Prevalence and treatment of neuropathic pain diagnoses among U.S. nursing home residents

Protein arginine methyltransferase-6 regulates heterogeneous nuclear ribonucleoprotein-F expression and is a potential target for the treatment of neuropathic pain

JOURNAL/nrgr/04.03/01300535-202509000-00029/figure1/v/2024-11-05T132919Z/r/image-tiff Protein arginine methyltransferase-6 participates in a range of biological functions, particularly RNA processing, transcription, chromatin remodeling, and endosomal trafficking. However, it remains unclear whether protein arginine methyltransferase-6 modifies neuropathic pain and, if so, what the mechanisms of this effect. In this study, protein arginine methyltransferase-6 expression levels and its effect on neuropathic pain were investigated in the spared nerve injury model, chronic constriction injury model and bone cancer pain model, using immunohistochemistry, western blotting, immunoprecipitation, and label-free proteomic analysis. The results showed that protein arginine methyltransferase-6 mostly co-localized with β-tubulin III in the dorsal root ganglion, and that its expression decreased following spared nerve injury, chronic constriction injury and bone cancer pain. In addition, PRMT6 knockout (Prmt6-/-) mice exhibited pain hypersensitivity. Furthermore, the development of spared nerve injury-induced hypersensitivity to mechanical pain was attenuated by blocking the decrease in protein arginine methyltransferase-6 expression. Moreover, when protein arginine methyltransferase-6 expression was downregulated in the dorsal root ganglion in mice without spared nerve injury, increased levels of phosphorylated extracellular signal-regulated kinases were observed in the ipsilateral dorsal horn, and the response to mechanical stimuli was enhanced. Mechanistically, protein arginine methyltransferase-6 appeared to contribute to spared nerve injury-induced neuropathic pain by regulating the expression of heterogeneous nuclear ribonucleoprotein-F. Additionally, protein arginine methyltransferase-6-mediated modulation of heterogeneous nuclear ribonucleoprotein-F expression required amino acids 319 to 388, but not classical H3R2 methylation. These findings indicated that protein arginine methyltransferase-6 is a potential therapeutic target for the treatment of peripheral neuropathic pain.

Current insights and therapeutic strategies for targeting TRPV1 in neuropathic pain management

Neuropathic pain, a common symptom of several disorders, exerts a substantial socioeconomic burden worldwide. Transient receptor potential vanilloid 1 (TRPV1), a non-selective cation channel predominantly ex-pressed in nociceptive neurons, plays a pivotal role in nociception, by detecting various endogenous and exogenous stimuli, including heat, pro-inflammatory mediators, and physical stressors. Dysregulation of TRPV1 signaling further contributes to the pathophysiology of neuropathic pain. Therefore, targeting TRPV1 is a promising strategy for developing novel analgesics with improved efficacy and safety profiles. Several pharmacological approaches to modulate TRPV1 activity, including agonists, antagonists, and biological TRPV1 RNA interference (RNAi, small interfering RNA [siRNA]) have been explored. Despite preclinical success, the clinical translation of TRPV1-targeted therapies has encountered challenges, including hyperthermia, hypothermia, pungency, and desensitization. Nevertheless, ongoing research efforts aim to refine TRPV1-targeted interventions through structural modifications, development of selective modulators, and discovery of natural, peptide-based drug candidates. Herein, we provide guidance for researchers and clinicians involved in the development of new interventions specifically targeting TRPV1 by reviewing the existing literature and highlighting current research activities. This study further discusses potential future research endeavors for enhancing the efficacy, safety, and tolerability of TRPV1 candidates, and thereby facilitates the translation of these discoveries into effective clinical interventions to alleviate neuropathic pain disorders.

Silencing of FTO inhibits oxidative stress to relieve neuropathic pain by m6A modification of GPR177

BACKGROUND

Neuropathic pain (NP) is a challenging health condition owing to its complex nature and associated multiple etiologies. The occurrence of NP involves the abnormal activity of neurons mediated by oxidative stress (OS). Previous research has demonstrated that m6A methylation plays a role in the regulatory pathway of NP. This study aimed to investigate the specific molecular pathways through which m6A methylation modifiers alleviate NP.

METHODS

For this purpose, an NO rat model was developed via spared nerve injury (SNI), followed by quantifying the animal's pain assessment via paw withdrawal threshold (PWT) and paw withdrawal latency (PWL). The OS in SNI rats was evaluated by measuring reactive oxygen species, superoxide dismutase, and catalase (CAT) in spinal cord tissues. Moreover, quantitative-real-time polymerase chain reaction and western blot analysis were employed for detecting fat mass and obesity-associated (FTO) and GPR177 levels, while m6A levels of GPR117 were analyzed via MeRIP.

RESULTS

The results indicated an enhanced OS with highly expressed FTO in spinal cord tissue samples, where knocking down Fto effectively relieved NP and OS in SNI rats. Mechanistic investigations revealed that Fto-mediated reduction of Grp177 m6A modification was involved in the WNT5a/TRPV1 axis-mediated OS remission of NP. Moreover, in vitro experiment results indicated that YTHDF2 was an important m6A methylated reading protein for this process.

CONCLUSIONS

Fto silencing leads to increased m6A methylation of Grp177 through a YTHDF2-dependent mechanism, resulting in decreased Grp177 stability and ultimately reducing NP in rats by OS suppression.

Sodium aescinate ameliorates chronic neuropathic pain in male mice via suppressing JNK/p38-mediated microglia activation

OBJECTIVE

A study confirmed that sodium aescinate (SA) can effectively relieve bone cancer pain, but its role in neuropathic pain (NP) remains confused.

METHODS

Eighty male mice were randomly divided into four groups: sham+vehicle, sham+SA (40 μg/L, intrathecal injection), chronic contraction injury (CCI)+vehicle, CCI+SA. Behavioral assessments were used to evaluate the locomotor activity and paw withdrawal threshold (PWT) of mice. At the end of the study, spinal cord tissues were collected for histopathological analysis. The JNK/p38 signaling activation, Iba-1 expression, pro-inflammatory cytokines levels, and microglia subtype were assessed by western blotting, immunohistochemical staining, enzyme-linked immunosorbent assay, and flow cytometry with CD86/CD206, respectively.

RESULTS

Early treatment with SA delayed the development of mechanical allodynia in CCI mice. Repeated SA treatment could prominently increase the reduction of PWT induced by CCI, and improve the locomotor activity of CCI mice. Mechanically, CCI surgery induced significant up-regulation of p-JNK and p-p38 protein levels, increased number and M1/M2 ratio of microglia, as well as pro-inflammatory factors in the spinal cords of mice, which could be blocked after SA administration.

CONCLUSIONS

SA might suppress the activation of microglia and neuroinflammation by selectively inhibiting the JNK/p38 signaling pathway, thereby alleviating CCI-induced NP in male mice.

Pharmacological treatment of pain in Swedish nursing homes: Prevalence and associations with cognitive impairment and depressive mood

OBJECTIVES

Chronic pain is highly prevalent in nursing home residents and often occurs with depression as well as cognitive impairment, which can severely influence and limit the expression of pain.

METHODS

The present cross-sectional study aimed to estimate the prevalence of pain, depressive mood, and cognitive impairment in association with pharmacological treatment against pain and depressive symptoms among Swedish nursing home residents.

RESULTS

We found an overall pain prevalence of 52.8%, a prevalence of 63.1% for being in a depressive mood, and a prevalence of cognitive impairment of 68.3%. Among individuals assessed to have depressive mood, 60.5% were also assessed to have pain. The prevalence of pharmacological treatment for pain was 77.5 and 54.1% for antidepressants. Prescription of pharmacological treatment against pain was associated with reports of currently having pain, and paracetamol was the most prescribed drug. A higher cognitive function was associated with more filled prescriptions of drugs for neuropathic pain, paracetamol, and nonsteroidal anti-inflammatory drugs (NSAIDs), which could indicate an undertreatment of pain in those cognitively impaired.

CONCLUSION

It is important to further explore the relationship between pain, depressive mood, and cognitive impairment in regard to pain management in nursing home residents.

Correlation between spinal cord stimulation analgesia and cortical dynamics in pain management

AIM

Spinal cord stimulation (SCS) is an effective method to treat neuropathic pain. It is necessary to identify the responders of SCS analgesia before implantation. The aim of this study is to investigate the relationship between the cortical dynamics and SCS analgesia responders in pain management.

METHODS

Resting-state EEG recording was performed in patients who underwent short-term implantation of spinal cord stimulation for pain therapy. We then did spectral analysis to capture the pattern of cortical oscillation between neuromodulation therapy analgesia responders and nonresponders.

RESULTS

About 58.3% (14 out of 24) of participants were considered as analgesia responders, with average visual analogue scores reduction of 4.8 ± 1.0 after surgery, and 2.1 ± 0.7 for the nonresponder subgroup, respectively. The alpha oscillation was significantly enhanced in responder cohort compared with nonresponders. We also observed an increasing spectral power of gamma band in responders. Furthermore, the attenuation of pain severity was significantly correlated with the global alpha oscillation activity (r = 0.60, P = 0.002). Likely, positive and significant correlation was found between the pain relief and gamma activity (r = 0.58, P = 0.003).

CONCLUSIONS

Distinct pattern of neural oscillation is associated with the analgesic effect of spinal cord stimulation in pain management, enhancement of cortical alpha and gamma oscillation may be a predictor of analgesia responders.

Safety of mirogabalin and pregabalin in Japanese patients with neuropathic pain: a retrospective cohort study

BACKGROUND

Few studies have compared the safety risks between the gabapentinoids, pregabalin, and mirogabalin in post-marketing clinical settings. We assessed reported events associated with gabapentinoid use in patients with neuropathic pain.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study between September 2020 and December 2020 using the community pharmacies records in Japan. The pharmacists identified new vs. prevalent users of mirogabalin and pregabalin in September 2020 and reported data regarding baseline and adverse events to the Japan Pharmaceutical Association using web-based questionnaires. The incidence of events and hazard ratio (HR) were consequently compared.

RESULTS

New users of mirogabalin and pregabalin were identified (n = 1,650 and 2,244; mean age (SD): 69 (15) and 68 (16) years; women: 59% and 56%, respectively). Although serious events were not reported, a marked difference in HRs of common adverse events, including somnolence (1.6), dizziness (1.3), nausea (2.8), edema (3.1), and acetaminophen (2.0)/antidepressant (2.4) addition, was observed.

CONCLUSION

No new serious safety concerns were found for mirogabalin and pregabalin use in patients with neuropathic pain, although the HR of some events indicated increased risk among mirogabalin users. However, further studies are needed as estimates for events occurring in small numbers with wide confidence intervals.

Recent Progress in Gels for Neuropathic Pain

Neuropathic pain is a complex and debilitating condition that affects millions of people worldwide. While several treatment options are available, they often have limited efficacy and are associated with adverse effects. In recent years, gels have emerged as a promising option for the treatment of neuropathic pain. Inclusion of various nanocarriers, such as cubosomes and niosomes, into gels results in pharmaceutical forms with higher drug stability and increased drug penetration into tissues compared to products currently marketed for the treatment of neuropathic pain. Furthermore, these compounds usually provide sustained drug release and are biocompatible and biodegradable, which makes them a safe option for drug delivery. The purpose of this narrative review was to provide a comprehensive analysis of the current state of the field and identify potential directions for future research in the development of effective and safe gels for the treatment of neuropathic pain, ultimately improving the quality of life for patients suffering from neuropathic pain.

Clinical characteristics of ankylosing spondylitis patients depending on neuropathic pain

Introduction

Neuropathic pain (NP) in ankylosing spondylitis (AS) is an important factor that complicates patients' everyday activities and leads to a decrease of life quality. Detection and diagnosis of NP can be facilitated by the use of screening instruments, and the comparative assessment of the sensitivity of different scales is important for improving the diagnosis and personalizing the treatment of AS.The aim of the study was to analyze prevalence of NP in patients with AS and clinical features of AS patients depending on the presence of NP.

Material and methods

We examined 94 patients with NP and 48 patients without pain in AS using the following questionnaires: LANSS, DN4, StEP, BASFI, BASMI, BASDAI, HAQ, ASAS HI/EF and BAS-G.

Results

The prevalence of NP according to LANSS was 51.7% in women and 32.7% in men (p = 0.048); according to DN4 - 58.6% and 32.7%, respectively (p = 0.010). Disease activity and functional disability of the patients were higher in the group of patients with NP than in the group of patients without NP according to the BASDAI, BASFI, BASMI, HAQ, ASAS HI/EF and BAS-G. Significance of differences between groups was at the level of p < 0.01.

Conclusions

The prevalence of NP in AS is alarmingly high. Even with low scores on screening scales, patients showed signs of NP, which may indicate higher prevalence of NP. Neuropathic pain is more associated with the activity of the disease, greater loss of functional capacity and a decrease in indicators of the general state of health, which allows it to be considered as an aggravating factor regarding these manifestations.

Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents

BACKGROUND

A concern with long-term opioid use is the increased risk arising when opioids are used concurrently with drugs that can potentiate their associated adverse effects. The drugs most often encountered are benzodiazepines (BZDs) and gabapentinoids. Our study objectives were to examine trends in the concurrent use of opioids and BZDs, or gabapentinoids, in a Canadian nursing home population over an 11-year period, and current resident-level correlates of this concurrent use.

METHODS

We conducted a population-based, repeated cross-sectional study among Ontario nursing home residents (>65 years) dispensed opioids between April 2009 and February 2020. For the last study year, we examined cross-sectional associations between resident characteristics and concurrent use of opioids with BZDs or gabapentinoids. Linked data on nursing home residents from clinical and health administrative databases was used. The yearly proportions of residents who were dispensed an opioid concurrently with a BZD or gabapentinoid were plotted with percent change derived from log-binomial regression models. Separate modified Poisson regression models estimated resident-level correlates of concurrent use of opioids with BZDs or gabapentinoids.

RESULTS

Over the study period, among residents dispensed an opioid there was a 53.2% relative decrease (30.7% to 14.4%) in concurrent BZD and a 505.4% relative increase (4.4% to 26.6%) in concurrent gabapentinoid use. In adjusted models, increasing age and worsening cognition were inversely associated with the concurrent use of both classes, but most other significantly related covariates were unique to each drug class (e.g., sex and anxiety disorders for BZD, pain severity and presence of pain-related conditions for gabapentinoids).

CONCLUSIONS

Co-administration of BZDs or gabapentinoids in Ontario nursing home residents dispensed opioids remains common, but the pattern of co-use has changed over time. Observed covariates of concurrent use in 2019/20 suggest distinct but overlapping resident populations requiring consideration of the relative risks versus benefits of this co-use and monitoring for potential harm.

Continuing professional development needs in pain management for Canadian health care professionals: A cross sectional survey

Background

Continuing professional development is an important means of improving access to effective patient care. Although pain content has increased significantly in prelicensure programs, little is known about how postlicensure health professionals advance or maintain competence in pain management.

Aims

The aim of this study was to investigate Canadian health professionals' continuing professional development needs, activities, and preferred modalities for pain management.

Methods

This study employed a cross-sectional self-report web survey.

Results

The survey response rate was 57% (230/400). Respondents were primarily nurses (48%), university educated (95%), employed in academic hospital settings (62%), and had ≥11 years postlicensure experience (70%). Most patients (>50%) cared for in an average week presented with pain. Compared to those working in nonacademic settings, clinicians in academic settings reported significantly higher acute pain assessment competence (mean 7.8/10 versus 6.9/10; P < 0.002) and greater access to pain specialist consultants (73% versus 29%; P < 0.0001). Chronic pain assessment competence was not different between groups. Top learning needs included neuropathic pain, musculoskeletal pain, and chronic pain. Recently completed and preferred learning modalities respectively were informal and work-based: reading journal articles (56%, 54%), online independent learning (44%, 53%), and attending hospital rounds (43%, 42%); 17% had not completed any pain learning activities in the past 12 months. Respondents employed in nonacademic settings and nonphysicians were more likely to use pocket cards, mobile apps, and e-mail summaries to improve pain management.

Conclusions

Canadian postlicensure health professionals require greater access to and participation in interactive and multimodal methods of continuing professional development to facilitate competency in evidence-based pain management.

Sodium aescinate ameliorates chronic neuropathic pain in mice via suppressing JNK/p-38-mediated microglia activation.. [DOI: 10.21203/rs.3.rs-2469196/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

A study confirmed that sodium aescinate (SA), a traditional Chinese medicine extracted from the dried ripe fruits of the aescin plant chestnut, can effectively relieve bone cancer pain, but its role in neuropathic pain (NP) remains confused. This study aimed to investigate whether SA has a protective effect on NP and its underlying mechanisms. Thirty mice were randomly divided into three groups (n = 10 per group): sham + vehicle, chronic contraction injury (CCI) + vehicle, CCI + SA. SA (40 µg/L, intrathecal injection) was administered once daily for 5 consecutive days starting on day 7 after surgery. The mechanical withdrawal thresholds (paw withdraw threshold, PWT) of the contralateral and ipsilateral paws of mice in each group were subsequently detected daily. The results displayed that repeated SA treatment could prominently increase the reduction of PWT induced by CCI in the ipsilateral paw of mice. Downregulation of p- c-Jun N-terminal kinase (JNK) and p-p38 protein levels and reduction of microglial activation marker Iba-1-positive ratio, M1/M2 ratio of microglia, and proinflammatory factors, including tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and IL-6, in the spinal cords of CCI-mice was observed after intrathecal SA. The above data illustrated that SA might suppress the activation of microglia and neuroinflammation by selectively inhibiting the JNK/p38 signaling pathway, which in turn alleviated CCI-induced NP in mice.

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

BACKGROUND

Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications.

METHODS

Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long-term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain.

RESULTS

Our study sample includes 973,074 persons living with ADRD who had a long-term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain.

CONCLUSIONS

Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk-benefit for dementia care warrants further scrutiny.

Chronic pain conditions and use of analgesics among nursing home patients with dementia

ABSTRACT

Pain management for patients with dementia is challenging because many experience pain while being unable to communicate their pain. The aim of this study was to describe pain, pain management, and to perform a thorough clinical examination of chronic pain conditions among patients with dementia. Residents (n = 498) from 12 nursing homes were assessed for dementia (Clinical Dementia Rating scale [CDR]) and for pain with the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) assessment form. Of all examined nursing home patients with dementia, 68% had moderate or severe chronic pain. The final study population (n = 262) with a CDR score of ≥1 and a MOBID-2 score of ≥3 were examined by pain expert physicians for chronic pain and categorized according to the International Classification of Disease (ICD-10/-11) classification systems. More than half (54.6%) had chronic pain conditions without underlying disease classified as chronic primary pain by ICD-11. Chronic widespread pain was the most prevalent (14.5%) followed by nonspecific pain from the back (13.4%), whereas the most prevalent chronic secondary pain conditions were chronic pain caused by osteoarthritis (15.4%) and stroke (8.0%). One-fourth received opioids, which was significantly associated with severe pain ( P < 0.001) compared with moderate pain, although no significant association was found between opioid use and the type of pain condition. Although knowledge of the severity and specific types of pain conditions is recommended to direct the choice of treatment, these areas are not sufficiently explored in the nursing home populations with dementia and may hinder a better treatment of pain in this population.

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

Background

Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management.

Objectives

The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity.

Methods

We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018–2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents’ health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents’ characteristics and opioid use, overall and across strata capturing pain frequency and intensity.

Results

Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57–0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66–0.72) or dementia (aRR = 0.76, 95% CI 0.74–0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32–1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74–1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28–1.38), or antidepressants (aRR = 1.31, 95% CI 1.27–1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata.

Conclusions

Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00972-9.