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Masoumi M, Soleimani M, Shekari T, Alaei M, Sheikhvatan M, Mojtahedzadeh M, Basiri K, Najmeddin F, Shafiei SH. Perioperative Use of Pregabalin vs. Duloxetine for Pain Management of Knee Fracture Surgery: A Double-Blind Randomized Clinical Trial. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH 2025; 24. [DOI: 10.5812/ijpr-157958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2025]
Abstract
Background: Effective postoperative pain management, particularly in orthopedic procedures, presents significant challenges. There is increasing evidence supporting the benefits of multimodal analgesia, including the use of gabapentinoids and serotonin norepinephrine reuptake inhibitors (SNRIs), to minimize opioid consumption while effectively managing pain. However, a gold-standard treatment has not been established. Objectives: This study aims to compare the efficacy of duloxetine and pregabalin within a multimodal analgesic regimen for managing postoperative pain and their opioid-sparing effects following knee fracture surgery. Methods: In this double-blind randomized clinical trial (RCT), 54 patients undergoing knee fracture surgery were randomized to receive either 75 mg oral pregabalin or 30 mg duloxetine twice daily, starting at least 24 hours prior to surgery and continuing up to 48 hours postoperatively. Pain severity was assessed at admission and at 6, 12, 24, and 48 hours post-operation. Patients reporting a pain score greater than six on a Numeric Rating Scale (NRS) received intramuscular morphine. Additionally, total opioid dose, associated complications, and drug adverse effects were monitored within the first 48 hours post-surgery. Results: Although there was no statistically significant difference between the duloxetine and pregabalin groups at each time point, the reduction in pain at the 48-hour mark was more pronounced in the duloxetine group compared to the pregabalin group. The duloxetine group required higher doses of morphine on the first day compared to the pregabalin group (3.96 ± 3.20 mg vs. 2.14 ± 2.72 mg, P = 0.022). However, on the second day, opioid rescue was required in three patients in the pregabalin group, whereas no patients in the duloxetine group required rescue. No clinically significant adverse effects were observed in either group. Conclusions: Duloxetine 60 mg per day is an equally effective perioperative alternative to pregabalin 150 mg per day, resulting in a slight increase in rescue opioid administration with equivalent analgesic efficacy during the first 24 hours postoperatively. It demonstrates notable analgesic outcomes with no increased need for opioids between 24 to 48 hours post-surgery.
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Qiao D, Li Y, Zhang X, Wen Y, Zhang X, Ma L, Li G, Yang C, Liu Z. Exploring the connectivity of dorsolateral prefrontal cortex and the modulatory impact of transcranial magnetic stimulation in adolescents with depression: a focus on pain-related cognitive processing. BMC Psychiatry 2024; 24:852. [PMID: 39604966 PMCID: PMC11600770 DOI: 10.1186/s12888-024-06321-x] [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: 10/19/2024] [Accepted: 11/21/2024] [Indexed: 11/29/2024] Open
Abstract
BACKGROUND Abnormal cognitive response to pain is consistently associated with deleterious outcomes among adolescents with depression. Highly relevant to both pain and cognition, dorsolateral prefrontal cortex (DLPFC) is important to understanding pain cognition. Our study aimed to characterize the circuit of DLPFC and the efficacy of transcranial magnetic stimulation (TMS) over DLPFC on pain cognition in adolescents with depression. METHODS Using neuroimaging data, we first compared functional connectivity (FC) of DLPFC between 60 adolescents with depression and 65 controls. The patients were then divided into add-on TMS group (N = 30) and Sertraline group (N = 30). Clinical outcome was determined using Pain Vigilance and Awareness Questionnaire (PVAQ) and Pain Catastrophizing Scale (PCS). Finally, we conducted regression analysis to assess the effect that FC of DLPFC contributes to in predicting clinical outcome. RESULTS FC analysis showed that compared to controls, patients displayed hyperconnection of left DLPFC - left triangular part of inferior frontal gyrus (IFG), which was significantly correlated with higher PCS total-, magnification- and helplessness-scores. Patients also showed hyperconnection of right DLPFC - right supramarginal gyrus (SMG), which was correlated with lower PCS total- and rumination- scores. After intervention, the add-on TMS group displayed significantly decreased score on PVAQ, PCS total and rumination. FC of left DLPFC - bilateral triangular part of IFG, - right SMG, as well as right DLPFC - left putamen, could predict the improvement of pain vigilance and magnification. CONCLUSION Our results point to a key role of DLPFC acting as a connection linking cognitive control and pain processing in adolescents with depression. TRIAL REGISTRATION The study is registered in https://www.chictr.org.cn/ with a registration number ChiCTR2000039503 (date: 10.30.2020).
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Affiliation(s)
- Dan Qiao
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Yiran Li
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Xiaoyu Zhang
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Yujiao Wen
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Xuemin Zhang
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Lu Ma
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Gaizhi Li
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Chunxia Yang
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China
| | - Zhifen Liu
- Department of Psychiatry, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, China.
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Pinsornsak P, Phunphakchit J, Pinsornsak P, Boontanapibul K. Does postoperative low-dose duloxetine provide analgesic effect and lower morphine consumption after primary total knee arthroplasty? A prospective, double-blind, randomized controlled trial. Arch Orthop Trauma Surg 2024; 144:4979-4987. [PMID: 39347965 DOI: 10.1007/s00402-024-05591-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION Duloxetine as an adjunct analgesic has shown effective results in trials of patients undergoing total knee arthroplasty (TKA). However, the regimen has not been standardized. We, therefore, evaluated the analgesic efficacy of low-dose duloxetine after TKA. MATERIALS AND METHODS We conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 30 mg/d of duloxetine for 6 weeks as an additive medication for pain control to modern multimodal analgesia after TKA. The primary outcome measure was a visual analogue scale (VAS) for pain at rest, during walking, and at night at 24 h, 72 h, 2 weeks, 6 weeks, and 12 weeks after the operation. Secondary outcomes were morphine consumption, adverse events, and functional outcomes: Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS Mean VAS for pain at rest, during walking, and at night at 24 h, 72 h, 2 weeks, 6 weeks, and 12 weeks showed no significant differences between the two groups, except a significantly lower mean VAS at night at 2 weeks in the duloxetine group. Mean total morphine consumption (0-72 h) was 33% less in the duloxetine group (6.8 ± 5.7 vs. 10.2 ± 7.3 mg, p = 0.04). There were no significant differences in adverse events and functional outcomes except better KOOS symptoms at 6 and 12 weeks in the duloxetine group. CONCLUSION Low-dose duloxetine could reduce postoperative morphine consumption and improve KOOS symptoms at 6 and 12 weeks with good tolerability. However, it did not significantly reduce pain at rest or during walking. Low-dose duloxetine can be considered an addition to contemporary multimodal pain management after TKA. LEVEL OF EVIDENCE V Therapeutic Level I.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, Pathum Thani, Thailand
| | | | - Prem Pinsornsak
- Kasetsart University Laboratory School Center for Educational Research and Development, Bangkok, Thailand
| | - Krit Boontanapibul
- Department of Orthopaedic Surgery, Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand.
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Tesic I, Pigoni A, Moltrasio C, Brambilla P, Delvecchio G. How does feeling pain look like in depression: A review of functional neuroimaging studies. J Affect Disord 2023; 339:400-411. [PMID: 37459979 DOI: 10.1016/j.jad.2023.07.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Major Depression Disorder (MDD) and pain appear to be reciprocal risk factors and sharing common neuroanatomical pathways and biological substrates. However, the role of MDD on pain processing remains still unclear. Therefore, this review aims to focus on the effect of depression on pain anticipation, and perception, before and after treatment, through functional magnetic resonance imaging (fMRI). METHODS A bibliographic search was conducted on PubMed, Scopus and Web of Science, looking for fMRI studies exploring pain processing in MDD patients. RESULTS Amongst the 602 studies retrieved, 12 met the inclusion criteria. In terms of pain perception, studies evidenced that MDD patients generally presented increased activation in brain regions within the prefrontal cortex, insula and in the limbic system (such as amygdala, hippocampus) and occipital cortex. The studies investigating the effect of antidepressant treatment evidenced a reduced activation in areas such as insula, anterior cingulate, and prefrontal cortices. In terms of pain anticipation, contrasting results were evidenced in MDD patients, which presented both increased and decreased activity in the prefrontal cortex, the insula and the temporal lobe, alongside with increased activity in the anterior cingulate cortex, the frontal gyrus and occipital lobes. LIMITATIONS The small number of included studies, the heterogeneous approaches of the studies might limit the conclusions of this review. CONCLUSIONS Acute pain processing in MDD patients seems to involve numerous and different brain areas. However, more specific fMRI studies with a more homogeneous population and rigorous approach should be conducted to better highlight the effect of depression on pain processing.
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Affiliation(s)
- Isidora Tesic
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandro Pigoni
- Social and Affective Neuroscience Group, MoMiLab, IMT School for Advanced Studies Lucca, Lucca, Italy; Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Moltrasio
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Brambilla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giuseppe Delvecchio
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Sato MT, Hasegawa T, Noma H, Sugita H, Ota E. Efficacy and safety of drug therapy for the prevention and treatment of chemotherapy-induced peripheral neuropathy: a protocol for a systematic review and network meta-analysis. BMJ Open 2023; 13:e070645. [PMID: 37699621 PMCID: PMC10503317 DOI: 10.1136/bmjopen-2022-070645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 08/22/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most common dose-limiting side effects of chemotherapeutic drugs. Numerous clinical trials of various targeted drugs for the prevention or treatment of CIPN have been conducted; however, previous systematic reviews with direct comparisons have failed to demonstrate the efficacy of these drugs in the prevention or treatment of CIPN. In addition, no systematic reviews have indirectly compared CIPN prevention and treatment. This article describes a protocol for evaluating the efficacy and safety of drug therapy for the prevention and treatment of CIPN. The results of the proposed systematic review with network meta-analysis (NMA) will provide new insights into the prevention and treatment of CIPN. METHODS AND ANALYSIS We will conduct a literature search in MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov to find relevant articles published through January 2023. We will include studies that investigated the efficacy and safety of vitamin B12, goshajinkigan, non-steroidal anti-inflammatory analgesics, opioids, calcium and magnesium, antidepressants and anticonvulsants on CIPN. Two authors will individually screen the retrieved reports and review the full text based on the selection criteria. The primary outcome is the incidence and severity of CIPN. The risk of bias will be assessed using V.2.0 of the Cochrane risk-of-bias tool. We will apply a frequentist random-effects NMA model to pool effect sizes across trials using risk ratios and mean differences with their 95% CIs. Competing interventions will be ranked using the surface under cumulative ranking probabilities. Heterogeneity will be assessed using the heterogeneity variance τ2, Cochran's Q test and I² statistic. ETHICS AND DISSEMINATION This review does not require ethical approval. The research will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022371829.
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Affiliation(s)
- Miki Takenaka Sato
- Department of Clinical Pharmacy, Showa University School of Pharmacy, Shinagawa-ku, Tokyo, Japan
| | - Takeshi Hasegawa
- Showa University Research Administration Center (SURAC), Showa University, Shinagawa-ku, Tokyo, Japan
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tachikawa, Tokyo, Japan
| | - Hideki Sugita
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, Shinagawa-ku, Tokyo, Japan
- Department of Pharmacy, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Chuo-ku, Tokyo, Japan
- Tokyo Foundation for Policy Research, Minato-ku, Tokyo, Japan
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Lawn T, Howard MA, Turkheimer F, Misic B, Deco G, Martins D, Dipasquale O. From neurotransmitters to networks: Transcending organisational hierarchies with molecular-informed functional imaging. Neurosci Biobehav Rev 2023; 150:105193. [PMID: 37086932 PMCID: PMC10390343 DOI: 10.1016/j.neubiorev.2023.105193] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/01/2023] [Accepted: 04/19/2023] [Indexed: 04/24/2023]
Abstract
The human brain exhibits complex interactions across micro, meso-, and macro-scale organisational principles. Recent synergistic multi-modal approaches have begun to link micro-scale information to systems level dynamics, transcending organisational hierarchies and offering novel perspectives into the brain's function and dysfunction. Specifically, the distribution of micro-scale properties (such as receptor density or gene expression) can be mapped onto macro-scale measures from functional MRI to provide novel neurobiological insights. Methodological approaches to enrich functional imaging analyses with molecular information are rapidly evolving, with several streams of research having developed relatively independently, each offering unique potential to explore the trans-hierarchical functioning of the brain. Here, we address the three principal streams of research - spatial correlation, molecular-enriched network, and in-silico whole brain modelling analyses - to provide a critical overview of the different sources of molecular information, how this information can be utilised within analyses of fMRI data, the merits and pitfalls of each methodology, and, through the use of key examples, highlight their promise to shed new light on key domains of neuroscientific inquiry.
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Affiliation(s)
- Timothy Lawn
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Matthew A Howard
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Federico Turkheimer
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Bratislav Misic
- Montreal Neurological Institute and Hospital, McGill University, Montreal, Québec, Canada
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Ramon Trias Fargas 25-27, Barcelona 08005, Spain; Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Daniel Martins
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ottavia Dipasquale
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Aghabozorgi R, Hesam M, Zahed G, Babaee M, Hashemi M, Rayegani SM. Efficacy of Duloxetine on electrodiagnostic findings of Paclitaxel-induced peripheral neuropathy, does it have a prophylactic effect? A randomized clinical trial. Anticancer Drugs 2023; 34:680-685. [PMID: 36730548 DOI: 10.1097/cad.0000000000001429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study aimed to evaluate the efficacy of Duloxetine on electrodiagnostic findings of Paclitaxel-induced peripheral neuropathy in patients with breast cancer. This randomized, double-blind clinical trial was conducted on 40 patients with breast cancer who received Paclitaxel as their first chemotherapy session. All the patients were randomly allocated into two groups, intervention (20 subjects) and placebo (20 subjects). The intervention group received 30 mg duloxetine/day in the first week, followed by 60 mg (twice daily) until 8 weeks. The patient neurotoxicity questionnaire (PNQ) was used to evaluate the severity of neuropathy. Nerve conduction study was also performed. The evaluations were performed at the baseline and 8 weeks after the treatment. Out of 20 subjects in the placebo group, 10 (50%) patients had neurotoxicity (two milds, three moderate, four severe, and one incapacitated), according to PNQ. However, in the duloxetine group, two patients had mild neurotoxicity ( P = 0.03). Significant differences between groups related to the mean of Median Sensory Latency ( P <0.001), Median Motor Latency ( P < 0.001), and Median Motor velocity ( P = 0.001) were reported. However, the relative risk of polyneuropathy between the two groups (relative risk: 1) was not significant. Regarding the results, duloxetine could be an effective treatment for preventing paclitaxel-induced peripheral neuropathy in patients with breast cancer, and an electrodiagnostic study confirmed this effect.
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Affiliation(s)
| | - Marzieh Hesam
- School of Medicine, Arak University of Medical Sciences, Arak
| | - Ghazal Zahed
- Child and Adolescent Psychiatry Division, Shahid Beheshti University of Medical Sciences
| | - Marzieh Babaee
- Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdis Hashemi
- Department of Physical medicine and Rehabilitation, Vancouver Island Health Authority
- International Collaboration on Repair Discoveries (ICORD) British Colombia, Vancouver, British Columbia, Canada
| | - Seyed Mansoor Rayegani
- Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Qin X, Xie C, Hakenjos JM, MacKenzie KR, Boyd SR, Barzi M, Bissig KD, Young DW, Li F. The roles of Cyp1a2 and Cyp2d in pharmacokinetic profiles of serotonin and norepinephrine reuptake inhibitor duloxetine and its metabolites in mice. Eur J Pharm Sci 2023; 181:106358. [PMID: 36513193 PMCID: PMC10395004 DOI: 10.1016/j.ejps.2022.106358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/03/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
Duloxetine (DLX) is widely used to treat major depressive disorder. Little is known about the mechanistic basis for DLX-related adverse effects (e.g., liver injury). Human CYP1A2 and CYP2D6 mainly contributes to DLX metabolism, which was proposed to be involved in its adverse effects. Here, we investigated the roles of Cyp1a2 and Cyp2d on DLX pharmacokinetic profile and tissue distribution using a Cyp1a2 knockout (Cyp1a2-KO) mouse model together with a Cyp2d inhibitor (propranolol). Cyp1a2-KO has the few effects on the systematic exposure (area under the plasma concentration-time curve, AUC) and tissue disposition of DLX and its primary metabolites. Propranolol dramatically increased the AUCs of DLX by 3 folds and 1.5 folds in WT and Cyp1a2-KO mice, respectively. Meanwhile, Cyp2d inhibitor decreased the AUC of Cyp2d-involved DLX metabolites (e.g., M16). Mouse tissue distribution revealed that DLX and its major metabolites were the most abundant in kidney, followed by liver and lung with/without Cyp2d inhibitor. Cyp2d inhibitor significantly increased DLX levels in tissues (e.g., liver) in WT and KO mice and decreases the levels of M3, M15, M16 and M17, while it increased the levels of M4, M28 and M29 in tissues. Our findings indicated that Cyp2d play a fundamental role on DLX pharmacokinetic profile and tissue distribution in mice. Clinical studies suggested that CYP1A2 has more effects on DLX systemic exposure than CYP2D6. Further studies in liver humanized mice or clinical studies concerning CYP2D6 inhibitors-DLX interaction study could clarify the roles of CYP2D6 on DLX pharmacokinetics and toxicity in human.
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Affiliation(s)
- Xuan Qin
- Center for Drug Discovery, Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Cen Xie
- Laboratory of Metabolism, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - John M Hakenjos
- Center for Drug Discovery, Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kevin R MacKenzie
- Center for Drug Discovery, Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX 77030, USA; NMR and Drug Metabolism Core, Advanced Technology Cores, Baylor College of Medicine, Houston, TX 77030, USA; Department of Pharmacology & Chemical Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Shelton R Boyd
- Department of Pharmacology & Chemical Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Mercedes Barzi
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27708, USA
| | - Karl-Dimiter Bissig
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27708, USA
| | - Damian W Young
- Center for Drug Discovery, Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX 77030, USA; Department of Pharmacology & Chemical Biology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Feng Li
- Center for Drug Discovery, Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX 77030, USA; NMR and Drug Metabolism Core, Advanced Technology Cores, Baylor College of Medicine, Houston, TX 77030, USA; Department of Pharmacology & Chemical Biology, Baylor College of Medicine, Houston, TX 77030, USA.
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Leaney AA, Lyttle JR, Segan J, Urquhart DM, Cicuttini FM, Chou L, Wluka AE. Antidepressants for hip and knee osteoarthritis. Cochrane Database Syst Rev 2022; 10:CD012157. [PMID: 36269595 PMCID: PMC9586196 DOI: 10.1002/14651858.cd012157.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although pain is common in osteoarthritis, most people fail to achieve adequate analgesia. Increasing acknowledgement of the contribution of pain sensitisation has resulted in the investigation of medications affecting pain processing with central effects. Antidepressants contribute to pain management in other conditions where pain sensitisation is present. OBJECTIVES To assess the benefits and harms of antidepressants for the treatment of symptomatic knee and hip osteoarthritis in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was January 2021. SELECTION CRITERIA We included randomised controlled trials of adults with osteoarthritis that compared use of antidepressants to placebo or alternative comparator. We included trials that focused on efficacy (pain and function), treatment-related adverse effects and had documentation regarding discontinuation of participants. We excluded trials of less than six weeks of duration or had participants with concurrent mental health disorders. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Major outcomes were pain; responder rate; physical function; quality of life; and proportion of participants who withdrew due to adverse events, experienced any adverse events or had serious adverse events. Minor outcomes were proportion meeting the OARSI (Osteoarthritis Research Society International) Response Criteria, radiographic joint structure changes and proportion of participants who dropped out of the study for any reason. We used GRADE to assess certainty of evidence. MAIN RESULTS Nine trials (2122 participants) met the inclusion criteria. Seven trials examined only knee osteoarthritis. Two also included participants with hip osteoarthritis. All trials compared antidepressants to placebo, with or without non-steroidal anti-inflammatory drugs. Trial sizes were 36 to 388 participants. Most participants were female, with mean ages of 54.5 to 65.9 years. Trial durations were 8 to 16 weeks. Six trials examined duloxetine. We combined data from nine trials in meta-analyses for knee and hip osteoarthritis. One trial was at low risk of bias in all domains. Five trials were at risk of attrition and reporting bias. High-certainty evidence found that antidepressants resulted in a clinically unimportant improvement in pain compared to placebo. Mean reduction in pain (0 to 10 scale, 0 = no pain) was 1.7 points with placebo and 2.3 points with antidepressants (mean difference (MD) -0.59, 95% confidence interval (CI) -0.88 to -0.31; 9 trials, 2122 participants). Clinical response was defined as achieving a 50% or greater reduction in 24-hour mean pain. High-certainty evidence demonstrated that 45% of participants receiving antidepressants had a clinical response compared to 28.6% receiving placebo (RR 1.55, 95% CI 1.32 to 1.82; 6 RCTs, 1904 participants). This corresponded to an absolute improvement in pain of 16% more responders with antidepressants (8.9% more to 26% more) and a number needed to treat for an additional beneficial effect (NNTB) of 6 (95% CI 4 to 11). High-certainty evidence showed that the mean improvement in function (on 0 to 100 Western Ontario and McMaster Universities Arthritis Index, 0 = best function) was 10.51 points with placebo and 16.16 points with antidepressants (MD -5.65 points, 95% CI -7.08 to -4.23; 6 RCTs, 1909 participants). This demonstrates a small, clinically unimportant response. Moderate-certainty evidence (downgraded for imprecision) showed that quality of life measured using the EuroQol 5-Dimension scale (-0.11 to 1.0, 1.0 = perfect health) improved by 0.07 points with placebo and 0.11 points with antidepressants (MD 0.04, 95% CI 0.01 to 0.07; 3 RCTs, 815 participants). This is clinically unimportant. High-certainty evidence showed that total adverse events increased in the antidepressant group (64%) compared to the placebo group (49%) (RR 1.27, 95% CI 1.15 to 1.41; 9 RCTs, 2102 participants). The number needed to treat for an additional harmful outcome (NNTH) was 7 (95% CI 5 to 11). Low-certainty evidence (downgraded twice for imprecision for very low numbers of events) found no evidence of a difference in serious adverse events between groups (RR 0.94, 95% CI 0.46 to 1.94; 9 RCTs, 2101 participants). The NNTH was 1000. Moderate-certainty evidence (downgraded for imprecision) showed that 11% of participants receiving antidepressants withdrew from trials due to an adverse event compared to 5% receiving placebo (RR 2.15, 95% CI 1.56 to 2.97; 6 RCTs, 1977 participants). The NNTH was 17 (95% CI 10 to 35). AUTHORS' CONCLUSIONS There is high-certainty evidence that use of antidepressants for knee osteoarthritis leads to a non-clinically important improvement in mean pain and function. However, a small number of people will have a 50% or greater important improvement in pain and function. This finding was consistent across all trials. Pain in osteoarthritis may be due to a variety of causes that differ between individuals. It may be that the cause of pain that responds to this therapy is only present in a small number of people. There is moderate-certainty evidence that antidepressants have a small positive effect on quality of life with heterogeneity between trials. High-certainty evidence indicates antidepressants result in more adverse events and moderate-certainty evidence indicates more withdrawal due to adverse events. There was little to no difference in serious adverse events (low-certainty evidence due to low numbers of events). This suggests that if antidepressants were being considered, there needs to be careful patient selection to optimise clinical benefit given the known propensity for adverse events with antidepressant use. Future trials should include alternative antidepressant agents or phenotyping of pain in people with osteoarthritis, or both.
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Affiliation(s)
- Alexandra A Leaney
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jenna R Lyttle
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julian Segan
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Donna M Urquhart
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Louisa Chou
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anita E Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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10
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Jia Z, Yu J, Zhao C, Ren H, Luo F. Outcomes and Predictors of Response of Duloxetine for the Treatment of Persistent Idiopathic Dentoalveolar Pain: A Retrospective Multicenter Observational Study. J Pain Res 2022; 15:3031-3041. [PMID: 36193165 PMCID: PMC9526422 DOI: 10.2147/jpr.s379430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 08/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Duloxetine has been reported to significantly relieve the pain of persistent idiopathic dentoalveolar pain (PIDP); however, the number of studies available is scarce and no study has identified the predictors of response of duloxetine for the treatment of PIDP. Objective To report the efficacy, safety, and identification of positive predictors of duloxetine for PIDP patients through a retrospective multicenter observational study. Methods We retrospectively reviewed the clinical database of PIDP patients who were prescribed duloxetine at 3 hospitals between January 2018 and November 2021. Demographic and pain-related baseline data, efficacy of patients after 3 months of medication by visual analog scale (VAS) scores for pain and adverse events were extracted and analyzed. The predictors of pain-relieving effect of duloxetine were identified by logistic regression analysis. Results A total of 135 patients were included in this study. Side effects occurred immediately after taking duloxetine in 24 (17.8%) patients, and the treatment with duloxetine was discontinued on 13 of them because they could not tolerate the side effects. Other 11 (8.1%) patients gradually tolerated the side effects within 2 weeks. Ninety-four out of 122 (77.0%) patients obtained pain relief with VAS significantly decreased (p < 0.01) and the other 28 (23.0%) patients stopped taking the drug because of weak efficacy. Binary logistic regression analysis showed that short disease duration (OR = 1.017, 95% CI = 1.004–1.030, P = 0.012) was an independent predictor of the positive response of duloxetine. Conclusion This study confirmed that duloxetine can significantly improve chronic pain of PIDP patients, and the safety was tolerable. Patients with shorter disease duration had more benefit from duloxetine. Limitations This is a retrospective observational study. Long-term efficacy and safety of duloxetine in the treatment of PIDP patients were not evaluated.
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Affiliation(s)
- Zipu Jia
- Department of Day Surgery Center; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jinyong Yu
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chunmei Zhao
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hao Ren
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fang Luo
- Department of Pain Management; Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Fang Luo, Department of Anesthesiology and Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, People’s Republic of China, Tel +86 13611326978, Email
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11
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Mayoral Rojals V, Canós Verdecho Á, Soler López B, the Team DUO. Assessment of the Management of Patients with Chronic Pain Referred to a Specialized Pain Unit: A Cross-Sectional Multicenter Study (the DUO Project). J Clin Med 2022; 11:jcm11133586. [PMID: 35806871 PMCID: PMC9267154 DOI: 10.3390/jcm11133586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 01/27/2023] Open
Abstract
A multicenter cross-sectional study was designed to assess the quality of treatment of 1190 patients with chronic pain at the time of referral to a specialized pain unit. A total of 119 physicians from 77 pain units throughout Spain collected 23 indicators of the quality of care from 10 consecutive clinical records of chronic pain patients (5 men, 5 women). Degenerative spinal diseases (38.6%) and lumbosciatic pain (29.8%) were the most common etiologies. At the time of referral to the pain unit, 9.8% of patients were not receiving any analgesic treatment. Treatment was modified in 88.1% of the patients by adding adjuvant drugs, adding opioids or increasing the doses of analgesic medications, and using analgesic techniques. Women had higher percentages of osteoarthritis, headache and fibromyalgia as the cause of pain, longer duration of pain and severe pain intensity, and a higher proportion of changes in the diagnosis of the underlying condition with which they had been referred to the pain unit. Improvements should be made in the patient management and referral protocols not only in the clinics prior to patient referral to the pain unit, but also in the pain units themselves.
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Affiliation(s)
- Víctor Mayoral Rojals
- Pain Unit, Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | | | - Begoña Soler López
- Medical Department, E-C-BIO, S.L., Las Rozas, 28230 Madrid, Spain
- Correspondence:
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12
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Shen Y, Wang J, Peng J, Wu X, Chen X, Liu J, Wei M, Zou D, Han Y, Wang A, Cheng O. Abnormal connectivity model of raphe nuclei with sensory-associated cortex in Parkinson's disease with chronic pain. Neurol Sci 2022; 43:3175-3185. [PMID: 35000015 DOI: 10.1007/s10072-022-05864-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/02/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVE There are indicates that raphe nuclei may be involved in the occurrence of chronic pain in Parkinson's disease (PD). In the study, we investigated the functional connectivity pattern of raphe nuclei in Parkinson's disease with chronic pain (PDP) to uncover its possible pathophysiology. METHODS Fifteen PDP, who suffered from pain, lasted longer than 3 months, sixteen Parkinson's disease patients with no pain (nPDP) and eighteen matched normal health controls (NCs) were recruited. All subjects completed the King's Parkinson's Pain Scale (KPPS) besides Parkinson-related scale and demographics. We performed a seed-based resting-state analysis of functional magnetic resonance imaging to explore whole-brain functional connectivity of the raphe nuclei. Multiple regression model was used to explore the related factors of pain including disease duration, disease severity, Hamilton Depression Rating Scale, age, sex, levodopa equivalent dose and the strength of network functional connectivity. RESULTS Compared with the nPDP, the PDP group showed stronger functional connectivity between raphe nuclei and pain-related brain regions, including parietal lobe, insular lobe, cingulum cortex and prefrontal cortex, and the functional connectivity values of those areas were significantly positively correlated with KPPS independent of the clinical variables. Compared with NCs, the combined PD groups showed decreased functional connectivity including prefrontal cortex and cingulum cortex. CONCLUSIONS Abnormal functional connectivity model of raphe nuclei may be partly involved in pathophysiological mechanism of pain in PD.
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Affiliation(s)
- Yalian Shen
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
- Department of Neurology, Yubei District People's Hospital, Chongqing, 401120, China
| | - Juan Wang
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Juan Peng
- Department of Radiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaolin Wu
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaocui Chen
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Jinjin Liu
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Min Wei
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Dezhi Zou
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Yu Han
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Anran Wang
- Department of Radiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China.
| | - Oumei Cheng
- Department of Neurology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China.
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Roberts KE, Adsett IT, Rickett K, Conroy SM, Chatfield MD, Woodward NE. Systemic therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer. Cochrane Database Syst Rev 2022; 1:CD013167. [PMID: 35005781 PMCID: PMC8743877 DOI: 10.1002/14651858.cd013167.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Adjuvant aromatase inhibitors (AI) improve survival compared to tamoxifen in postmenopausal women with hormone receptor-positive stage I to III breast cancer. In approximately half of these women, AI are associated with aromatase inhibitor-induced musculoskeletal symptoms (AIMSS), often described as symmetrical pain and soreness in the joints, musculoskeletal pain and joint stiffness. AIMSS may have significant and prolonged impact on women's quality of life. AIMSS reduces adherence to AI therapy in up to a half of women, potentially compromising breast cancer outcomes. Differing systemic therapies have been investigated for the prevention and treatment of AIMSS, but the effectiveness of these therapies remains unclear. OBJECTIVES To assess the effects of systemic therapies on the prevention or management of AIMSS in women with stage I to III hormone receptor-positive breast cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to September 2020 and the Cochrane Breast Cancer Group (CBCG) Specialised Register to March 2021. SELECTION CRITERIA: We included all randomised controlled trials that compared systemic therapies to a comparator arm. Systemic therapy interventions included all pharmacological therapies, dietary supplements, and complementary and alternative medicines (CAM). All comparator arms were allowed including placebo or standard of care (or both) with analgesia alone. Published and non-peer-reviewed studies were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, extracted data, and assessed risk of bias and certainty of the evidence using the GRADE approach. Outcomes assessed were pain, stiffness, grip strength, safety data, discontinuation of AI, health-related quality of life (HRQoL), breast cancer-specific quality of life (BCS-QoL), incidence of AIMSS, breast cancer-specific survival (BCSS) and overall survival (OS). For continuous outcomes, we used vote-counting by reporting how many studies reported a clinically significant benefit within the confidence intervals (CI) of the mean difference (MD) between treatment arms, as determined by the minimal clinically importance difference (MCID) for that outcome scale. For dichotomous outcomes, we reported outcomes as a risk ratio (RR) with 95% CI. MAIN RESULTS We included 17 studies with 2034 randomised participants. Four studies assessed systemic therapies for the prevention of AIMSS and 13 studies investigated treatment of AIMSS. Due to the variation in systemic therapy studies, including pharmacological, and CAM, or unavailable data, meta-analysis was limited, and only two trials were combined for meta-analysis. The certainty of evidence for all outcomes was either low or very low certainty. Prevention studies The evidence is very uncertain about the effect of systemic therapies on pain (from baseline to the end of the intervention; 2 studies, 183 women). The two studies, investigating vitamin D and omega-3 fatty acids, showed a treatment effect with 95% CIs that did not include an MCID for pain. Systemic therapies may have little to no effect on grip strength (RR 1.08, 95% CI 0.37 to 3.17; 1 study, 137 women) or on women continuing to take their AI (RR 0.16, 95% 0.01 to 2.99; 1 study, 147 women). The evidence suggests little to no effect on HRQoL and BCS-QoL from baseline to the end of intervention (the same single study; 44 women, both quality of life outcomes showed a treatment effect with 95% CIs that did include an MCID). The evidence is very uncertain for outcomes assessing incidence of AIMSS (RR 0.82, 95% CI 0.63 to 1.06; 2 studies, 240 women) and the safety of systemic therapies (4 studies, 344 women; very low-certainty evidence). One study had a US Food and Drug Administration alert issued for the intervention (cyclo-oxygenase-2 inhibitor) during the study, but there were no serious adverse events in this or any study. There were no data on stiffness, BCSS or OS. Treatment studies The evidence is very uncertain about the effect of systemic therapies on pain from baseline to the end of intervention in the treatment of AIMSS (10 studies, 1099 women). Four studies showed an MCID in pain scores which fell within the 95% CI of the measured effect (vitamin D, bionic tiger bone, Yi Shen Jian Gu granules, calcitonin). Six studies showed a treatment effect with 95% CI that did not include an MCID (vitamin D, testosterone, omega-3 fatty acids, duloxetine, emu oil, cat's claw). The evidence was very uncertain for the outcomes of change in stiffness (4 studies, 295 women), HRQoL (3 studies, 208 women) and BCS-QoL (2 studies, 147 women) from baseline to the end of intervention. The evidence suggests systemic therapies may have little to no effect on grip strength (1 study, 107 women). The evidence is very uncertain about the safety of systemic therapies (10 studies, 1250 women). There were no grade four/five adverse events reported in any of the studies. The study of duloxetine reported more all-grade adverse events in this treatment group than comparator group. There were no data on the incidence of AIMSS, the number of women continuing to take AI, BCCS or OS from the treatment studies. AUTHORS' CONCLUSIONS AIMSS are chronic and complex symptoms with a significant impact on women with early breast cancer taking AI. To date, evidence for safe and effective systemic therapies for prevention or treatment of AIMSS has been minimal. Although this review identified 17 studies with 2034 randomised participants, the review was challenging due to the heterogeneous systemic therapy interventions and study methodologies, and the unavailability of certain trial data. Meta-analysis was thus limited and findings of the review were inconclusive. Further research is recommended into systemic therapy for AIMSS, including high-quality adequately powered RCT, comprehensive descriptions of the intervention/placebo, and robust definitions of the condition and the outcomes being studied.
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Affiliation(s)
- Kate E Roberts
- Department of Medical Oncology, Princess Alexandra Hospital, Woolloongabba, Australia
- School of Clinical Medicine, Mater Clinical Unit, Mater Hospital, University of Queensland, South Brisbane, Australia
| | | | - Kirsty Rickett
- The University of Queensland Library, UQ/Mater McAuley Library, Brisbane, Australia
| | | | - Mark D Chatfield
- Centre for Health Services Research, The University of Queensland, Woolloongabba, Australia
| | - Natasha E Woodward
- School of Clinical Medicine, Mater Clinical Unit, Mater Hospital, University of Queensland, South Brisbane, Australia
- Department of Medical Oncology, Mater Misericordiae Ltd, South Brisbane, Australia
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14
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Burgess J, Ferdousi M, Gosal D, Boon C, Matsumoto K, Marshall A, Mak T, Marshall A, Frank B, Malik RA, Alam U. Chemotherapy-Induced Peripheral Neuropathy: Epidemiology, Pathomechanisms and Treatment. Oncol Ther 2021; 9:385-450. [PMID: 34655433 PMCID: PMC8593126 DOI: 10.1007/s40487-021-00168-y] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/12/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This review provides an update on the current clinical, epidemiological and pathophysiological evidence alongside the diagnostic, prevention and treatment approach to chemotherapy-induced peripheral neuropathy (CIPN). FINDINGS The incidence of cancer and long-term survival after treatment is increasing. CIPN affects sensory, motor and autonomic nerves and is one of the most common adverse events caused by chemotherapeutic agents, which in severe cases leads to dose reduction or treatment cessation, with increased mortality. The primary classes of chemotherapeutic agents associated with CIPN are platinum-based drugs, taxanes, vinca alkaloids, bortezomib and thalidomide. Platinum agents are the most neurotoxic, with oxaliplatin causing the highest prevalence of CIPN. CIPN can progress from acute to chronic, may deteriorate even after treatment cessation (a phenomenon known as coasting) or only partially attenuate. Different chemotherapeutic agents share both similarities and key differences in pathophysiology and clinical presentation. The diagnosis of CIPN relies heavily on identifying symptoms, with limited objective diagnostic approaches targeting the class of affected nerve fibres. Studies have consistently failed to identify at-risk cohorts, and there are no proven strategies or interventions to prevent or limit the development of CIPN. Furthermore, multiple treatments developed to relieve symptoms and to modify the underlying disease in CIPN have failed. IMPLICATIONS The increasing prevalence of CIPN demands an objective approach to identify at-risk patients in order to prevent or limit progression and effectively alleviate the symptoms associated with CIPN. An evidence base for novel targets and both pharmacological and non-pharmacological treatments is beginning to emerge and has been recognised recently in publications by the American Society of Clinical Oncology and analgesic trial design expert groups such as ACTTION.
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Affiliation(s)
- Jamie Burgess
- Department of Cardiovascular and Metabolic Medicine, The Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital NHS Trust, Liverpool, UK.
- Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL, UK.
| | - Maryam Ferdousi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - David Gosal
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Cheng Boon
- Department of Clinical Oncology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Kohei Matsumoto
- Department of Cardiovascular and Metabolic Medicine, The Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital NHS Trust, Liverpool, UK
| | - Anne Marshall
- Department of Cardiovascular and Metabolic Medicine, The Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital NHS Trust, Liverpool, UK
| | - Tony Mak
- Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Andrew Marshall
- Faculty of Health and Life Sciences, Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, UK
- Faculty of Health and Life Sciences, The Pain Research Institute, University of Liverpool, Liverpool, L9 7AL, UK
- Department of Pain Medicine, The Walton Centre, Liverpool, L9 7LJ, UK
| | - Bernhard Frank
- Department of Pain Medicine, The Walton Centre, Liverpool, L9 7LJ, UK
| | - Rayaz A Malik
- Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar, Education City, Doha, Qatar
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, The Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital NHS Trust, Liverpool, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, M13 9PT, UK.
- Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool, L9 7AL, UK.
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15
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Fanelli D, Weller G, Liu H. New Serotonin-Norepinephrine Reuptake Inhibitors and Their Anesthetic and Analgesic Considerations. Neurol Int 2021; 13:497-509. [PMID: 34698218 PMCID: PMC8544373 DOI: 10.3390/neurolint13040049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 01/12/2023] Open
Abstract
Serotonin-norepinephrine reuptake inhibitors (SNRIs) inhibit the presynaptic neuronal uptake of serotonin and norepinephrine and prolong the effects of the monoamines in the synaptic cleft within the central nervous system, leading to increased postsynaptic receptor activation and neuronal activities. Serotonin-norepinephrine reuptake inhibitors can have multiple clinical indications, including as the first-line agents for the management of depression and anxiety, and as analgesics in the treatment of chronic pain. The effects of reuptake inhibition of norepinephrine and serotonin are often dose-dependent and agent-dependent. There are five FDA-approved serotonin-norepinephrine reuptake inhibitors (desvenlafaxine, duloxetine, levomilnacipran, milnacipran and sibutramine) currently being marketed in the United States. As the COVID-19 pandemic significantly increased the incidence and prevalence of anxiety and depression across the country, there are significantly increased prescriptions of these medications perioperatively. Thus, anesthesiologists are more likely than ever to have patients administered with these agents and scheduled for elective or emergency surgical procedures. A thorough understanding of these commonly prescribed serotonin-norepinephrine reuptake inhibitors and their interactions with commonly utilized anesthetic agents is paramount. There are two potentially increased risks related to the continuation of SNRIs through the perioperative period: intraoperative bleeding and serotonin syndrome. SNRIs have some off-label uses, more new indications, and ever-increasing new applications in perioperative practice. This article aims to review the commonly prescribed serotonin-norepinephrine reuptake inhibitors and the current clinical evidence regarding their considerations in perioperative anesthesia and analgesia.
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16
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Li Y, Lustberg MB, Hu S. Emerging Pharmacological and Non-Pharmacological Therapeutics for Prevention and Treatment of Chemotherapy-Induced Peripheral Neuropathy. Cancers (Basel) 2021; 13:cancers13040766. [PMID: 33673136 PMCID: PMC7918689 DOI: 10.3390/cancers13040766] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Chemotherapy-induced peripheral neuropathy (CIPN) is a common and persistent complication of commonly used chemotherapy drugs. This article provides an overview of emerging therapeutics for the prevention and treatment of CIPN and focuses on pharmacological strategies that are derived from novel mechanistic insights and have the potential to be translated into clinically beneficial approaches. It is our contention to call for fostering collaboration between basic and clinical researchers to improve the development of effective strategies. Abstract Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse event of several first-line chemotherapeutic agents, including platinum compounds, taxanes, vinca alkaloids, thalidomide, and bortezomib, which negatively affects the quality of life and clinical outcome. Given the dearth of effective established agents for preventing or treating CIPN, and the increasing number of cancer survivors, there is an urgent need for the identification and development of new, effective intervention strategies that can prevent or mitigate this debilitating side effect. Prior failures in the development of effective interventions have been due, at least in part, to a lack of mechanistic understanding of CIPN and problems in translating this mechanistic understanding into testable hypotheses in rationally-designed clinical trials. Recent progress has been made, however, in the pathogenesis of CIPN and has provided new targets and pathways for the development of emerging therapeutics that can be explored clinically to improve the management of this debilitating toxicity. This review focuses on the emerging therapeutics for the prevention and treatment of CIPN, including pharmacological and non-pharmacological strategies, and calls for fostering collaboration between basic and clinical researchers to improve the development of effective strategies.
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Affiliation(s)
- Yang Li
- Division of Pharmaceutics and Pharmacology, College of Pharmacy & Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA;
| | - Maryam B. Lustberg
- Comprehensive Cancer Center, Department of Medical Oncology, The Ohio State University, Columbus, OH 43210, USA;
| | - Shuiying Hu
- Division of Pharmaceutics and Pharmacology, College of Pharmacy & Comprehensive Cancer Center, The Ohio State University, Columbus, OH 43210, USA;
- Correspondence: ; Tel.: +1-614-685-8028
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Lu Y, Zhang P, Zhang Q, Yang C, Qian Y, Suo J, Tao X, Zhu J. Duloxetine Attenuates Paclitaxel-Induced Peripheral Nerve Injury by Inhibiting p53-Related Pathways. J Pharmacol Exp Ther 2020; 373:453-462. [PMID: 32238452 DOI: 10.1124/jpet.120.265082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/18/2020] [Indexed: 03/08/2025] Open
Abstract
Paclitaxel (PTX) is an antineoplastic drug extracted from the Taxus species, and peripheral neuropathy is a common side effect. Paclitaxel-induced peripheral neuropathy (PIPN) seriously affects patient quality of life. Currently, the mechanism of PIPN is still unknown, and few treatments are recognized clinically. Duloxetine is recommended as the only potential treatment of chemotherapy-induced peripheral neuropathy (CIPN) by the American Society of Clinical Oncology. However, this guidance lacks a theoretical basis and experimental evidence. Our study suggested that duloxetine could improve PIPN and provide neuroprotection. We explored the potential mechanisms of duloxetine on PIPN. As a result, duloxetine acts by inhibiting poly ADP-ribose polymerase cleavage (PARP) and tumor suppressor gene p53 activation and regulating apoptosis regulator the Bcl2 family to reverse PTX-induced oxidative stress and apoptosis. Taken together, the present study shows that using duloxetine to attenuate PTX-induced peripheral nerve injury and peripheral pain may provide new clinical therapeutic targets for CIPN. SIGNIFICANCE STATEMENT: This study reported that duloxetine significantly alleviates neuropathic pain induced by paclitaxel and is related to poly ADP-ribose polymerase (PARP), tumor suppressor gene p53, and apoptosis regulator the Bcl2 family. Our findings thus not only provide important guidance to support duloxetine to become the first standard chemotherapy-induced peripheral neuropathy (CIPN) drug but also will find potential new targets and positive control for new CIPN drug development.
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Affiliation(s)
- Yuting Lu
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Peng Zhang
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Qiuyan Zhang
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Chao Yang
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Yangyan Qian
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Jinshuai Suo
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Xinxia Tao
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
| | - Jing Zhu
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Department of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China (Y.L., P.Z., Q.Z., C.Y., Y.Q., J.S., X.T., J.Z.); Departments of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland (J.Z.)
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Kim MJ, Kho HS. Treatment Outcomes of Venlafaxine and Duloxetine in Refractory Burning Mouth Syndrome Patients. ACTA ACUST UNITED AC 2019. [DOI: 10.14476/jomp.2019.44.3.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Moon-Jong Kim
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Hong-Seop Kho
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
- Institute on Aging Seoul National University, Seoul, Korea
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Preliminary Effectiveness of Auricular Point Acupressure on Chemotherapy-Induced Neuropathy: Part 1 Self-Reported Outcomes. Pain Manag Nurs 2019; 20:614-622. [PMID: 31155279 DOI: 10.1016/j.pmn.2019.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 03/18/2019] [Accepted: 04/24/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To reduce chemotherapy-induced neuropathy (CIN)-a significant challenge among cancer patients following chemotherapy-we explored the effects of auricular point acupressure (APA), which involves needleless, acupuncture-like stimulation on specific ear points. DESIGN/METHOD This pilot study examined the effects of a 4-week APA intervention in the management of CIN. Descriptive analysis was used to examine the changes in study outcomes. RESULTS Fifteen participants were enrolled. Two participants dropped out because they developed new medical conditions. Thirteen participants completed the study (87% retention rate). Study participants had more severe symptoms in their lower extremities (i.e., toes, feet, soles) than in their upper extremities (i.e., fingers, wrists, elbows). After the 4-week APA intervention, the mean percentage change scores ranged from 38% (tingling) to 49% (numbness); compared to pre-intervention, the therapeutic effects of APA were sustained at the 1-month follow-up. Function in both upper and lower extremities improved after the APA intervention (≥28%) and continued to improve at the 1-month follow-up (≥36%). CONCLUSIONS Preliminary results from this small sample provide initial evidence of the effectiveness of APA on CIN. Future studies should confirm these results using a larger sample, a comparative sham control, and an examination of the underlying physiological mechanisms of the anti-CIN effects of APA. CLINICAL IMPLICATIONS APA may provide an inexpensive and effective complementary approach for the self-management of CIN. Once the seeds have been taped to the patient's ear by the provider, patients are empowered to self-manage their CIN in their own environment.
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Hu LY, Mi WL, Wu GC, Wang YQ, Mao-Ying QL. Prevention and Treatment for Chemotherapy-Induced Peripheral Neuropathy: Therapies Based on CIPN Mechanisms. Curr Neuropharmacol 2019; 17:184-196. [PMID: 28925884 PMCID: PMC6343206 DOI: 10.2174/1570159x15666170915143217] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 08/20/2017] [Accepted: 01/01/1970] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chemotherapy-induced peripheral neuropathy (CIPN) is a progressive, enduring, and often irreversible adverse effect of many antineoplastic agents, among which sensory abnormities are common and the most suffering issues. The pathogenesis of CIPN has not been completely understood, and strategies for CIPN prevention and treatment are still open problems for medicine. OBJECTIVES The objective of this paper is to review the mechanism-based therapies against sensory abnormities in CIPN. METHODS This is a literature review to describe the uncovered mechanisms underlying CIPN and to provide a summary of mechanism-based therapies for CIPN based on the evidence from both animal and clinical studies. RESULTS An abundance of compounds has been developed to prevent or treat CIPN by blocking ion channels, targeting inflammatory cytokines and combating oxidative stress. Agents such as glutathione, mangafodipir and duloxetine are expected to be effective for CIPN intervention, while Ca/Mg infusion and venlafaxine, tricyclic antidepressants, and gabapentin display limited efficacy for preventing and alleviating CIPN. And the utilization of erythropoietin, menthol and amifostine needs to be cautious regarding to their side effects. CONCLUSIONS Multiple drugs have been used and studied for decades, their effect against CIPN are still controversial according to different antineoplastic agents due to the diverse manifestations among different antineoplastic agents and complex drug-drug interactions. In addition, novel therapies or drugs that have proven to be effective in animals require further investigation, and it will take time to confirm their efficacy and safety.
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Affiliation(s)
- Lang-Yue Hu
- Department of Integrative Medicine and Neurobiology, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture Research, Institutes of Brain Science, Collaborative Innovation Center for Brain Science, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Wen-Li Mi
- Department of Integrative Medicine and Neurobiology, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture Research, Institutes of Brain Science, Collaborative Innovation Center for Brain Science, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Gen-Cheng Wu
- Department of Integrative Medicine and Neurobiology, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture Research, Institutes of Brain Science, Collaborative Innovation Center for Brain Science, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Yan-Qing Wang
- Department of Integrative Medicine and Neurobiology, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture Research, Institutes of Brain Science, Collaborative Innovation Center for Brain Science, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Qi-Liang Mao-Ying
- Department of Integrative Medicine and Neurobiology, State Key Laboratory of Medical Neurobiology, Institute of Acupuncture Research, Institutes of Brain Science, Collaborative Innovation Center for Brain Science, School of Basic Medical Science, Fudan University, Shanghai, China
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Prabhala T, Sabourin S, DiMarzio M, Gillogly M, Prusik J, Pilitsis JG. Duloxetine Improves Spinal Cord Stimulation Outcomes for Chronic Pain. Neuromodulation 2018; 22:215-218. [PMID: 30325091 DOI: 10.1111/ner.12872] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/21/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) has been shown to be effective in treating chronic pain in patients with varying etiologies. However, the impact of pharmacological treatment on augmenting response to SCS has not been previously studied. METHODS We enrolled 108 patients who had undergone SCS surgery and documented their pain preoperatively and at 12 months postoperatively using the Numeric Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Beck Depression Inventory (BDI), Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCS), and Global Impression of Change (GIC). Pain outcomes were compared between patients receiving SCS alone and in addition to duloxetine. RESULTS At 1-year follow-up, patients receiving duloxetine and SCS (n = 41) had better pain relief in the affective component of MPQ (p < 0.05) than those receiving SCS alone (n = 71). Patients on duloxetine with SCS also were significantly more willing to receive SCS again (p < 0.01). This willingness appeared to be duloxetine dose dependent (p < 0.05). Patients receiving pregabalin or gabapentin with SCS did not have significantly more pain relief than patients receiving SCS alone. CONCLUSION This study shows the combination therapy to be an effective strategy to provide more holistic pain relief and further improve the quality of life of SCS patients.
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Affiliation(s)
- Tarun Prabhala
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA.,Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Shelby Sabourin
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Marisa DiMarzio
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Michael Gillogly
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Julia Prusik
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA.,Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
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Zhang TT, Xue R, Fan SY, Fan QY, An L, Li J, Zhu L, Ran YH, Zhang LM, Zhong BH, Li YF, Ye CY, Zhang YZ. Ammoxetine attenuates diabetic neuropathic pain through inhibiting microglial activation and neuroinflammation in the spinal cord. J Neuroinflammation 2018; 15:176. [PMID: 29879988 PMCID: PMC5992688 DOI: 10.1186/s12974-018-1216-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/24/2018] [Indexed: 02/07/2023] Open
Abstract
Background Diabetic neuropathic pain (DNP) is a common and distressing complication in patients with diabetes, and the underlying mechanism remains unclear. Tricyclic antidepressants (TCAs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are recommended as first-line drugs for DNP. Ammoxetine is a novel and potent SNRI that exhibited a strong analgesic effect on models of neuropathic pain, fibromyalgia-related pain, and inflammatory pain in our primary study. The present study was undertaken to investigate the chronic treatment properties of ammoxetine on DNP and the underlying mechanisms for its effects. Methods The rat model of DNP was established by a single streptozocin (STZ) injection (60 mg/kg). Two weeks after STZ injection, the DNP rats were treated with ammoxetine (2.5, 5, and 10 mg/kg/day) for 4 weeks. The mechanical allodynia and locomotor activity were assayed to evaluate the therapeutic effect of ammoxetine. In mechanism study, the activation of microglia, astrocytes, the protein levels of pro-inflammatory cytokines, the mitogen-activated protein kinases (MAPK), and NF-κB were evaluated. Also, microglia culture was used to assess the direct effects of ammoxetine on microglial activation and the signal transduction mechanism. Results Treatment with ammoxetine for 4 weeks significantly relieved the mechanical allodynia and ameliorated depressive-like behavior in DNP rats. In addition, DNP rats displayed increased activation of microglia in the spinal cord, but not astrocytes. Ammoxetine reduced the microglial activation, accumulation of pro-inflammatory cytokines, and activation of p38 and c-Jun N-terminal kinase (JNK) in the spinal cord of DNP rats. Furthermore, ammoxetine displayed anti-inflammatory effects upon challenge with LPS in BV-2 microglia cells. Conclusion Our results suggest that ammoxetine may be an effective treatment for relieving DNP symptoms. Moreover, a reduction in microglial activation and pro-inflammatory release by inhibiting the p-p38 and p-JNK pathways is involved in the mechanism.
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Affiliation(s)
- Ting-Ting Zhang
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China.,Department of Pharmacology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100005, China
| | - Rui Xue
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Shi-Yong Fan
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Qiong-Yin Fan
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Lei An
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China.,Beijing Laboratory for Food Quality and Safety, Beijing Technology and Business University (BTBU), No.11, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Juan Li
- Department of Pharmacology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100005, China
| | - Lei Zhu
- Department of Pharmacology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100005, China
| | - Yu-Hua Ran
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Li-Ming Zhang
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Bo-Hua Zhong
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Yun-Feng Li
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China
| | - Cai-Ying Ye
- Department of Pharmacology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100005, China.
| | - You-Zhi Zhang
- Institute of Pharmacology and Toxicology, Beijing Key laboratory of Neuropsychopharmacology, 27th Taiping Road, Haidian District, Beijing, 100850, China.
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Abstract
OBJECTIVE To systematically review the evidence for duloxetine in the management of painful diabetic neuropathy (PDN). METHODS Electronic searches of Medline and PubMed were performed from 2005 till October 2015 using medical subject headings and free-text words. Two independent reviewers extracted the data and assessed the methodological quality of the selected studies. RESULTS Twenty-three studies met our inclusion criteria and 8 were considered of high quality and were included to this review. Because of heterogeneity of the studies included in this review, statistical pooling of the data was not possible. We found good evidence for use of duloxetine in PDN over placebo and pregabalin but there was no benefit of duloxetine over amitriptyline. CONCLUSIONS Duloxetine has a beneficial effect over placebo. Nevertheless, the evidence of superiority of duloxetine over pregabalin and amitriptyline should be explored further as there was only 1 trial for each category. Provided majority of the PDN patients share cardiovascular complications, use of duloxetine will be a good option for treating pain associated with PDN over amitriptyline. Future randomized controlled trials should be designed keeping this in mind.
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Duloxetine Plasma Concentrations and Its Effectiveness in the Treatment of Nonorganic Chronic Pain in the Orofacial Region. Clin Neuropharmacol 2017. [DOI: 10.1097/wnf.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Patients with functional GI disorders (FGIDs) are commonplace in the gastroenterologist's practice. A number of these patients may be refractory to peripherally acting agents, yet respond to central neuromodulators. There are benefits and potential adverse effects to using TCAs, SSRIs, SNRIs, atypical antipsychotics, and miscellaneous central neuromodulators in these patients. These agents can benefit mood, pain, diarrhea, constipation, nausea, sleep, and depression. The mechanisms by which they work, the differences between classes and individual agents, and the various adverse effects are outlined. Dosing, augmentation strategies, and treatment scenarios specifically for painful FGIDs, FD with PDS, and chronic nausea and vomiting syndrome are outlined.
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Kaszuba BC, Walling I, Gee LE, Shin DS, Pilitsis JG. Effects of subthalamic deep brain stimulation with duloxetine on mechanical and thermal thresholds in 6OHDA lesioned rats. Brain Res 2016; 1655:233-241. [PMID: 27984022 DOI: 10.1016/j.brainres.2016.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 10/24/2016] [Accepted: 10/27/2016] [Indexed: 01/31/2023]
Abstract
Chronic pain is the most common non-motor symptom of Parkinson's disease (PD) and is often overlooked. Unilateral 6-hydroxydopamine (6-OHDA) medial forebrain bundle lesioned rats used as models for PD exhibit decreased sensory thresholds in the left hindpaw. Subthalamic deep brain stimulation (STN DBS) increases mechanical thresholds and offers improvements with chronic pain in PD patients. However, individual responses to STN high frequency stimulation (HFS) in parkinsonian rats vary with 58% showing over 100% improvement, 25% showing 30-55% improvement, and 17% showing no improvement. Here we augment STN DBS by supplementing with a serotonin-norepinephrine reuptake inhibitor commonly prescribed for pain, duloxetine. Duloxetine was administered intraperitoneally (30mg/kg) in 15 parkinsonian rats unilaterally implanted with STN stimulating electrodes in the lesioned right hemisphere. Sensory thresholds were tested using von Frey, Randall-Selitto and hot-plate tests with or without duloxetine, and stimulation to the STN at HFS (150Hz), low frequency (LFS, 50Hz), or off stimulation. With HFS or LFS alone (left paw; p=0.016; p=0.024, respectively), animals exhibited a higher mechanical thresholds stable in the three days of testing, but not with duloxetine alone (left paw; p=0.183). Interestingly, the combination of duloxetine and HFS produced significantly higher mechanical thresholds than duloxetine alone (left paw, p=0.002), HFS alone (left paw, p=0.028), or baseline levels (left paw; p<0.001). These findings show that duloxetine paired with STN HFS increases mechanical thresholds in 6-OHDA-lesioned animals more than either treatment alone. It is possible that duloxetine augments STN DBS with a central and peripheral additive effect, though a synergistic mechanism has not been excluded.
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Affiliation(s)
- Brian C Kaszuba
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Ian Walling
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Lucy E Gee
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Damian S Shin
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Julie G Pilitsis
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States; Department of Neurosurgery, Albany Medical Center, Albany, NY, United States.
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Dubois JD, Cantin V, Piché M, Descarreaux M. Physiological and Psychological Predictors of Short-Term Disability in Workers with a History of Low Back Pain: A Longitudinal Study. PLoS One 2016; 11:e0165478. [PMID: 27783666 PMCID: PMC5082621 DOI: 10.1371/journal.pone.0165478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/12/2016] [Indexed: 11/18/2022] Open
Abstract
Despite an elusive pathophysiology, common characteristics are often observed in individuals with chronic low back pain (LBP). These include psychological symptoms, altered pain perception, altered pain modulation and altered muscle activation. These factors have been explored as possible determinants of disability, either separately or in cross-sectional studies, but were never assessed in a single longitudinal study. Therefore, the objective was to determine the relative contribution of psychological and neurophysiological factors to future disability in individuals with past LBP. The study included two experimental sessions (baseline and six months later) to assess cutaneous heat pain and pain tolerance thresholds, pain inhibition, as well as trunk muscle activation. Both sessions included the completion of validated questionnaires to determine clinical pain, disability, pain catastrophizing, fear-avoidance beliefs and pain vigilance. One hundred workers with a history of LBP and 19 healthy individuals took part in the first experimental session. The second experimental session was exclusively conducted on workers with a history of LBP (77/100). Correlation analyses between initial measures and disability at six months were conducted, and measures significantly associated with disability were used in multiple regression analyses. A first regression analysis showed that psychological symptoms contributed unique variance to future disability (R2 = 0.093, p = .009). To control for the fluctuating nature of LBP, a hierarchical regression was conducted while controlling for clinical pain at six months (R2 = 0.213, p < .001) where pain inhibition contributed unique variance in the second step of the regression (R2 change = 0.094, p = .005). These results indicate that pain inhibition processes may constitute potential targets for treatment to alleviate future disability in individuals with past or present LBP. Then again, the link between psychological symptoms and pain inhibition needs to be clarified as both of these factors are linked together and influence disability in their own way.
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Affiliation(s)
- Jean-Daniel Dubois
- Département de psychologie, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
- * E-mail: (MD); (JDD)
| | - Vincent Cantin
- Département des sciences de l’activité physique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Mathieu Piché
- Département de chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Martin Descarreaux
- Département des sciences de l’activité physique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
- * E-mail: (MD); (JDD)
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Abstract
OBJECTIVES The paradoxical development of chronic abdominal pain is an underrecognized side effect of opioid use. Narcotic bowel syndrome (NBS), occurring in a small proportion of chronic opioid users, consists of chronic or intermittent abdominal pain, which often increases in severity despite continued or escalating dosages of opioids prescribed to relieve pain. METHODS A PubMed search was conducted using terms such as "narcotic bowel syndrome" and "opioid hyperalgesia" through January 2014. RESULTS Abdominal pain is the defining symptom of NBS and is thought to be mediated by central nervous system dysfunction; it should be distinguished from the peripheral side effects of opioids, such as nausea, bloating, intermittent vomiting, abdominal distension, and constipation. This latter cluster of symptoms is called opioid bowel dysfunction, although it may co-occur with NBS. Hypothesized mechanisms of the central effects of opioids on nociception in NBS include spinal cord inflammation and dysfunction in opioid receptor activity and related neuroanatomical substrates. With continued use, ∼6% of patients taking narcotics chronically will develop NBS, with profound consequences in terms of daily function. The primary management paradigm for NBS is a structured opioid withdrawal program accompanied by centrally acting adjunctive therapy comprising antidepressants, benzodiazepines, and clonidine to target pain, anxiety, and depression, and prevent withdrawal effects, in addition to peripherally acting agents such as laxatives (e.g., osmotic laxatives and chloride channel activators) to control transient constipation. Such structured withdrawal programs have been prospectively evaluated in small clinical trials and have met with considerable success in the short term. CONCLUSIONS Because rates of NBS are likely to rise, integrated intensive pharmacotherapy and psychosocial interventions are needed to help patients with NBS go off and stay off opioids. These programs will likely also reduce comorbid psychopathology and lead to adequate pain control and improved quality of life.
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[Recommendations for treatment and prevention of herpes zoster and associated pain in aged adults]. Rev Med Interne 2015; 37:35-42. [PMID: 26383768 DOI: 10.1016/j.revmed.2015.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/25/2015] [Accepted: 08/17/2015] [Indexed: 12/23/2022]
Abstract
Initiated within the first 72 hours of the rash, prescribing antiviral drugs reduces both acute neuralgia (AN) and later complications and especially postherpetic neuralgia (PHN). But their analgesic as well as preventative effect on AN and PHN is modest. Combination with analgesic drugs is more often needed for pain management. However, the pharmacological management of pain, in the context of old patients' frailty, co-morbidities and often polypharmacy, must be carefully considered. Based on analyses of the evidences from the literature, this review presents the therapeutic options we have at one's disposal and proposes a stepwise management for both AN and PHN specifically designed for aged population.
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Antihyperalgesic effect of duloxetine and amitriptyline in rats after peripheral nerve injury: Influence of descending noradrenergic plasticity. Neurosci Lett 2015; 602:62-7. [DOI: 10.1016/j.neulet.2015.06.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 06/21/2015] [Accepted: 06/22/2015] [Indexed: 01/12/2023]
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Szigethy E, Schwartz M, Drossman D. Narcotic bowel syndrome and opioid-induced constipation. Curr Gastroenterol Rep 2014; 16:410. [PMID: 25183577 DOI: 10.1007/s11894-014-0410-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Prescription opioid use for chronic non-cancer pain has reached epidemic levels in the USA. With this increased use is the recognition of serious opioid-related gastrointestinal complications such as narcotic bowel syndrome (NBS) and opioid-induced constipation (OIC). NBS consists of a paradoxical worsening of abdominal pain with escalating doses of opioids and is likely mediated by the central nervous system. Therapy requires an intensive multidisciplinary approach to detoxification. OIC is the most common gastrointestinal side effect of opioids. Several novel therapeutics are available to treat OIC that fails to respond to laxative therapy. This review will summarize recent findings on the pathophysiology and treatment approaches to NBS and OIC with a focus on controversies about diagnosis and intervention.
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Affiliation(s)
- Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Medical Arts Building, 3708 Fifth Ave, Pittsburgh, PA, 15213, USA,
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Piccolo J, Kolesar JM. Prevention and treatment of chemotherapy-induced peripheral neuropathy. Am J Health Syst Pharm 2014; 71:19-25. [PMID: 24352178 DOI: 10.2146/ajhp130126] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The prevention and treatment of chemotherapy-induced peripheral neuropathy (CIPN) are reviewed. SUMMARY A number of agents, including amifostine, glutathione, and vitamin E, were evaluated as prevention strategies for CIPN, with no agent demonstrating efficacy. Calcium and magnesium are effective for the prevention of CIPN; however, concerns regarding reduced chemotherapy efficacy linger. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), was evaluated for the prevention of neuropathy in a randomized, double-blind, placebo-controlled Phase III trial of patients receiving an oxaliplatin-based regimens every two weeks and demonstrated significantly less acute neurotoxicity compared with the control group. Treatment options for CIPN include reducing the dosage of the chemotherapy, changing the chemotherapy, and treating CIPN with adjunct therapy. Adjunct therapy with topical agents, tricyclic antidepressants, and anticonvulsants, such as pregabalin and gabapentin, have shown limited efficacy. However, a randomized, double-blind, crossover, Phase III trial of duloxetine versus placebo for the treatment of CIPN caused by paclitaxel or oxaliplatin found that patients treated with duloxetine 60 mg daily had a larger average decrease in pain score than those receiving placebo, regardless of the chemotherapy used. CONCLUSION Calcium and magnesium infusions and venlafaxine are effective in preventing CIPN but are not routinely used because of concerns related to decreased chemotherapy efficacy. Adjunct treatment options for CIPN include a topical analgesic, a tricyclic antidepressant, an anticonvulsant, or an SNRI. Duloxetine is more effective than placebo in treating oxaliplatin- or paclitaxel-induced CIPN, is well tolerated, and should be considered to be a first-line treatment option for CIPN.
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Affiliation(s)
- Jennifer Piccolo
- Jennifer Piccolo, Pharm.D., is Clinical Oncology Pharmacist, Froedert and The Medical College of Wisconsin, Milwaukee. Jill M. Kolesar, Pharm.D., BCPS, FCCP, is Professor of Pharmacy, School of Pharmacy, University of Wisconsin-Madison, and Director, 3P Analytical Laboratory, University of Wisconsin Carbone Comprehensive Cancer Center, Madison
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Gardella B, Porru D, Allegri M, Bogliolo S, Iacobone AD, Minella C, Nappi RE, Ferrero S, Spinillo A. Pharmacokinetic considerations for therapies used to treat interstitial cystitis. Expert Opin Drug Metab Toxicol 2014; 10:673-84. [PMID: 24621003 DOI: 10.1517/17425255.2014.896338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Interstitial cystitis (IC) or bladder pain syndrome (BPS) is defined as supra-pubic pain related to bladder filling. IC is characterized by a particular symptom complex with no identifiable causes; as with bladder hypersensitivity it is usually associated with urinary frequency and urgency with bladder pain. No current treatments have a significant impact on symptoms over time. AREAS COVERED This systematic review examines the pharmacokinetic aspects and adverse event of present IC therapy to highlight appropriate treatment to improve the symptoms of IC. This article reviews material obtained via Medline, PubMed, and EMBASE literature searches up to October 2013. EXPERT OPINION The correct approach to IC should consider a multidisciplinary team of specialists and a multimodal treatment package that include psychotherapy, behavior change, physical activation, and analgesic treatment. Unfortunately, a single therapeutic target for IC is not yet known. With regard to pathophysiology and therapy, there is more to discover. The first insult damages the bladder urothelium, hence vehicles that lead the drug to penetrate the wall of the bladder might be a novel strategic approach.
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Affiliation(s)
- Barbara Gardella
- University of Pavia, Fondazione IRCCS, Policlinico San Matteo, Department of Obstetrics and Gynecology , 19 Viale Camillo Golgi, 27100 Pavia , Italy +390382503722 ; +390382503885 ;
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Hsu YC, Tzeng NS. Can topical duloxetine be used for neuropathic pain? Med Hypotheses 2014; 82:175-6. [DOI: 10.1016/j.mehy.2013.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/04/2013] [Accepted: 11/19/2013] [Indexed: 11/25/2022]
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Kaufman KR, Parikh A, Chan L, Bridgeman M, Shah M. Myoclonus in renal failure: Two cases of gabapentin toxicity. EPILEPSY & BEHAVIOR CASE REPORTS 2013; 2:8-10. [PMID: 25667856 PMCID: PMC4307962 DOI: 10.1016/j.ebcr.2013.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/03/2013] [Indexed: 01/07/2023]
Abstract
Gabapentin, an AED approved for the adjunctive treatment of partial seizures with/without secondary generalization and for the treatment of postherpetic neuralgia, is frequently used off-label for the treatment of both psychiatric and pain disorders. Since gabapentin is cleared solely by renal excretion, dosing requires consideration of the patient's renal function. Myoclonic activity may occur as a complication of gabapentin toxicity, especially with acute kidney injury or end-stage renal disease. We report 2 cases of myoclonic activity associated with gabapentin toxicity in the setting of renal disease which resolved with discontinuation of gabapentin and treatment with hemodialysis and peritoneal dialysis. As gabapentin has multiple indications and off-label uses, an understanding of myoclonus, neurotoxicity, and renal dosing is important to clinicians in multiple specialties.
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Affiliation(s)
- Kenneth R. Kaufman
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, USA
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, USA
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, USA
- Corresponding author at: Departments of Psychiatry, Neurology, and Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA. Fax: + 1 732 235 7677.
| | - Amay Parikh
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, USA
| | - Lili Chan
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, USA
| | - Mary Bridgeman
- Department of Pharmacy Practice and Administration, Rutgers Ernest Mario School of Pharmacy, USA
| | - Milisha Shah
- Pharmaceutical Services, West Virginia University Healthcare, USA
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Wielage RC, Bansal M, Andrews JS, Klein RW, Happich M. Cost-utility analysis of duloxetine in osteoarthritis: a US private payer perspective. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:219-236. [PMID: 23616247 DOI: 10.1007/s40258-013-0031-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Duloxetine has recently been approved in the USA for chronic musculoskeletal pain, including osteoarthritis and chronic low back pain. The cost effectiveness of duloxetine in osteoarthritis has not previously been assessed. Duloxetine is targeted as post first-line (after acetaminophen) treatment of moderate to severe pain. OBJECTIVE The objective of this study was to estimate the cost effectiveness of duloxetine in the treatment of osteoarthritis from a US private payer perspective compared with other post first-line oral treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), and both strong and weak opioids. METHODS A cost-utility analysis was performed using a discrete-state, time-dependent semi-Markov model based on the National Institute for Health and Clinical Excellence (NICE) model documented in its 2008 osteoarthritis guidelines. The model was extended for opioids by adding titration, discontinuation and additional adverse events (AEs). A life-long time horizon was adopted to capture the full consequences of NSAID-induced AEs. Fourteen health states comprised the structure of the model: treatment without persistent AE, six during-AE states, six post-AE states and death. Treatment-specific utilities were calculated using the transfer-to-utility method and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores from a meta-analysis of osteoarthritis clinical trials of 12 weeks and longer. Costs for 2011 were estimated using Red Book, The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project database, the literature and, sparingly, expert opinion. One-way and probabilistic sensitivity analyses were undertaken, as well as subgroup analyses of patients over 65 years old and a population at greater risk of NSAID-related AEs. RESULTS In the base case the model estimated naproxen to be the lowest total-cost treatment, tapentadol the highest cost, and duloxetine the most effective after considering AEs. Duloxetine accumulated 0.027 discounted quality-adjusted life-years (QALYs) more than naproxen and 0.013 more than oxycodone. Celecoxib was dominated by naproxen, tramadol was subject to extended dominance, and strong opioids were dominated by duloxetine. The model estimated an incremental cost-effectiveness ratio (ICER) of US$47,678 per QALY for duloxetine versus naproxen. One-way sensitivity analysis identified the probabilities of NSAID-related cardiovascular AEs as the inputs to which the ICER was most sensitive when duloxetine was compared with an NSAID. When compared with a strong opioid, duloxetine dominated the opioid under nearly all sensitivity analysis scenarios. When compared with tramadol, the ICER was most sensitive to the costs of duloxetine and tramadol. In subgroup analysis, the cost per QALY for duloxetine versus naproxen fell to US$24,125 for patients over 65 years and to US$18,472 for a population at high risk of cardiovascular and gastrointestinal AEs. CONCLUSION The model estimated that duloxetine was potentially cost effective in the base-case population and more cost effective for subgroups over 65 years or at high risk of NSAID-related AEs. In sensitivity analysis, duloxetine dominated all strong opioids in nearly all scenarios.
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Affiliation(s)
- Ronald C Wielage
- Medical Decision Modeling Inc., 8909 Purdue Road, Suite #550, Indianapolis, IN 46268, USA.
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Depressione e malattia di Parkinson. Neurologia 2013. [DOI: 10.1016/s1634-7072(12)63928-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Effectiveness of Duloxetine for the Treatment of Chronic Nonorganic Orofacial Pain. Clin Neuropharmacol 2012; 35:273-7. [DOI: 10.1097/wnf.0b013e31827453fa] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zomkowski ADE, Engel D, Cunha MP, Gabilan NH, Rodrigues ALS. The role of the NMDA receptors and l-arginine-nitric oxide-cyclic guanosine monophosphate pathway in the antidepressant-like effect of duloxetine in the forced swimming test. Pharmacol Biochem Behav 2012; 103:408-17. [PMID: 23010381 DOI: 10.1016/j.pbb.2012.09.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 09/10/2012] [Accepted: 09/16/2012] [Indexed: 11/19/2022]
Abstract
Duloxetine is a selective serotonin and noradrenaline reuptake inhibitor used as antidepressant. However, its mechanisms of action are not fully understood. This study investigated the effect of duloxetine in the mouse forced swimming test (FST) and in the tail suspension test (TST) and the involvement of the NMDA receptors and the l-arginine-NO-cGMP pathway in its effect in the FST. Duloxetine reduced the immobility time both in the FST and in the TST (dose range of 1-30mg/kg, i.p.), without changing locomotion in an open-field. Duloxetine administered orally (1-30mg/kg) also reduced the immobility time in the FST. The effect of duloxetine (10mg/kg, p.o.) in the FST was prevented by pre-treatment with NMDA (0.1pmol/site, i.c.v.), d-serine (30μg/site, i.c.v.), (l-arginine (750mg/kg, i.p.), S-nitroso-N-acetyl-penicillamine (SNAP, 25μg/site, i.c.v) or sildenafil (5mg/kg, i.p.). The administration of MK-801 (0.001mg/kg, i.p.), 7-nitroindazole (50mg/kg, i.p.), methylene blue (20mg/kg, i.p.) or 1H-[1,2,4]oxadiazole[4,3-a]quinoxalin-1-one (ODQ) (30pmol/site i.c.v.) in combination with a sub-effective dose of duloxetine (0.3mg/kg, p.o.) reduced the immobility time in the FST. Moreover, the administration of duloxetine (10mg/kg) produced a reduction in NOx levels in the hippocampus and cerebral cortex. Altogether the results suggest that the effect of duloxetine in the FST is dependent on either a blockade of NMDA receptors or an inhibition of NO. In addition, our results further reinforce the role of NMDA receptors and l-arginine-NO-cGMP pathway, besides the monoaminergic systems, in the mechanism of action of current prescribed antidepressant agents.
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Affiliation(s)
- Andréa D E Zomkowski
- Departamento de Bioquímica, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Florianópolis 88040-900, SC, Brazil
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Cui Z, Zhao Y, Novick D, Faries D. Predictors of duloxetine adherence and persistence in patients with fibromyalgia. J Pain Res 2012; 5:193-201. [PMID: 22792005 PMCID: PMC3392711 DOI: 10.2147/jpr.s31800] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Adherence to medication for the treatment of fibromyalgia (FM) is predictive of lower overall health-care costs, and thus a lower burden on both patients and providers. The objectives of this study were to examine the predictors of adherence to and persistence with duloxetine therapy among commercially insured FM patients, and to identify subgroups of patients with high duloxetine persistence and adherence. STUDY DESIGN This cross-sectional, retrospective study analyzed medical and pharmacy records over 1 year for patients in the US aged 18-64 years with FM who initiated (no prior 90-day use) duloxetine treatment in 2008. METHODS Adherence to duloxetine was measured by medication possession ratio (MPR), with high adherence defined as MPR ≥ 0.8. Persistence was defined as the duration of therapy from the index date to the earliest of: the ending date of the last prescription, the date of the first gap of >15 days between prescriptions, or the end of the study period (12 months). Demographic and clinical predictors of adherence were examined via multiple logistic regression (MLR), and subgroups of duloxetine-persistent and -adherent patients were identified using classification and regression trees (CART). RESULTS Among 4660 duloxetine patients, 33% achieved high adherence. Factors associated with high adherence from MLR included older age, North Central and Northeast regions, prior venlafaxine, pregabalin, selective serotonin reuptake inhibitor (SSRI), or other antidepressant use, or comorbid dyslipidemia or osteoarthritis (all P < 0.05). CART analysis revealed that patients with prior antidepressant use, aged ≥46, or prior osteoarthritis had higher MPR (all P < 0.05), and patients aged ≥45 with a history of SSRI, venlafaxine, or anticonvulsant use had longer duration of therapy (all P < 0.05). CONCLUSIONS Patients with high adherence to and persistence with duloxetine were significantly older and had prior antidepressant use.
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Affiliation(s)
| | - Yang Zhao
- Eli Lilly and Company, Indianapolis, IN, USA
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Pergolizzi JV, Raffa RB, Taylor R, Rodriguez G, Nalamachu S, Langley P. A review of duloxetine 60 mg once-daily dosing for the management of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic osteoarthritis pain and low back pain. Pain Pract 2012; 13:239-52. [PMID: 22716295 DOI: 10.1111/j.1533-2500.2012.00578.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Duloxetine is a selective dual neuronal serotonin (5-Hydroxytryptamine, 5-HT) and norepinephrine reuptake inhibitor (SSNRI). It is indicated in the United States for treatment of major depressive disorder (MDD), generalized anxiety disorder (GAD), and several chronic pain conditions, including management of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic osteoarthritis (OA) pain and chronic low back pain (LBP). Its use for antidepressant and anxiolytic actions has been extensively reviewed previously. We here review the evidence for the efficacy of 60 mg once-daily dosing of duloxetine for chronic pain conditions. METHOD The literature was searched for clinical trials in humans conducted in the past 10 years involving duloxetine. RESULTS There were 199 results in the initial search. Studies not in the English language were excluded. We then included only studies of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain (OA and LBP). Studies of painful symptoms reported in mental health studies were excluded. This resulted in 32 studies. Articles that did not include a 60 mg/day daily dose as a study arm were excluded. This resulted in 30 studies, broken down as follows: 12 for diabetic peripheral neuropathy, 9 for fibromyalgia, 6 for LBP, and 3 for OA pain. CONCLUSIONS The studies reviewed report that duloxetine 60 mg once-daily dosing is an effective option for the management of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic OA pain and chronic LBP. As these pains are often comorbid with MDD or GAD, duloxetine might possess the pharmacologic properties to be a versatile agent able to address several symptoms in these patients. With adequate attention to FDA prescribing guidance regarding safety and drug-drug interactions, duloxetine 60 mg once-daily dosing appears to be an effective option in the appropriate pain patient population.
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Evidence for Interventional Procedures as an Adjunct Therapy in the Treatment of Shingles Pain. Adv Skin Wound Care 2012; 25:276-84; quiz 285-6. [DOI: 10.1097/01.asw.0000415345.22307.f3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perez-Lloret S, Rey MV, Dellapina E, Pellaprat J, Brefel-Courbon C, Rascol O. Emerging analgesic drugs for Parkinson's disease. Expert Opin Emerg Drugs 2012; 17:157-71. [DOI: 10.1517/14728214.2012.677949] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Skljarevski V, Zhang S, Iyengar S, D'Souza D, Alaka K, Chappell A, Wernicke J. Efficacy of Duloxetine in Patients with Chronic Pain Conditions. CURRENT DRUG THERAPY 2011; 6:296-303. [PMID: 22876216 PMCID: PMC3412202 DOI: 10.2174/157488511798109592] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 09/12/2011] [Accepted: 09/23/2011] [Indexed: 12/31/2022]
Abstract
The primary objective of this study is to review the efficacy of duloxetine in treating chronic pain using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations for clinical significance across chronic pain states. These include pain intensity, patient ratings of overall improvement, physical functioning, and mental functioning. This review comprised the side-by-side analyses of 12 double-blind, placebo-controlled trials of duloxetine in patients with chronic pain (diabetic peripheral neuropathic pain, fibromyalgia, chronic pain due to osteoarthritis, and chronic low back pain). Patients received duloxetine (60 to 120 mg/day) or placebo. Average pain reduction was assessed over 3 months as the primary efficacy outcome. Other measures used were physical function and Patient Global Impression of Improvement. In 10 of the 12 studies, statistically significant greater pain reduction was observed for duloxetine- compared with placebo-treated patients. The response rates based on average pain reduction, improvement of physical function, and global impression were comparable across all 4 chronic pain states. Compared with patients on placebo, significantly more patients treated with duloxetine reported a moderately important pain reduction (≥30% reduction) in 9 of the 12 studies, a minimally important improvement in physical function in 8 of the 12 studies, and a moderately important to substantial improvement in Patient Global Impression of Improvement rating in 11 of the 12 studies. The analyses reported here show that duloxetine is efficacious in treating chronic pain as demonstrated by significant improvement in pain intensity, physical functioning, and patient ratings of overall improvement.
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Philippsohn S, Kruger THC. Persistent genital arousal disorder: successful treatment with duloxetine and pregabalin in two cases. J Sex Med 2011; 9:213-7. [PMID: 22024021 DOI: 10.1111/j.1743-6109.2011.02518.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Persistent genital arousal disorder (PGAD) is a rare condition in women that causes a lot of suffering. The pathophysiology is not well understood and an approach promising effective treatment has not been established so far. AIM This study aims to make colleagues aware of two treatment options, which proved to be successful in one case each and which might be worth further investigation. MAIN OUTCOME MEASURES Subjective distress from unwanted sexual arousal, unwanted orgasms, and pain in the genital area. METHODS Treatment of two women--36 and 41 years old--suffering from PGAD with duloxetine and pregabalin, respectively. RESULTS In both women, the treatment proved to be very successful over a long period of time. One of them experienced full remission (duloxetine) and the other one experienced substantial improvement (pregabalin), over a period now lasting for more than a year. CONCLUSION Pregabalin and duloxetine, in particular, should be further investigated as possible medication for the treatment of PGAD.
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Affiliation(s)
- Susanne Philippsohn
- Department of Psychiatry, Social Psychiatry, and Psychotherapy, Clinical Psychology, Hannover Medical School, Hannover, Germany.
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