - Camila S Dale
- Departamento de Anatomia, Instituto de Ciências Biomedicas, Universidade de Sao Paulo, Brazil
| | - Daniela Nebuloni
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luiz Senna
- Instituto do Cancer do Estado de São Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Helena Brentani
- LIM 23, Instituto de Psiquiatria, Universidade de Sao Paulo, Brazil
| | - Rosana L Pagano
- Laboratory of Neuromodulation and Experimental Pain, Hospital Sírio Libanês, Brazil
| | - Ângela M de Souza
- Centro de Dor, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
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Braghiroli MI, de Celis Ferrari ACR, Pfiffer TE, Alex AK, Nebuloni D, Carneiro AS, Caparelli F, Senna L, Lobo J, Hoff PM, Riechelmann RP. Phase II trial of metformin and paclitaxel for patients with gemcitabine-refractory advanced adenocarcinoma of the pancreas. Ecancermedicalscience 2015; 9:563. [PMID: 26316884 PMCID: PMC4544571 DOI: 10.3332/ecancer.2015.563] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In patients with adenocarcinoma of the pancreas, there are no standard second-line regimens. Many pre-clinical studies have shown that metformin alone or when combined with paclitaxel has antitumour effects on this tumour. We have tested here the combination of paclitaxel and metformin for patients with gemcitabine-refractory pancreatic cancer. METHODS An uncontrolled phase II trial was carried out based on a two-stage Simon's design, with metformin and paclitaxel for patients with locally advanced or metastatic pancreatic cancer whose disease had progressed during first line treatment with a gemcitabine-based regimen. The primary endpoint was the disease control rate at eight weeks as per response evaluation criteria in solid tumours (RECIST) 1.1. Patients received paclitaxel 80 mg/m(2) weekly for three weeks every 28 days and metformin 850 mg p.o. t.i.d. continuously until progression or intolerance state was reached. RESULTS Twenty patients were enrolled from July 2011 to January 2014: N = 6 (31.6%) achieved the primary endpoint, with all presenting stable disease. Median overall survival (OS) was 128 days (range 17-697) and the median progression free survival (PFS) was 44 days (range 14-210). Eight patients (40%) presented treatment-related G3-4 toxicities with the most common one being diarrhoea. CONCLUSIONS Despite the encouraging pre-clinical evidence of the antitumour activity of metformin in adenocarcinoma of the pancreas, the primary endpoint of the disease control rate was not met. Besides, the treatment combination was poorly tolerated and could not be studied further. This study highlights the importance of performing clinical trials to reassure preclinical or observational data.
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Affiliation(s)
- Maria Ignez Braghiroli
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Anezka C R de Celis Ferrari
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Tulio Eduardo Pfiffer
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Alexandra Kichfy Alex
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Daniela Nebuloni
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Allyne S Carneiro
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Fernanda Caparelli
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Luiz Senna
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Juliana Lobo
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Paulo Marcelo Hoff
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
| | - Rachel P Riechelmann
- Discipline of Radiology and Oncology, Instituto do Cancer do Estado de São Paulo, Universidade de São Paulo, Brazil, Av Dr Arnaldo 251, 12º andar São Paulo, SP, 01246-000 Brazil
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