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Brown MT, Cornblath DR, Koltzenburg M, Gorson KC, Hickman A, Pixton GC, Gaitonde P, Viktrup L, West CR. Peripheral Nerve Safety of Nerve Growth Factor Inhibition by Tanezumab: Pooled Analyses of Phase III Clinical Studies in Over 5000 Patients with Osteoarthritis. Clin Drug Investig 2023; 43:551-563. [PMID: 37460782 DOI: 10.1007/s40261-023-01286-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Tanezumab, a humanized anti-nerve growth factor antibody, was developed for the treatment of pain associated with osteoarthritis. Due to its mechanism of action, peripheral nerve safety was assessed in all clinical studies. OBJECTIVES To summarize the neurological safety of intravenous (IV) and subcutaneous (SC) tanezumab versus placebo in patients with osteoarthritis. METHODS Data were pooled from 3389 patients across seven studies that investigated IV administration, and from 1840 patients across three studies that investigated SC administration. The treatment period of each study ranged from 16 to 24 weeks, and follow-up periods ranged from 8 to 24 weeks. Neurological safety evaluations focused on adverse events (AEs) of abnormal peripheral sensation (APS), neurologic examinations, and consultations. RESULTS Across datasets, the incidence of AEs of APS was higher in tanezumab groups versus placebo. Paresthesia and hypoesthesia were the most frequently reported AEs in tanezumab-treated patients, compared with placebo. In both datasets, most AEs were of mild severity, resolved, and rarely resulted in discontinuation. In all treatment groups in both IV and SC studies, over 90% of patients had no new or worsened neurological examination abnormalities at the last study visit. Across datasets, mononeuropathy was diagnosed more frequently in tanezumab groups compared with placebo. Polyneuropathy was diagnosed in ≤ 0.9% of patients in tanezumab and placebo groups. CONCLUSIONS Tanezumab IV or SC had an increased incidence of AEs of APS, such as paresthesia and hypoesthesia, and diagnoses of mononeuropathy compared with placebo. However, tanezumab was not associated with generalized peripheral neuropathy. CLINICALTRIALS GOV IDENTIFIERS NCT00733902, NCT00744471, NCT00830063, NCT00863304, NCT00863772, NCT01089725, NCT00985621, NCT02697773, and NCT02709486.
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Affiliation(s)
| | - David R Cornblath
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Martin Koltzenburg
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
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Preston FG, Riley DR, Azmi S, Alam U. Painful Diabetic Peripheral Neuropathy: Practical Guidance and Challenges for Clinical Management. Diabetes Metab Syndr Obes 2023; 16:1595-1612. [PMID: 37288250 PMCID: PMC10243347 DOI: 10.2147/dmso.s370050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023] Open
Abstract
Painful diabetic peripheral neuropathy (PDPN) is present in nearly a quarter of people with diabetes. It is estimated to affect over 100 million people worldwide. PDPN is associated with impaired daily functioning, depression, sleep disturbance, financial instability, and a decreased quality of life. Despite its high prevalence and significant health burden, it remains an underdiagnosed and undertreated condition. PDPN is a complex pain phenomenon with the experience of pain associated with and exacerbated by poor sleep and low mood. A holistic approach to patient-centred care alongside the pharmacological therapy is required to maximise benefit. A key treatment challenge is managing patient expectation, as a good outcome from treatment is defined as a reduction in pain of 30-50%, with a complete pain-free outcome being rare. The future for the treatment of PDPN holds promise, despite a 20-year void in the licensing of new analgesic agents for neuropathic pain. There are over 50 new molecular entities reaching clinical development and several demonstrating benefit in early-stage clinical trials. We review the current approaches to its diagnosis, the tools, and questionnaires available to clinicians, international guidance on PDPN management, and existing pharmacological and non-pharmacological treatment options. We synthesise evidence and the guidance from the American Association of Clinical Endocrinology, American Academy of Neurology, American Diabetes Association, Diabetes Canada, German Diabetes Association, and the International Diabetes Federation into a practical guide to the treatment of PDPN and highlight the need for future research into mechanistic-based treatments in order to prioritise the development of personalised medicine.
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Affiliation(s)
- Frank G Preston
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
| | - David R Riley
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Uazman Alam
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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Different Dosage Regimens of Tanezumab for the Treatment of Chronic Low Back Pain: A Meta-analysis of Randomized Controlled Trials. Clin Neuropharmacol 2023; 46:6-16. [PMID: 36542785 DOI: 10.1097/wnf.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy of different dosage regimens of tanezumab among individuals living with chronic low back pain (CLBP). METHODS PubMed, Embase, The Cochrane Library, and other databases were searched from inception until August 2021. Randomized controlled trials investigating the efficacy and safety of tanezumab in individuals with CLBP were included. Data were extracted independently by 2 investigators and assessed the study quality by the Cochrane risk-of-bias tool. The measurements include low back pain intensity and Roland-Morris Disability Questionnaire. The incidence of adverse events and serious adverse events was set to assess the safety of tanezumab for CLBP. RESULTS AND DISCUSSION Three high-quality randomized controlled trials with 3414 patients were finally included in our analysis. Tanezumab, respectively, led to a notable decrease compared with placebo in low back pain intensity (mean difference, -0.62; 95% confidence interval [CI], -0.77 to -0.46; P < 0.01) and Roland-Morris Disability Questionnaire (mean difference, -0.64; 95% CI, -0.80 to -0.47; P = 0.01). In addition, no significant difference existed between tanezumab and placebo groups (risk ratio, 1.10; 95% CI, 0.81-1.49; P = 0.55) in the adverse events and (risk ratio, 1.06; 95% CI, 0.34-3.27; P = 0.93) serious adverse events. CONCLUSIONS Intravenous and subcutaneous tanezumab injections as treatment for improving CLBP have promising clinical application as its great improvement on all efficacy and its controllable safety issues. Furthermore, intravenous and subcutaneous tanezumab injections were proved to achieve excellent and long-term curative effect on CLBP through our subgroup analysis and comparison.
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Sachau J, Sendel M, Péchard M, Schnabel K, Schmieg I, Medkour T, Ecochard L, Woischnik M, Liedgens H, Pogatzki-Zahn E, Baron R, Bouhassira D. Patient Reported Outcome Measures in Chronic Neuropathic Pain Clinical Trials - A Systematic Literature Review. THE JOURNAL OF PAIN 2023; 24:38-54. [PMID: 36216128 DOI: 10.1016/j.jpain.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/22/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
In neuropathic pain clinical trials, the patient's perspective is often insufficiently reflected focusing mainly on pain intensity. Comparability of outcome assessment is limited due to heterogenous patient reported outcome measures (PROMs). The MEDLINE, CENTRAL, and Embase databases and reference lists of published meta-analyses were searched. Randomized controlled studies assessing treatment efficacy of drugs for chronic neuropathic pain were included. PROMs were assigned to recommended IMMPACT/NeuPSIG domains: pain intensity, pain other aspects, physical functioning, emotional functioning, global improvement and satisfaction, adverse events, participant disposition. Domains and PROMs were compared regarding the publication year and methodological quality of the studies. Within the 251 included studies 200 PROMs were used with 27 being recommended by IMMPACT/NeuPSIG. The number of domains was higher in high/moderate quality studies. The (sub-) domains 'physical functioning', 'global improvement and satisfaction', and 'neuropathic pain quality' were assessed more frequently in high/moderate quality studies and those published after 2011. Recent studies and those of better quality more often used the recommended PROMs. Although neuropathic assessment via PROMs has improved, there is still a high heterogeneity. A standardized core set of outcome domains and should be defined to improve neuropathic pain treatment and to achieve better comparability of clinical trials. Perspective: This systematic literature review assesses the use of patient reported outcome measures (PROMs) in chronic neuropathic pain. The results show that there is still a high heterogeneity, highlighting the need for a standardized core set of outcome domains and PROMs to improve comparability of clinical trials and neuropathic pain treatment.
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Affiliation(s)
- Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany.
| | - Manon Sendel
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Marie Péchard
- Inserm U987, APHP, UVSQ, Paris-Saclay University, CHU Ambroise Paré, Boulogne-Billancourt, France
| | - Kathrin Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Münster
| | - Iris Schmieg
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Münster
| | - Terkia Medkour
- Inserm U987, APHP, UVSQ, Paris-Saclay University, CHU Ambroise Paré, Boulogne-Billancourt, France
| | | | | | | | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Münster
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Didier Bouhassira
- Inserm U987, APHP, UVSQ, Paris-Saclay University, CHU Ambroise Paré, Boulogne-Billancourt, France
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Liang ZJ, Tan J, Tang L, Xie ZB, Chen GJ, Liu GJ, Yuan L, Wang KX, Ding HP, Qiu H, Wang Q, Wang GF, Chen YL, Wang CH. NGF monoclonal antibody DS002 alleviates chemotherapy-induced peripheral neuropathy in rats. Acta Pharmacol Sin 2022; 43:2841-2847. [PMID: 35468993 PMCID: PMC9622678 DOI: 10.1038/s41401-022-00904-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/27/2022] [Indexed: 12/25/2022] Open
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN) is one of the pervasive side effects of chemotherapy, leading to poor quality of life in cancer patients. Discovery of powerful analgesics for CIPN is an urgent and substantial clinical need. Nerve growth factor (NGF), a classic neurotrophic factor, has been identified as a potential therapeutic target for pain. In this study, we generated a humanized NGF monoclonal antibody (DS002) that most effectively blocked the interaction between NGF and tropomyosin receptor kinase A (TrkA). We showed that DS002 blocked NGF binding to TrkA in a dose-dependent manner with an IC50 value of 6.6 nM; DS002 dose-dependently inhibited the proliferation of TF-1 cells by blocking the TrkA-mediated downstream signaling pathway. Furthermore, DS002 did not display noticeable species differences in its binding and blocking abilities. In three chemotherapy-induced rat models of CIPN, subcutaneous injection of DS002 produced a significant prophylactic effect against paclitaxel-, cisplatin- and vincristine-induced peripheral neuropathy. In conclusion, we demonstrate for the first time that an NGF inhibitor effectively alleviates pain in animal models of CIPN. DS002 has the potential to treat CIPN pain in the clinic.
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Affiliation(s)
- Zhi-Juan Liang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Jie Tan
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
- Shanghai Mabstone Biotechnologies, Ltd., Shanghai, 201203, China
| | - Lei Tang
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
| | - Zuo-Bin Xie
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
| | - Gan-Jun Chen
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
- Shanghai Mabstone Biotechnologies, Ltd., Shanghai, 201203, China
| | - Guo-Jian Liu
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
| | - Lin Yuan
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
| | - Kai-Xin Wang
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
| | - Hua-Ping Ding
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
| | - Hong Qiu
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Qi Wang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Gui-Feng Wang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yi-Li Chen
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China
- Shanghai Mabstone Biotechnologies, Ltd., Shanghai, 201203, China
| | - Chun-He Wang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China.
- University of Chinese Academy of Sciences, Beijing, 100049, China.
- Dartsbio Pharmaceuticals, Ltd., Zhongshan, 528400, China.
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Neurological safety of subcutaneous tanezumab versus NSAID in patients with osteoarthritis. J Neurol Sci 2022; 434:120184. [DOI: 10.1016/j.jns.2022.120184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/27/2021] [Accepted: 02/10/2022] [Indexed: 11/15/2022]
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Zhao D, Luo MH, Pan JK, Zeng LF, Liang GH, Han YH, Liu J, Yang WY. Based on minimal clinically important difference values, a moderate dose of tanezumab may be a better option for treating hip or knee osteoarthritis: a meta-analysis of randomized controlled trials. Ther Adv Musculoskelet Dis 2022; 14:1759720X211067639. [PMID: 35069811 PMCID: PMC8777347 DOI: 10.1177/1759720x211067639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/01/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Tanezumab is a nerve growth factor monoclonal antibody that may regulate pain
in hip or knee osteoarthritis (OA). This meta-analysis was performed to
evaluate the efficacy and safety of low and moderate doses of tanezumab in
treating hip or knee OA. Methods: PubMed, EMBASE, the Cochrane Library, and Web of Science were comprehensively
searched for clinical trials published before 1 May 2021. Patients were
assessed via efficacy and safety outcomes. Results: Twelve randomized controlled trials including 6022 patients were identified.
Both low and moderate doses of tanezumab significantly improved efficacy
outcomes. However, only the point estimates (mean difference, MD) of
moderate-dose tanezumab significantly exceeded the minimal clinically
important differences (MCIDs). There were no significant differences in the
incidence of treatment-related adverse events (AEs), withdrawals due to AEs,
serious AEs, and total joint replacement between the tanezumab and placebo
groups, whereas the incidence of AEs was higher in the tanezumab group
(relative risk, RR = 1.10; 95% confidence interval, 95% CI = 1.04–1.17). The
incidence of rapidly progressive OA was significantly higher in the combined
low- and moderate-dose tanezumab groups than in the placebo group
(RR = 5.01; 95% CI = 1.17–21.33). Furthermore, both low and moderate doses
of tanezumab significantly increased the incidence of abnormal peripheral
sensation (RR = 1.99, 95% CI = 1.21–3.28; RR = 2.64, 95% CI = 1.91–3.67,
respectively). Compared with nonsteroidal anti-inflammatory drugs (NSAIDs)
and opioids, tanezumab showed significantly improved efficacy outcomes
(p < 0.05). However, the point estimates (MD) of
tanezumab were not greater than the MCID. Pooled analysis showed no
significant differences between tanezumab and NSAIDs and opioids in safety
outcomes (p > 0.05). Conclusion: Tanezumab is efficacious in patients with hip or knee OA. Tanezumab is
relatively well tolerated and safe but increases the incidence of AEs and
reversible abnormal peripheral sensation. Additional studies on the
occurrence of rapidly progressive OA are needed. A moderate dose of
tanezumab may maximize the benefits for hip or knee OA.
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Affiliation(s)
- Di Zhao
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Ming-hui Luo
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jian-ke Pan
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ling-feng Zeng
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Gui-hong Liang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan-hong Han
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun Liu
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
- Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
- The Fifth Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei-yi Yang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou 510120, China
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Bönhof GJ, Herder C, Ziegler D. Diagnostic Tools, Biomarkers, and Treatments in Diabetic polyneuropathy and Cardiovascular Autonomic Neuropathy. Curr Diabetes Rev 2022; 18:e120421192781. [PMID: 33845748 DOI: 10.2174/1573399817666210412123740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Abstract
The various manifestations of diabetic neuropathy, including distal symmetric sensorimotor polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN), are among the most prevalent chronic complications of diabetes. Major clinical complications of diabetic neuropathies, such as neuropathic pain, chronic foot ulcers, and orthostatic hypotension, are associated with considerable morbidity, increased mortality, and diminished quality of life. Despite the substantial individual and socioeconomic burden, the strategies to diagnose and treat diabetic neuropathies remain insufficient. This review provides an overview of the current clinical aspects and recent advances in exploring local and systemic biomarkers of both DSPN and CAN assessed in human studies (such as biomarkers of inflammation and oxidative stress) for better understanding of the underlying pathophysiology and for improving early detection. Current therapeutic options for DSPN are (I) causal treatment, including lifestyle modification, optimal glycemic control, and multifactorial risk intervention, (II) pharmacotherapy derived from pathogenetic concepts, and (III) analgesic treatment against neuropathic pain. Recent advances in each category are discussed, including non-pharmacological approaches, such as electrical stimulation. Finally, the current therapeutic options for cardiovascular autonomic complications are provided. These insights should contribute to a broader understanding of the various manifestations of diabetic neuropathies from both the research and clinical perspectives.
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Affiliation(s)
- Gidon J Bönhof
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Christian Herder
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
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Jingxuan L, Litian M, Jianfang F. Different Drugs for the Treatment of Painful Diabetic Peripheral Neuropathy: A Meta-Analysis. Front Neurol 2021; 12:682244. [PMID: 34777192 PMCID: PMC8585758 DOI: 10.3389/fneur.2021.682244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 01/16/2023] Open
Abstract
Objective: To systematically evaluate the effects of different drugs for the treatment of painful diabetic peripheral neuropathy. Methods: All literature from PubMed, Embase, and Cochrane Central Register of Controlled Trials published over the past 12 years (from January 1, 2008 to June 1, 2020) was searched, and two reviewers independently assessed study eligibility, continuous data extraction, independent assessment of bias risk, and graded strength of evidence. The pain score was used as the main result, and 30 and 50% pain reduction and adverse events were used as secondary results. Results: A total of 37 studies were included. Pregabalin, duloxetine, tapentadol, lacosamide, mirogabalin, and capsaicin were all more effective than placebo in alleviating the pain associated with diabetic peripheral neuropathy, while ABT-894 and gabapentin showed no significant effect. In addition, the efficacy of buprenorphine, tanezumab, fulranumab and others could not be concluded due to insufficient studies. Conclusion: Pregabalin and duloxetine showed good therapeutic effects on painful DPN, but adverse events were also significant. The analgesic effects of ABT-894 and gabapentin need to be further studied with longer and larger RCTs. As an opioid drug, tapentadol has a good analgesic effect, but due to its addiction, it needs to be very cautious in clinical use. Although lacosamide, mirogabalin, and capsaicin are more effective than placebo, the therapeutic effect is weaker than pregabalin. For the results of our meta-analysis, long-term studies are still needed to verify their efficacy and safety in the future. Systematic Review Registration: PROSPERO, identifier: CRD42020197397.
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Affiliation(s)
- Lian Jingxuan
- Department of Endocrinology, Xijing Hospital of Air Force Medical University, Xi'an, China
| | - Ma Litian
- Department of Gastroenterology, Xijing Hospital of Air Force Medical University, Xi'an, China
| | - Fu Jianfang
- Department of Endocrinology, Xijing Hospital of Air Force Medical University, Xi'an, China
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Sánchez-Robles EM, Girón R, Paniagua N, Rodríguez-Rivera C, Pascual D, Goicoechea C. Monoclonal Antibodies for Chronic Pain Treatment: Present and Future. Int J Mol Sci 2021; 22:ijms221910325. [PMID: 34638667 PMCID: PMC8508878 DOI: 10.3390/ijms221910325] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic pain remains a major problem worldwide, despite the availability of various non-pharmacological and pharmacological treatment options. Therefore, new analgesics with novel mechanisms of action are needed. Monoclonal antibodies (mAbs) are directed against specific, targeted molecules involved in pain signaling and processing pathways that look to be very effective and promising as a novel therapy in pain management. Thus, there are mAbs against tumor necrosis factor (TNF), nerve growth factor (NGF), calcitonin gene-related peptide (CGRP), or interleukin-6 (IL-6), among others, which are already recommended in the treatment of chronic pain conditions such as osteoarthritis, chronic lower back pain, migraine, or rheumatoid arthritis that are under preclinical research. This narrative review summarizes the preclinical and clinical evidence supporting the use of these agents in the treatment of chronic pain.
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11
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Wang M, Zhang Z, Mi J, Wang G, Tian L, Zhao Y, Li X, Li X, Wang X. Interventional Clinical Trials on Diabetic Peripheral Neuropathy: A Retrospective Analysis. J Pain Res 2021; 14:2651-2664. [PMID: 34471381 PMCID: PMC8405224 DOI: 10.2147/jpr.s320364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022] Open
Abstract
Aims/Introduction Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes. At present, there is no comprehensive summary of the clinical trials related to DPN. In this article, we summarized the basic characteristics of the interventional clinical trials pertaining to DPN to determine the current status of research in this field and the existing issues. Materials and Methods We searched the World Health Organization International Clinical Trial Registration Platform (ICTRP), PubMed and Web of Science for clinical trials from 2005 to April 2021 and extracted 149 registered and 459 published clinical trials on DPN. We summarized the characteristics of the clinical trials, including the source registration, recruitment status, stage, age group, allocation method, intervention, end point classification, funding source, and treatment. Results After excluding noninterventional and nontreatment trials, 149 registered clinical trials out of 292 records from 12 registration centers and 459 published articles were included in this study. Among the registered trials, 43% had been completed, and 34.4% had been published in peer-reviewed journals. Among these trials, more than half used random allocation and blinded placebo-controlled methodologies. A total of 40.3% of the trials were multicenter studies, 63.8% of the treatments were drug therapies, and the endpoint classifications of 49% were efficacy and safety. Of the 459 published interventional clinical trials on DPN, 69.7% of the trials used drug treatments; more than half were randomized, double-blind, placebo-controlled clinical trials; 94.1% had positive outcomes; 46.4% had a target size of 50; and 22.9% were multicenter. Conclusion This paper systematically summarizes the current status of interventional trials on DPN registered in the ICTRP and published clinical trials and provides a reference for the development of high-quality intervention strategies for DPN in the future.
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Affiliation(s)
- Mengmeng Wang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Zepeng Zhang
- Research Center of Traditional Chinese Medicine, The First Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China.,College of Acupuncture and Tuina, Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Jia Mi
- Department of Endocrinology, The First Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Guoqiang Wang
- Department of Endocrinology, The First Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Lulu Tian
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Yunyun Zhao
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Xiaomin Li
- Research Center of Traditional Chinese Medicine, The First Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China.,Acupuncture and Massage Center, The Third Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Xiangyan Li
- Jilin Ginseng Academy, Key Laboratory of Active Substances and Biological Mechanisms of Ginseng Efficacy, Ministry of Education, Jilin Provincial Key Laboratory of Bio-Macromolecules of Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
| | - Xiuge Wang
- Department of Endocrinology, The First Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin, People's Republic of China
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12
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Pergolizzi JV, Varrassi G, Magnusson P, Breve F, Raffa RB, Christo PJ, Chopra M, Paladini A, LeQuang JA, Mitchell K, Coluzzi F. Pharmacologic agents directed at the treatment of pain associated with maladaptive neuronal plasticity. Expert Opin Pharmacother 2021; 23:105-116. [PMID: 34461795 DOI: 10.1080/14656566.2021.1970135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The definition of nociplastic pain in 2016 has changed the way maladaptive chronic pain is viewed in that it may emerge without neural lesions or neural disease. Many endogenous and pharmacologic substances are being investigated for their role in treating the pain associated with neuronal plasticity. AREAS COVERED The authors review promising pharmacologic agents for the treatment of pain associated with maladaptive neuronal plasticity. The authors then provide the reader with their expert opinion and provide their perspectives for the future. EXPERT OPINION An imbalance between the amplification of ascending pain signals and the poor activation of descending inhibitory signals may be at the root of many chronic pain syndromes. The inhibitory activity of noradrenaline reuptake may play a role in neuropathic and nociplastic analgesia. A better understanding of the brain's pain matrix, its signaling cascades, and the complex bidirectional communication between the immune system and the nervous system may help meet the urgent and unmet medical need for safe, effective chronic pain treatment, particularly for pain with a neuropathic and/or nociplastic component.
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Affiliation(s)
| | | | - Peter Magnusson
- Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle, Sweden.,Department of Medicine, Cardiology Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Frank Breve
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, USA
| | - Robert B Raffa
- College of Pharmacy (Adjunct), University of Arizona, Tucson, USA.,Temple University School of Pharmacy (Professor Emeritus), Philadelphia, USA
| | - Paul J Christo
- Associate Professor, the Johns Hopkins School of Medicine, Baltimore, USA
| | | | | | | | | | - Flaminia Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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13
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Helou AY, Martins DO, Arruda BP, de Souza MC, Cruz-Ochoa NA, Nogueira MI, Chacur M. Neonatal anoxia increases nociceptive response in rats: Sex differences and lumbar spinal cord and insula alterations. Int J Dev Neurosci 2021; 81:686-697. [PMID: 34342028 DOI: 10.1002/jdn.10145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/15/2022] Open
Abstract
Neonatal anoxia is a well-known world health problem that results in neurodevelopmental deficits, such as sensory alterations that are observed in patients with cerebral palsy and autism disorder, for which oxygen deprivation is a risk factor. Nociceptive response, as part of the sensory system, has been reported as altered in these patients. To determine whether neonatal oxygen deprivation alters nociceptive sensitivity and promotes medium- and long-term inflammatory feedback in the central nervous system, Wistar rats of around 30 h old were submitted to anoxia (100% nitrogen flux for 25 min) and evaluated on PND23 (postpartum day) and PND90. The nociceptive response was assessed by mechanical, thermal, and tactile tests in the early postnatal and adulthood periods. The lumbar spinal cord (SC, L4-L6) motor neurons (MNs) and the posterior insular cortex neurons were counted and compared with their respective controls after anoxia. In addition, we evaluated the possible effect of anoxia on the expression of astrocytes in the SC at adulthood. The results showed increased nociceptive responses in both males and females submitted to anoxia, although these responses were different according to the nociceptive stimulus. A decrease in MNs in adult anoxiated females and an upregulation of GFAP expression in the SC were observed. In the insular cortex, a decrease in the number of cells of anoxiated males was observed in the neonatal period. Our findings suggest that oxygen-deprived nervous systems in rats may affect their response at the sensorimotor pathways and respective controlling centers with sex differences, which were related to the used stimulus.
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Affiliation(s)
- Ammir Yacoub Helou
- Neurosciences Laboratory, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Daniel Oliveira Martins
- Laboratory of Functional Neuroanatomy of Pain, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Bruna Petrucelli Arruda
- Neurosciences Laboratory, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Matheus Cerussi de Souza
- Neurosciences Laboratory, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Natalia Andrea Cruz-Ochoa
- Neurosciences Laboratory, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Maria Inês Nogueira
- Neurosciences Laboratory, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Marucia Chacur
- Laboratory of Functional Neuroanatomy of Pain, Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
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14
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Berenbaum F, Schnitzer TJ, Kivitz AJ, Viktrup L, Hickman A, Pixton G, Brown MT, Davignon I, West CR. General Safety and Tolerability of Subcutaneous Tanezumab for Osteoarthritis: A Pooled Analysis of 3 Randomized, Placebo-Controlled Trials. Arthritis Care Res (Hoboken) 2021; 74:918-928. [PMID: 33973384 PMCID: PMC9310640 DOI: 10.1002/acr.24637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/07/2021] [Accepted: 04/27/2021] [Indexed: 11/08/2022]
Abstract
Objective This pooled analysis of 3 randomized, placebo‐controlled trials (16–24 week treatment and 8–24 week follow‐up) assessed safety of subcutaneous tanezumab (2.5–10 mg every 8 weeks) in 1,840 patients with hip or knee osteoarthritis. Methods Overall treatment‐emergent adverse events (TEAEs) and TEAEs of abnormal peripheral sensation (APS) were prospectively assessed in 3 trials. Joint safety events (primary osteonecrosis, rapidly progressive osteoarthritis [RPOA], subchondral insufficiency fracture, and pathologic fracture; adjudicated by an independent expert committee) and TEAEs potentially associated with sympathetic neuropathy were prospectively assessed in 2 trials. Results During the treatment period, overall TEAE rates were 51.7% for placebo and 39.5–54.8% for tanezumab 2.5–10 mg; treatment discontinuation rates were 2.0% for placebo and 0–1.3% for tanezumab. Rates of composite joint safety events (predominantly RPOA type 1) over the treatment plus follow‐up period were 0% for placebo and 0.5–3.2% for tanezumab 2.5–5 mg (5 mg was statistically greater than placebo); total joint replacement rates with tanezumab (5.9–7.0%) were not significantly different from placebo (4.5%). Rates of TEAEs of APS (predominantly paresthesia and hypoesthesia) were 2.2% for placebo and 3.2–12.8% for tanezumab 2.5–10 mg. Rates of TEAEs potentially associated with sympathetic neuropathy (predominantly bradycardia and orthostatic hypotension) were 0.8% for placebo and 0.5–2.8% for tanezumab 2.5–5 mg (exposure‐adjusted rates were not significantly different from placebo). Conclusion Tanezumab was generally well tolerated. TEAEs of APS (mostly mild and transient) and joint safety events were infrequent but more common with tanezumab than placebo. A tanezumab dose of 2.5 mg demonstrated a more favorable safety profile than higher doses.
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Affiliation(s)
- Francis Berenbaum
- Sorbonne Université, INSERM, AP-HP Hospital Saint Antoine, Paris, France
| | - Thomas J Schnitzer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alan J Kivitz
- Altoona Center for Clinical Research, Duncansville, Pennsylvania, USA
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Pharmacotherapeutic Options for Managing Neuropathic Pain: A Systematic Review and Meta-Analysis. Pain Res Manag 2021; 2021:6656863. [PMID: 33986899 PMCID: PMC8093054 DOI: 10.1155/2021/6656863] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/20/2021] [Indexed: 01/02/2023]
Abstract
Despite an increasing number of available therapies, the treatment of neuropathic pain remains a major issue. Systematic reviews and meta-analyses indicate that only a minority of patients with neuropathic pain have an adequate response to pharmacological treatment and that most drugs have dose-limiting side effects. We conducted a systematic review and meta-analysis of randomised controlled trials published in the last five years. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov). Two authors independently selected studies for inclusion, data extraction, and bias assessment. We identified 39 randomised controlled trials and included 16 in the meta-analysis. Trial outcomes were generally modest even for first-line drugs such as tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, and gabapentinoids. Many drugs acting on new pain targets are currently under development. Clinical data are currently available for sodium channel isoform-specific antagonists, anti-nerve growth factor molecules, and fatty acid amide hydrolase inhibitors.
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16
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Rastogi A, Jude EB. Novel treatment modalities for painful diabetic neuropathy. Diabetes Metab Syndr 2021; 15:287-293. [PMID: 33484985 DOI: 10.1016/j.dsx.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Painful diabetic neuropathy significantly affects the quality of life in people with diabetic peripheral neuropathy (DPN). Existing pharmacological agents have limited efficacy and development of tolerance is a limitation. METHODS The present review focuses on novel pharmacological (systemic and topical) and non-pharmacological modalities for the alleviation of pain in people with DPN. We identified English language articles concerning studies with novel agents (animal or human) targeting symptomatic relief of painful diabetic neuropathy. RESULTS Though the pathophysiology of pain in DPN is complex, a better understanding of pain pathways (peripheral and central) have helped to identify potential targets for therapeutic success. Studies of pharmacological agents acting on various aspects of pain pathways including μ-opioid receptor agonist- norepinephrine reuptake inhibitor (MONRI), cannabinoid receptor, dual serotonin-nor-adrenergic (SNRI)-and triple dopamine reuptake inhibitor (SNDRI), purinergic receptors and sodium channel v1.7 blockers have undergone trials in humans and shown to improve pain symptoms and quality of life in people with DPN. A few other investigational agents targeting acetylcholine receptor, vanilloid channel, chemokine signaling, micro-RNA or mesenchymal stem cell based therapies (animal studies) have demonstrated promise in alleviation of pain. Topical agents like high-dose lidocaine, capsaicin, clonidine, amitriptyline and ketamine may benefit refractory neuropathic pain. CONCLUSIONS Novel MONRI, SNRI and cannabinoid receptor agonists have shown some promise for neuropathic pain relief in human trials, but await regulatory approvals. However, most of the novel pharmacological agents (systemic or topical) require appropriately powered placebo-controlled studies for clinical usage in painful diabetic neuropathy.
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Affiliation(s)
- A Rastogi
- Foot Care Division, Department of Endocrinology and Metabolism, PGIMER, Chandigarh, 160012, India.
| | - E B Jude
- Diabetes and Endocrinology Department, Tameside and Glossop Integrated Care NHS FT, Ashton Under Lyne, Lancs, OL69RW, UK
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17
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Liampas A, Rekatsina M, Vadalouca A, Paladini A, Varrassi G, Zis P. Pharmacological Management of Painful Peripheral Neuropathies: A Systematic Review. Pain Ther 2020; 10:55-68. [PMID: 33145709 PMCID: PMC8119529 DOI: 10.1007/s40122-020-00210-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/08/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction Peripheral neuropathic pain (PNP) arises either acutely or in the chronic phase of a lesion or disease of the peripheral nervous system and is associated with a notable disease burden. The management of PNP is often challenging. The aim of this systematic review was to evaluate current evidence, derived from randomized controlled trials (RCTs) that have assessed pharmacological interventions for the treatment of PNP due to polyneuropathy (PN). Methods A systematic search of the PubMed database led to the identification of 538 papers, of which 457 were excluded due to not meeting the eligibility criteria, and two articles were identified through screening of the reference lists of the 81 eligible studies. Ultimately, 83 papers were included in this systematic review. Results The best available evidence for the management of painful diabetic polyneuropathy (DPN) is for amitriptyline, duloxetine, gabapentin, pregabalin and venlafaxine as monotherapies and oxycodone as add-on therapy (level II of evidence). Tramadol appears to be effective when used as a monotherapy and add-on therapy in patients with PN of various etiologies (level II of evidence). Weaker evidence (level III) is available on the effectiveness of several other agents discussed in this review for the management of PNP due to PN. Discussion Response to treatment may be affected by the underlying pathophysiological mechanisms that are involved in the pathogenesis of the PN and, therefore, it is very important to thoroughly investigate patients presenting with PNP to determine the causes of this neuropathy. Future RCTs should be conducted to shed more light on the use of pharmacological approaches in patients with other forms of PNP and to design specific treatment algorithms. Electronic supplementary material The online version of this article (10.1007/s40122-020-00210-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Athina Vadalouca
- Pain and Palliative Care Center, Athens Medical Center, Athens, Greece
| | - Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
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18
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Abstract
Supplemental Digital Content is Available in the Text. A ligand-guided, light-activated photosensitizer tool targets TrkA-expressing nociceptors, reversing acute and chronic pain in mice. Nerve growth factor (NGF) and its receptors TrkA and p75 play a key role in the development and function of peripheral nociceptive neurons. Here, we describe novel technology to selectively photoablate TrkA-positive nociceptors through delivery of a phototoxic agent coupled to an engineered NGF ligand and subsequent near-infrared illumination. We demonstrate that this approach allows for on demand and localized reversal of pain behaviors in mouse models of acute, inflammatory, neuropathic, and joint pain. To target peripheral nociceptors, we generated a SNAP-tagged NGF derivative NGFR121W that binds to TrkA/p75 receptors but does not provoke signaling in TrkA-positive cells or elicit pain behaviors in mice. NGFR121W-SNAP was coupled to the photosensitizer IRDye700DX phthalocyanine (IR700) and injected subcutaneously. After near-infrared illumination of the injected area, behavioral responses to nociceptive mechanical and sustained thermal stimuli, but not innocuous stimuli, were substantially reduced. Similarly, in models of inflammatory, osteoarthritic, and neuropathic pain, mechanical hypersensitivity was abolished for 3 weeks after a single treatment regime. We demonstrate that this loss of pain behavior coincides with the retraction of neurons from the skin which then reinnervate the epidermis after 3 weeks corresponding with the return of mechanical hypersensitivity. Thus NGFR121W-SNAP-mediated photoablation is a minimally invasive approach to reversibly silence nociceptor input from the periphery, and control pain and hypersensitivity to mechanical stimuli.
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19
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Neurologic Manifestations of Systemic Disease: Peripheral Nervous System. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Schnitzer TJ, Khan A, Bessette L, Davignon I, Brown MT, Pixton G, Prucka WR, Tive L, Viktrup L, West CR. Onset and maintenance of efficacy of subcutaneous tanezumab in patients with moderate to severe osteoarthritis of the knee or hip: A 16-week dose-titration study. Semin Arthritis Rheum 2020; 50:387-393. [PMID: 32252976 DOI: 10.1016/j.semarthrit.2020.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/13/2020] [Accepted: 03/13/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To examine the onset and maintenance of efficacy of subcutaneous tanezumab for pain relief and functional improvement in difficult-to-treat patients with moderate-to-severe osteoarthritis (OA) in a 16-week dose-titration study (NCT02697773). METHODS Patients were randomized to placebo (placebo group) or tanezumab 2.5 mg at baseline and week 8 (tanezumab 2.5 mg group), or tanezumab 2.5 mg at baseline and tanezumab 5 mg at week 8 (tanezumab 2.5/5 mg group). Analyses included change from baseline in average daily index joint pain and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Physical Function, and treatment responses (WOMAC Pain improvement criteria and Outcome Measures in Rheumatology-Osteoarthritis Research Society International [OMERACT-OARSI] criteria). RESULTS The 696 patients received placebo (n = 232), tanezumab 2.5 mg (n = 231), or tanezumab 2.5/5 mg (n = 233). Average daily index joint pain was statistically significantly improved within the first week (day 3-5) with tanezumab 2.5 mg compared with placebo. On first post-randomization WOMAC measurement (week 2), both tanezumab groups had statistically significant improvements compared with placebo in WOMAC Pain and Physical Function, and more tanezumab-treated patients achieved treatment response criteria (≥30%, ≥50%, or ≥70% reduction in WOMAC Pain or OMERACT-OARSI response). Efficacy was generally maintained throughout the 16-week treatment period. CONCLUSION Subcutaneous tanezumab provided statistically significant improvements compared with placebo in average daily index joint pain within the first week and WOMAC Pain and Physical Function (week 2) that were generally maintained throughout the 16-week treatment period. Tanezumab 5 mg provided only modest additional efficacy over tanezumab 2.5 mg.
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Affiliation(s)
- Thomas J Schnitzer
- Northwestern University Feinberg School of Medicine, 710 N Lake Shore Drive, Room 1020, Chicago, IL 60611, United States.
| | - Arifulla Khan
- Northwest Clinical Research Center, Bellevue, WA, United States
| | | | | | | | | | | | | | - Lars Viktrup
- Eli Lilly and Company, Indianapolis, IN, United States
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22
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Tive L, Bello AE, Radin D, Schnitzer TJ, Nguyen H, Brown MT, West CR. Pooled analysis of tanezumab efficacy and safety with subgroup analyses of phase III clinical trials in patients with osteoarthritis pain of the knee or hip. J Pain Res 2019; 12:975-995. [PMID: 30936738 PMCID: PMC6430070 DOI: 10.2147/jpr.s191297] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose A pooled analysis was conducted to evaluate tanezumab efficacy and safety in patients with osteoarthritis (OA), including subgroup analyses of at-risk patients with diabetes, severe OA symptoms, and those aged ≥65 years. Patients and methods Data from phase III placebo-controlled clinical trials of patients with moderate-to-severe OA of the knee or hip were pooled to evaluate tanezumab efficacy (four trials) and safety (nine trials). Patients received intravenous tanezumab, tanezumab plus an oral NSAID (naproxen, celecoxib, or diclofenac), active comparator (naproxen, celecoxib, diclofenac, or oxycodone), or placebo. Efficacy assessments included change from baseline to week 16 in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function scores, Patient’s Global Assessment (PGA) of OA, and percentage of patients with ≥30%, ≥50%, ≥70%, and ≥90% improvement in WOMAC pain. Safety assessments included adverse event (AE) documentation and physical and neurologic examinations. Results Tanezumab significantly improved all efficacy end points in the overall population. Efficacy in at-risk patient subgroups was similar to the overall population. Incidence of AEs was highest in the tanezumab plus NSAID group and lowest in the placebo group. Incidence of AEs in the tanezumab monotherapy and active comparator groups was similar. Overall incidence of AEs was similar across subgroups. AEs of abnormal peripheral sensation were more frequently reported in tanezumab-treated patients compared with placebo or active comparator. Patients receiving active comparator had a slightly higher incidence of AEs suggestive of postganglionic sympathetic dysfunction. Conclusion Tanezumab consistently provided significant improvement of pain, physical function, and PGA in individuals with OA, including patients with diabetes, severe OA symptoms, or aged ≥65 years. No increased safety risk was observed in at-risk patient subgroups. Trial registration NCT00733902, NCT00744471, NCT00830063, NCT00863304, NCT00809354, NCT00864097, NCT00863772, NCT01089725, NCT00985621.
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Affiliation(s)
| | | | - David Radin
- Stamford Therapeutics Consortium, Stamford, CT, USA
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
Persistent, in particular neuropathic pain affects millions of people worldwide. However, the response rate of patients to existing analgesic drugs is less than 50%. There are several possibilities to increase this response rate, such as optimization of the pharmacokinetic and pharmacodynamic properties of analgesics. Another promising approach is to use prognostic biomarkers in patients to determine the optimal pharmacological therapy for each individual. Here, we discuss recent efforts to identify plasma and CSF biomarkers, as well as genetic biomarkers and sensory testing, and how these readouts could be exploited for the prediction of a suitable pharmacological treatment. Collectively, the information on single biomarkers may be stored in knowledge bases and processed by machine-learning and related artificial intelligence techniques, resulting in the optimal pharmacological treatment for individual pain patients. We highlight the potential for biomarker-based individualized pain therapies and discuss biomarker reliability and their utility in clinical practice, as well as limitations of this approach.
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da Silva JT, Evangelista BG, Venega RA, Seminowicz DA, Chacur M. Anti-NGF treatment can reduce chronic neuropathic pain by changing peripheral mediators and brain activity in rats. Behav Pharmacol 2019; 30:79-88. [DOI: 10.1097/fbp.0000000000000422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nair AS. Tanezumab: Finally a Monoclonal Antibody for Pain Relief. Indian J Palliat Care 2018; 24:384-385. [PMID: 30111960 PMCID: PMC6069623 DOI: 10.4103/ijpc.ijpc_208_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Abhijit S Nair
- Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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26
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Dewanjee S, Das S, Das AK, Bhattacharjee N, Dihingia A, Dua TK, Kalita J, Manna P. Molecular mechanism of diabetic neuropathy and its pharmacotherapeutic targets. Eur J Pharmacol 2018; 833:472-523. [DOI: 10.1016/j.ejphar.2018.06.034] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 06/15/2018] [Accepted: 06/26/2018] [Indexed: 02/07/2023]
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Abstract
Although there is an unmet need for pain medications that are both effective and safe, virtually no novel analgesics have been approved over the past two decades. In view of both experimental and clinical evidence of a major role for nerve growth factor (NGF) in the generation and maintenance of a wide range of pain states, the clinical development of humanised anti-nerve growth factor monoclonal antibodies (anti-NGF mAbs) aroused particular interest. However, the US Food and Drug Administration (FDA) placed a clinical hold on anti-NGF mAb clinical studies in late 2010, first because of reports of serious joint-related adverse events, and afterwards because of sympathetic nervous system safety concerns. The development programmes of tanezumab and fasinumab resumed after the FDA lifted its hold in March 2015, whereas other anti-NGF mAbs were dropped by their sponsors. This article provides an updated review on the analgesic efficacy and safety of anti-NGF agents based on data from fully published studies and public information from websites, and discusses the possible future role of these agents in managing chronic pain. The efficacy of anti-NGF mAbs was highly variable depending on the chronic pain condition studied. The most consistent and convincing results were obtained in patients with symptomatic osteoarthritis of the knee and/or hip. Conversely, studies in non-specific lower back pain and peripheral neuropathic pain generated mixed results. Finally, there was no conclusive evidence of the effectiveness of anti-NGF mAbs in cancer pain and urological chronic pelvic pain syndromes. Treatment-emergent adverse events were similar across anti-NGF mAbs, thus being suggestive of 'class-specific effects'. Although most patients tolerated anti-NGF agents well, neurosensory symptoms occurred frequently, and some patients developed new or worsened peripheral neuropathies. However, the most problematic safety issue was rapidly destructive arthropathies, leading to joint replacement surgery. To date, the aetiologies of joint-related side effects and their pathophysiology have not been clearly elucidated. However, some risk factors have been identified, such as higher doses of anti-NGF mAbs and longer drug exposure, concurrent nonsteroidal anti-inflammatory drug use and pre-existing subchondral insufficiency fractures. Taken together, the present data suggest that low-dose anti-NGF mABs may exhibit a favourable risk-benefit ratio in selected patients with certain chronic pain conditions, especially symptomatic osteoarthritis.
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Bélanger P, West CR, Brown MT. Development of pain therapies targeting nerve growth factor signal transduction and the strategies used to resolve safety issues. J Toxicol Sci 2018; 43:1-10. [PMID: 29415946 DOI: 10.2131/jts.43.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Therapeutic agents commonly used in the management of chronic pain have limited effectiveness and may be associated with issues of dependence and tolerability. Thus, a large unmet medical need exists for the development of safe and effective therapeutics for treatment of chronic pain. A novel approach includes identification of intracellular signals involved in the pain transduction pathway, such as nerve growth factor (NGF). Monoclonal antibodies targeting NGF, such as tanezumab, fulranumab and fasinumab, have been investigated for the treatment of chronic pain conditions. Due to unexpected joint adverse events in clinical studies and concerns about sympathetic nervous system toxicity in animals, these agents were placed on 2 separate partial clinical holds, which were subsequently lifted after rigorous evaluations were conducted to understand how inhibition of NGF impacts safety. To share learnings regarding the rigorous evaluation of clinical and nonclinical safety data which contributed to the removal of these partial clinical holds, this article reviews the rationale for developing agents that target NGF as potential treatments for chronic pain, describes nonclinical and clinical studies of these agents, and describes strategies used to evaluate whether inhibition of NGF has negative effects on joint or sympathetic nervous system safety.
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29
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Park SH, Eber MR, Widner DB, Shiozawa Y. Role of the Bone Microenvironment in the Development of Painful Complications of Skeletal Metastases. Cancers (Basel) 2018; 10:cancers10050141. [PMID: 29747461 PMCID: PMC5977114 DOI: 10.3390/cancers10050141] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/02/2023] Open
Abstract
Cancer-induced bone pain (CIBP) is the most common and painful complication in patients with bone metastases. It causes a significant reduction in patient quality of life. Available analgesic treatments for CIBP, such as opioids that target the central nervous system, come with severe side effects as well as the risk of abuse and addiction. Therefore, alternative treatments for CIBP are desperately needed. Although the exact mechanisms of CIBP have not been fully elucidated, recent studies using preclinical models have demonstrated the role of the bone marrow microenvironment (e.g., osteoclasts, osteoblasts, macrophages, mast cells, mesenchymal stem cells, and fibroblasts) in CIBP development. Several clinical trials have been performed based on these findings. CIBP is a complex and challenging condition that currently has no standard effective treatments other than opioids. Further studies are clearly warranted to better understand this painful condition and develop more effective and safer targeted therapies.
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Affiliation(s)
- Sun H Park
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA.
| | - Matthew R Eber
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA.
| | - D Brooke Widner
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA.
| | - Yusuke Shiozawa
- Department of Cancer Biology and Comprehensive Cancer Center, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA.
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First-in-human randomized clinical trials of the safety and efficacy of tanezumab for treatment of chronic knee osteoarthritis pain or acute bunionectomy pain. Pain Rep 2018; 3:e653. [PMID: 29922745 PMCID: PMC5999411 DOI: 10.1097/pr9.0000000000000653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 02/13/2018] [Accepted: 03/13/2018] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Introduction: The neurotrophin nerve growth factor has a demonstrated role in pain transduction and pathophysiology. Objectives: Two randomized, double-blind, placebo-controlled, phase 1 studies were conducted to evaluate safety, tolerability, and analgesic efficacy of single doses of tanezumab, a humanized anti–nerve growth factor monoclonal antibody, in chronic or acute pain. Methods: In the first study (CL001), patients with moderate to severe pain from osteoarthritis (OA) of the knee received a single intravenous infusion of tanezumab (3–1000 μg/kg) or placebo in a dose-escalation (part 1; N = 42) or parallel-arm (part 2; N = 79) study design. The second study (CL002) was a placebo-controlled dose-escalation (tanezumab 10–1000 μg/kg; N = 50) study in patients undergoing bunionectomy surgery. Results: Adverse event rates were generally similar across treatments. Most adverse events were generally mild to moderate in severity and no patients discontinued as a result of adverse events. Adverse events of abnormal peripheral sensation were more common with higher doses of tanezumab (≥100 μg/kg) than with placebo. These were generally mild to moderate in severity. Tanezumab provided up to 12 weeks of effective analgesia for OA knee pain, with statistically significant improvements at doses ≥100 μg/kg (P < 0.05). By contrast, no trend for analgesic activity was found when tanezumab was administered 8 to 16 hours before bunionectomy. Conclusions: The demonstration of a favorable safety profile and clinical efficacy in OA pain supports clinical development of tanezumab as a potential treatment for chronic pain conditions.
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Iqbal Z, Azmi S, Yadav R, Ferdousi M, Kumar M, Cuthbertson DJ, Lim J, Malik RA, Alam U. Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy. Clin Ther 2018; 40:828-849. [PMID: 29709457 DOI: 10.1016/j.clinthera.2018.04.001] [Citation(s) in RCA: 240] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Diabetic peripheral neuropathy (DPN) is the commonest cause of neuropathy worldwide, and its prevalence increases with the duration of diabetes. It affects approximately half of patients with diabetes. DPN is symmetric and predominantly sensory, starting distally and gradually spreading proximally in a glove-and-stocking distribution. It causes substantial morbidity and is associated with increased mortality. The unrelenting nature of pain in this condition can negatively affect a patient's sleep, mood, and functionality and result in a poor quality of life. The purpose of this review was to critically review the current literature on the diagnosis and treatment of DPN, with a focus on the treatment of neuropathic pain in DPN. METHODS A comprehensive literature review was undertaken, incorporating article searches in electronic databases (EMBASE, PubMed, OVID) and reference lists of relevant articles with the authors' expertise in DPN. This review considers seminal and novel research in epidemiology; diagnosis, especially in relation to novel surrogate end points; and the treatment of neuropathic pain in DPN. We also consider potential new pharmacotherapies for painful DPN. FINDINGS DPN is often misdiagnosed and inadequately treated. Other than improving glycemic control, there is no licensed pathogenetic treatment for diabetic neuropathy. Management of painful DPN remains challenging due to difficulties in personalizing therapy and ascertaining the best dosing strategy, choice of initial pharmacotherapy, consideration of combination therapy, and deciding on defining treatment for poor analgesic responders. Duloxetine and pregabalin remain first-line therapy for neuropathic pain in DPN in all 5 of the major published guidelines by the American Association of Clinical Endocrinologists, American Academy of Neurology, European Federation of Neurological Societies, National Institute of Clinical Excellence (United Kingdom), and the American Diabetes Association, and their use has been approved by the US Food and Drug Administration. IMPLICATIONS Clinical recognition of DPN is imperative for allowing timely symptom management to reduce the morbidity associated with this condition.
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Affiliation(s)
- Zohaib Iqbal
- Department of Endocrinology, Pennine Acute Hospitals NHS Trust, Greater Manchester, United Kingdom
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, United Kingdom
| | - Rahul Yadav
- Department of Endocrinology, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, United Kingdom
| | - Maryam Ferdousi
- Institute of Cardiovascular Science, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, United Kingdom
| | - Mohit Kumar
- Department of Endocrinology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom
| | - Daniel J Cuthbertson
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Jonathan Lim
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Rayaz A Malik
- Institute of Cardiovascular Science, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, United Kingdom; Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, United Kingdom; Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, United Kingdom.
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Patel MK, Kaye AD, Urman RD. Tanezumab: Therapy targeting nerve growth factor in pain pathogenesis. J Anaesthesiol Clin Pharmacol 2018; 34:111-116. [PMID: 29643634 PMCID: PMC5885425 DOI: 10.4103/joacp.joacp_389_15] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In recent years, nerve growth factor (NGF) and the NGF receptor have become potential therapeutic targets in the treatment of acute and chronic pain states. NGF is a neurotrophin involved in regulating the function of sensory and sympathetic neurons during development. Numerous pain states have been linked to elevated levels of NGF and its role in increasing the perception of pain. Tanezumab, a recombinant humanized monoclonal antibody (IgG), was developed to target NGF, binding both circulating and local tissue NGF preventing interaction with the tropomyosin-related kinase-A and p75 receptors. Recent clinical studies with tanezumab in different patient populations to date, including osteoarthritis, low back pain, and diabetic peripheral neuropathy, demonstrate efficacy with few side effects, including transient arthralgias, paresthesias, hypoesthesia, and rarely, osteonecrosis. Anti-NGF antibodies are a novel therapy in pain management and have shown promise in the treatment of certain pain conditions, which at present are poorly treated. Tanezumab offers an exciting new class of analgesics that has the potential to change the treatment of pain.
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Affiliation(s)
- Mona K. Patel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alan D. Kaye
- Departments of Anesthesiology and Pharmacology, Louisiana State University Health Science Center, New Orleans, LA 70112, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Fulranumab in Patients With Pain Associated With Postherpetic Neuralgia and Postraumatic Neuropathy: Efficacy, Safety, and Tolerability Results From a Randomized, Double-blind, Placebo-controlled, Phase-2 Study. Clin J Pain 2017; 33:99-108. [PMID: 27153360 PMCID: PMC5228615 DOI: 10.1097/ajp.0000000000000388] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: Fulranumab is an antibody that specifically neutralizes the biological activity of human nerve growth factor. This multicenter, phase-2, randomized, double-blind (DB), placebo-controlled study evaluated the analgesic efficacy and safety of fulranumab in postherpetic neuralgia (PHN) and posttraumatic neuropathy (PTN) patients. Methods: Patients (18 to 80 y) with inadequately controlled moderate-to-severe pain received study medication (subcutaneous injection) every 4 weeks. PHN patients were randomized (3:2:2:3) to receive either placebo or one of 3 doses of fulranumab: 1 mg (1 mgQ4 wk), 3 mg (3 mgQ4 wk), or 10 mg (10 mgQ4 wk). PTN patients were randomized (1:1) to receive either placebo or fulranumab 10 mgQ4 wk. Results: The US Food and Drug Administration placed a clinical hold (December 23, 2010) on all trials of antinerve growth factor drugs, including fulranumab, due to identified risks of osteonecrosis or rapidly progressing osteoarthritis; therefore, only 49 (of 150 planned) PHN patients and 34 (of 50 planned) PTN patients completed the DB efficacy evaluation. There was no significant difference (P>0.05, fulranumab vs. placebo) for change in 7-day average of daily pain intensity scores from DB baseline to end of 12-week DB efficacy phase in PHN or PTN patients (primary endpoint). No significant difference was found with fulranumab versus placebo (P>0.05) in other efficacy measures in either PHN or PTN patients. The most common treatment-emergent adverse events (>10% incidence) in PTN patients were sinusitis, carpal tunnel syndrome, and headache, whereas in PHN patients it was arthralgia. Discussion: Fulranumab did not demonstrate efficacy in either PHN or PTN patients, but was generally well-tolerated in this small underpowered and abbreviated study.
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Loudon P, Siebenga P, Gorman D, Gore K, Dua P, van Amerongen G, Hay JL, Groeneveld GJ, Butt RP. Demonstration of an anti-hyperalgesic effect of a novel pan-Trk inhibitor PF-06273340 in a battery of human evoked pain models. Br J Clin Pharmacol 2017; 84:301-309. [PMID: 29178434 DOI: 10.1111/bcp.13448] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 08/30/2017] [Accepted: 09/23/2017] [Indexed: 02/06/2023] Open
Abstract
AIM Inhibitors of nerve growth factor (NGF) reduce pain in several chronic pain indications. NGF signals through tyrosine kinase receptors of the tropomyosin-related kinase (Trk) family and the unrelated p75 receptor. PF-06273340 is a small molecule inhibitor of Trks A, B and C that reduces pain in nonclinical models, and the present study aimed to investigate the pharmacodynamics of this first-in-class molecule in humans. METHODS A randomized, double-blind, single-dose, placebo- and active-controlled five-period crossover study was conducted in healthy human subjects (NCT02260947). Subjects received five treatments: PF-06273340 50 mg, PF-06273340 400 mg, pregabalin 300 mg, ibuprofen 600 mg and placebo. The five primary endpoints were the pain detection threshold for the thermal pain tests and the pain tolerance threshold for the cold pressor, electrical stair and pressure pain tests. The trial had predefined decision rules based on 95% confidence that the PF-06273340 effect was better than that of placebo. RESULTS Twenty subjects entered the study, with 18 completing all five periods. The high dose of PF-06273340 met the decision rules on the ultraviolet (UV) B skin thermal pain endpoint [least squares (LS) mean vs. placebo: 1.13, 95% confidence interval: 0.64-1.61], but not on the other four primary endpoints. The low dose did not meet the decision criteria for any of the five primary endpoints. Pregabalin (cold pressor and electrical stair tests) and ibuprofen (UVB thermal pain) showed significant analgesic effects on expected endpoints. CONCLUSIONS The study demonstrated, for the first time, the translation of nonclinical effects into man in an inflammatory pain analgesic pharmacodynamic endpoint using a pan-Trk inhibitor.
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Affiliation(s)
- Peter Loudon
- Neuroscience and Pain Research Unit, Pfizer WRD, Cambridge, UK
| | - Pieter Siebenga
- Centre for Human Drug Research, Zernikedreef, 8,2333 CL, Leiden, the Netherlands
| | - Donal Gorman
- Neuroscience and Pain Research Unit, Pfizer WRD, Cambridge, UK
| | - Katrina Gore
- Neuroscience and Pain Research Unit, Pfizer WRD, Cambridge, UK
| | - Pinky Dua
- Neuroscience and Pain Research Unit, Pfizer WRD, Cambridge, UK
| | - Guido van Amerongen
- Centre for Human Drug Research, Zernikedreef, 8,2333 CL, Leiden, the Netherlands
| | - Justin L Hay
- Centre for Human Drug Research, Zernikedreef, 8,2333 CL, Leiden, the Netherlands
| | - Geert Jan Groeneveld
- Centre for Human Drug Research, Zernikedreef, 8,2333 CL, Leiden, the Netherlands
| | - Richard P Butt
- Neuroscience and Pain Research Unit, Pfizer WRD, Cambridge, UK
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Affiliation(s)
- Franziska Denk
- Neurorestoration Group, Wolfson Centre for Age-Related Diseases, King's College London, London SE1 1UL, United Kingdom
| | - David L. Bennett
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Stephen B. McMahon
- Neurorestoration Group, Wolfson Centre for Age-Related Diseases, King's College London, London SE1 1UL, United Kingdom
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Abstract
Acute and chronic pain complaints, although common, are generally poorly served by existing therapies. This unmet clinical need reflects a failure to develop novel classes of analgesics with superior efficacy, diminished adverse effects and a lower abuse liability than those currently available. Reasons for this include the heterogeneity of clinical pain conditions, the complexity and diversity of underlying pathophysiological mechanisms, and the unreliability of some preclinical pain models. However, recent advances in our understanding of the neurobiology of pain are beginning to offer opportunities for developing novel therapeutic strategies and revisiting existing targets, including modulating ion channels, enzymes and G-protein-coupled receptors.
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Bannister K, Kucharczyk M, Dickenson AH. Hopes for the Future of Pain Control. Pain Ther 2017; 6:117-128. [PMID: 28536900 PMCID: PMC5693804 DOI: 10.1007/s40122-017-0073-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 12/26/2022] Open
Abstract
Here we aim to present an accessible review of the pharmacological targets for pain management, and succinctly discuss the newest trends in pain therapy. A key task for current pain pharmacotherapy is the identification of receptors and channels orchestrating nociception. Notwithstanding peripheral alterations in the receptors and channels following pathophysiological events, the modulatory mechanisms in the central nervous system are also fundamental to the regulation of pain perception. Bridging preclinical and clinical studies of peripheral and central components of pain modulation, we present the different types of pain and relate these to pharmacological interventions. We firstly highlight the roles of several peripheral nociceptors, such as NGF, CGRP, sodium channels, and TRP-family channels that may become novel targets for therapies. In the central nervous system, the roles of calcium channels and gabapentinoids as well as NMDA receptors in generating excitability are covered including ideas on central sensitization. We then turn to central modulatory systems and discuss opioids and monoamines. We aim to explain the importance of central sensitization and the dialogue of the spinal circuits with the brain descending modulatory controls before discussing a mechanism-based effectiveness of antidepressants in pain therapy and their potential to modulate the descending controls. Emphasizing the roles of conditioned pain modulation and its animal's equivalent, diffuse noxious inhibitory controls, we discuss these unique descending modulations as a potential tool for understanding mechanisms in patients suffering from pain. Mechanism-based therapy is the key to picking the correct treatments and recent clinical studies using sensory symptoms of patients as surrogates for underlying mechanisms can be used to subgroup patients and reveal actions of drugs that may be lost when studying heterogenous groups of patients. Key advances in the understanding of basic pain principles will impact our thinking about therapy targets. The complexity of pain syndromes will require tailored pharmacological drugs, often in combination or through drugs with more than one action, and often psychotherapy, to fully control pain.
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Affiliation(s)
- Kirsty Bannister
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Mateusz Kucharczyk
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Anthony H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK.
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Abstract
INTRODUCTION The management of pain associated with chronic musculoskeletal conditions represents a significant challenge for the clinician. There remains a need for novel medications that have a significant analgesic benefit and are also safe and well tolerated. Both pre-clinical and clinical data have provided evidence of the role of nerve growth factor (NGF) in a multitude of pain eliciting conditions. Therefore, the development of monoclonal antibodies to NGF for chronic painful musculoskeletal conditions has generated interest. Areas covered: This manuscript is a review that examines both the pharmacological properties and clinical studies of tanezumab, the most widely studied antibody to NGF, for management of osteoarthritis (OA) and low back pain. In addition, the safety and tolerability profile and development history of tanezumab are also discussed. Expert opinion: Most studies provide strong support for the ability of tanezumab to provide clinically meaningful pain relief in individuals with these conditions, with longer-term studies suggesting durability of effect. The adverse event profile appears favorable, assuming the risk mitigation strategies are effective at reducing the incidence of joint-related side effects. Further data are being collected to define the optimal dose and dosing strategy in both OA and chronic low back pain.
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Affiliation(s)
- Prakash Jayabalan
- Rehabilitation Institute of Chicago, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thomas J Schnitzer
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Wang H, Russell LJ, Kelly KM, Wang S, Thipphawong J. Fulranumab in patients with interstitial cystitis/bladder pain syndrome: observations from a randomized, double-blind, placebo-controlled study. BMC Urol 2017; 17:2. [PMID: 28056917 PMCID: PMC5217311 DOI: 10.1186/s12894-016-0193-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study was designed to evaluate the efficacy and safety of fulranumab, a fully human monoclonal antibody directed against nerve growth factor (NGF), for pain relief in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS In this multicenter, double-blind study, adults with IC/BPS (i.e., interstitial cystitis symptom index [ICSI] total score ≥8) accompanied by chronic, moderate-to-severe pain were randomized to fulranumab 9 mg or matching placebo, administered subcutaneously at weeks 1, 5, and 9. The primary efficacy endpoint was change from baseline to study endpoint (week 12 or at withdrawal) in average daily pain intensity score. Key secondary endpoints included change from baseline to study endpoint in worst pain intensity score, ICSI total score, Pelvic Pain and Urgency/Frequency total score, Patient Perception of Bladder Condition score, and global response assessment. RESULTS This study was terminated prematurely based on concern that this class may be associated with rapidly progressing osteoarthritis or osteonecrosis. Thirty-one patients (of the targeted 70 patients) were randomized, 17 to placebo and 14 to fulranumab, with 15 and 10 patients, respectively, receiving all 3 doses of double-blind treatment. In ANOVA analyses, there was no statistically significant difference between treatment groups for the primary endpoint (LS mean difference [95% CI] vs. placebo, -0.2 [-1.52, 1.10]) or any of the secondary endpoints. Fulranumab was well tolerated, with no patient discontinuing due to an adverse event or experiencing a joint-related serious adverse event over a 26-week follow-up period. No events related to the neurologic or motor systems were reported. CONCLUSIONS Efficacy was not demonstrated in the present study with the single dose tested and a limited sample size, leading to lack of statistical power. These findings do not exclude the possibility that fulranumab would provide clinical benefit in a larger study and/or specific populations (phenotypes) in this difficult to treat pain condition. TRIAL REGISTRATION NCT01060254 , registered January 29, 2010.
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Affiliation(s)
- Hao Wang
- Office of Translational Research, National Institute of Neurological Disorders and Stroke (NINDS), Bethesda, MD, USA
| | | | - Kathleen M Kelly
- Janssen Research & Development, LLC, Raritan/Titusville, NJ, USA
| | - Steven Wang
- Janssen Research & Development, LLC, Raritan/Titusville, NJ, USA
| | - John Thipphawong
- Janssen Research & Development, LLC, Raritan/Titusville, NJ, USA.
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Yeh JF, Akinci A, Al Shaker M, Chang MH, Danilov A, Guillen R, Johnson KW, Kim YC, El-Shafei AA, Skljarevski V, Dueñas HJ, Tassanawipas W. Monoclonal antibodies for chronic pain: a practical review of mechanisms and clinical applications. Mol Pain 2017; 13:1744806917740233. [PMID: 29056066 PMCID: PMC5680940 DOI: 10.1177/1744806917740233] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/27/2017] [Accepted: 08/21/2017] [Indexed: 12/24/2022] Open
Abstract
Context Monoclonal antibodies are being investigated for chronic pain to overcome the shortcomings of current treatment options. Objective To provide a practical overview of monoclonal antibodies in clinical development for use in chronic pain conditions, with a focus on mechanisms of action and relevance to specific classes. Methods Qualitative review using a systematic strategy to search for randomized controlled trials, systematic and nonsystematic (narrative) reviews, observational studies, nonclinical studies, and case reports for inclusion. Studies were identified via relevant search terms using an electronic search of MEDLINE via PubMed (1990 to June 2017) in addition to hand-searching reference lists of retrieved systematic and nonsystematic reviews. Results Monoclonal antibodies targeting nerve growth factor, calcitonin gene-related peptide pathways, various ion channels, tumor necrosis factor-α, and epidermal growth factor receptor are in different stages of development. Mechanisms of action are dependent on specific signaling pathways, which commonly involve those related to peripheral neurogenic inflammation. In clinical studies, there has been a mixed response to different monoclonal antibodies in several chronic pain conditions, including migraine, neuropathic pain conditions (e.g., diabetic peripheral neuropathy), osteoarthritis, chronic back pain, ankylosing spondylitis, and cancer. Adverse events observed to date have generally been mild, although further studies are needed to ensure safety of monoclonal antibodies in early stages of development, especially where there is an overlap with non-pain-related pathways. High acquisition cost remains another treatment limitation. Conclusion Monoclonal antibodies for chronic pain have the potential to overcome the limitations of current treatment options, but strategies to ensure their appropriate use need to be determined.
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Affiliation(s)
| | - Aysen Akinci
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Hacettepe, Ankara, Turkey
| | - Mohammed Al Shaker
- King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
| | | | - Andrei Danilov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Rocio Guillen
- Pain Clinic, National Cancer Institute, México DF, México
| | | | - Yong-Chul Kim
- Seoul National University School of Medicine, Pain Management Center of the Seoul National University Hospital, Seoul, Republic of Korea
| | | | | | | | - Warat Tassanawipas
- Department of Orthopaedics, Phramongkutklao Army Hospital, Bangkok, Thailand
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Papanas N, Ziegler D. Emerging drugs for diabetic peripheral neuropathy and neuropathic pain. Expert Opin Emerg Drugs 2016; 21:393-407. [DOI: 10.1080/14728214.2016.1257605] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Fiore NT, Austin PJ. Are the emergence of affective disturbances in neuropathic pain states contingent on supraspinal neuroinflammation? Brain Behav Immun 2016; 56:397-411. [PMID: 27118632 DOI: 10.1016/j.bbi.2016.04.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/11/2016] [Accepted: 04/22/2016] [Indexed: 12/28/2022] Open
Abstract
Neuro-immune interactions contribute to the pathogenesis of neuropathic pain due to peripheral nerve injury. A large body of preclinical evidence supports the idea that the immune system acts to modulate the sensory symptoms of neuropathy at both peripheral and central nervous system sites. The potential involvement of neuro-immune interactions in the highly debilitating affective disturbances of neuropathic pain, such as depression, anhedonia, impaired cognition and reduced motivation has received little attention. This is surprising given the widely accepted view that sickness behaviour, depression, cognitive impairment and other neuropsychiatric conditions can arise from inflammatory mechanisms. Moreover, there is a set of well-described immune-to-brain transmission mechanisms that explain how peripheral inflammation can lead to supraspinal neuroinflammation. In the last 5years increasing evidence has emerged that peripheral nerve injury induces supraspinal changes in cytokine or chemokine expression and alters glial cell activity. In this systematic review, based on strong preclinical evidence, we advance the argument that the emergence of affective disturbances in neuropathic pain states are contingent on pro-inflammatory mediators in the interconnected hippocampal-medial prefrontal circuitry that subserve affective behaviours. We explore how dysregulation of inflammatory mediators in these networks may result in affective disturbances through a wide variety of neuromodulatory mechanisms. There are also promising results from clinical trials showing that anti-inflammatory agents have efficacy in the treatment of a variety of neuropsychiatric conditions including depression and appear suited to sub-groups of patients with elevated pro-inflammatory profiles. Thus, although further research is required, aggressively targeting supraspinal pro-inflammatory mediators at critical time-points in appropriate clinical populations is likely to be a novel avenue to treat debilitating affective disturbances in neuropathic conditions.
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Affiliation(s)
- Nathan T Fiore
- Discipline of Anatomy & Histology, School of Medical Sciences, The University of Sydney, Sydney, NSW 2006, Australia
| | - Paul J Austin
- Discipline of Anatomy & Histology, School of Medical Sciences, The University of Sydney, Sydney, NSW 2006, Australia.
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Chang DS, Hsu E, Hottinger DG, Cohen SP. Anti-nerve growth factor in pain management: current evidence. J Pain Res 2016; 9:373-83. [PMID: 27354823 PMCID: PMC4908933 DOI: 10.2147/jpr.s89061] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
There continues to be an unmet need for safe and effective pain medications. Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) dominate the clinical landscape despite limited effectiveness and considerable side-effect profiles. Although significant advancements have identified myriad potential pain targets over the past several decades, the majority of new pain pharmacotherapies have failed to come to market. The discovery of nerve growth factor (NGF) and its interaction with tropomyosin receptor kinase A (trkA) have been well characterized as important mediators of pain initiation and maintenance, and pharmacotherapies targeting this pathway have the potential to be considered promising methods in the treatment of a variety of nociceptive and neuropathic pain conditions. Several methodologic approaches, including sequestration of free NGF, prevention of NGF binding and trkA activation, and inhibition of trkA function, have been investigated in the development of new pharmacotherapies. Among these, NGF-sequestering antibodies have exhibited the most promise in clinical trials. However, in 2010, reports of rapid joint destruction leading to joint replacement prompted the US Food and Drug Administration (FDA) to place a hold on all clinical trials involving anti-NGF antibodies. Although the FDA has since lifted this hold and a number of new trials are under way, the long-term efficacy and safety profile of anti-NGF antibodies are yet to be established.
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Affiliation(s)
- David S Chang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eugene Hsu
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel G Hottinger
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Peripheral Brain Derived Neurotrophic Factor Precursor Regulates Pain as an Inflammatory Mediator. Sci Rep 2016; 6:27171. [PMID: 27251195 PMCID: PMC4890020 DOI: 10.1038/srep27171] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/13/2016] [Indexed: 02/08/2023] Open
Abstract
The precursor of brain derived neurotrophic factor (proBDNF), the unprocessed BDNF gene product, binds to its receptors and exerts the opposing biologic functions of mature BDNF. proBDNF is expressed in the peripheral tissues but the functions of peripheral proBDNF remain elusive. Here we showed that proBDNF and its predominant receptor, p75 pan-neurotrophin receptor were upregulated in the nerve fibers and inflammatory cells in the local tissue in inflammatory pain. Neutralization of proBDNF by polyclonal antibody attenuated pain in different models of inflammatory pain. Unilateral intra-plantar supplementation of proBDNF by injecting exogenous proBDNF or ectopic overexpression resulted in pain hypersensitivity and induced spinal phosphorylated extracellular signal-regulated kinase activation. Exogenous proBDNF injection induced the infiltration of inflammatory cells and the activation of proinflammatory cytokines, suggesting that inflammatory reaction contributed to the pro-algesic effect of proBDNF. Finally, we generated monoclonal anti-proBDNF antibody that could biologically block proBDNF. Administration of monoclonal Ab-proBDNF attenuated various types of inflammatory pain and surgical pain. Thus, peripheral proBDNF is a potential pain mediator and anti-proBDNF pretreatment may alleviate the development of inflammatory pain.
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Tajti J, Szok D, Majláth Z, Csáti A, Petrovics-Balog A, Vécsei L. Alleviation of pain in painful diabetic neuropathy. Expert Opin Drug Metab Toxicol 2016; 12:753-64. [PMID: 27149100 DOI: 10.1080/17425255.2016.1184648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Painful diabetic neuropathy (PDN) is a disabling pain condition. Its pathomechanism remains unknown, but a sensitization and neuronal hyperexcitabilty have been suggested. Only symptomatic pharmacological pain management treatment is currently available. AREAS COVERED The origin of PDN is enigmatic, and the evidence-based therapeutic guidelines therefore consist only of antidepressants and antiepileptics as first-line recommended drugs. This article relates to a MEDLINE/PubMed systematic search (2005-2015). EXPERT OPINION The results of the meta-analysis from the aspect of the efficacy of amitriptyline, duloxetine, venlafaxine, gabapentin and pregabalin are favorable, but the placebo response rate is relatively high in patients with neuropathic pain. For personalization of the medication of PDN patients, the optimum dosing, the genotyping of the metabolizing enzymes and optimum biomarkers are needed. As concerns the future perspectives, specific sodium channel subtype inhibitors acting on peripheral nociceptive neurons or modified T-type voltage-gated calcium channel blockers may be promising targets for pharmaceutical innovations. Another attractive strategy for the treatment is based on the effects of monoclonal antibodies against nerve growth factor, sodium channels, specific receptor and cytokines. Botulinum toxin A, capsaicin patch and spinal cord stimulation therapies are the nearest future therapeutic options for the treatment of PDN patients.
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Affiliation(s)
- János Tajti
- a Department of Neurology, Faculty of Medicine , University of Szeged , Szeged , Hungary
| | - Délia Szok
- a Department of Neurology, Faculty of Medicine , University of Szeged , Szeged , Hungary
| | - Zsófia Majláth
- a Department of Neurology, Faculty of Medicine , University of Szeged , Szeged , Hungary
| | - Anett Csáti
- a Department of Neurology, Faculty of Medicine , University of Szeged , Szeged , Hungary
| | - Anna Petrovics-Balog
- a Department of Neurology, Faculty of Medicine , University of Szeged , Szeged , Hungary
| | - László Vécsei
- a Department of Neurology, Faculty of Medicine , University of Szeged , Szeged , Hungary.,b MTA - SZTE Neuroscience Research Group , Szeged , Hungary
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46
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Losina E, Michl G, Collins JE, Hunter DJ, Jordan JM, Yelin E, Paltiel AD, Katz JN. Model-based evaluation of cost-effectiveness of nerve growth factor inhibitors in knee osteoarthritis: impact of drug cost, toxicity, and means of administration. Osteoarthritis Cartilage 2016; 24:776-85. [PMID: 26746146 PMCID: PMC4838505 DOI: 10.1016/j.joca.2015.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/03/2015] [Accepted: 12/16/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Studies suggest nerve growth factor inhibitors (NGFi) relieve pain but may accelerate disease progression in some patients with osteoarthritis (OA). We sought cost and toxicity thresholds that would make NGFi a cost-effective treatment for moderate-to-severe knee OA. DESIGN We used the Osteoarthritis Policy (OAPol) model to estimate the cost-effectiveness of NGFi compared to standard of care (SOC) in OA, using Tanezumab as an example. Efficacy and rates of accelerated OA progression were based on published studies. We varied the price/dose from $200 to $1000. We considered self-administered subcutaneous (SC) injections (no administration cost) vs provider-administered intravenous (IV) infusion ($69-$433/dose). Strategies were defined as cost-effective if their incremental cost-effectiveness ratio (ICER) was less than $100,000/quality-adjusted life year (QALY). In sensitivity analyses we varied efficacy, toxicity, and costs. RESULTS SOC in patients with high levels of pain led to an average discounted quality-adjusted life expectancy of 11.15 QALYs, a lifetime risk of total knee replacement surgery (TKR) of 74%, and cumulative discounted direct medical costs of $148,700. Adding Tanezumab increased QALYs to 11.42, reduced primary TKR utilization to 63%, and increased costs to between $155,400 and $199,500. In the base-case analysis, Tanezumab at $600/dose was cost-effective when delivered outside of a hospital. At $1000/dose, Tanezumab was not cost-effective in all but the most optimistic scenario. Only at rates of accelerated OA progression of 10% or more (10-fold higher than reported values) did Tanezumab decrease QALYs and fail to represent a viable option. CONCLUSIONS At $100,000/QALY, Tanezumab would be cost effective if priced ≤$400/dose in all settings except IV hospital delivery.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/economics
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Cost-Benefit Analysis
- Disease Progression
- Drug Costs/statistics & numerical data
- Female
- Health Care Costs
- Health Services Research/methods
- Humans
- Infusions, Intravenous
- Injections, Subcutaneous
- Male
- Middle Aged
- Models, Econometric
- Nerve Growth Factor/antagonists & inhibitors
- Osteoarthritis, Knee/drug therapy
- Osteoarthritis, Knee/economics
- Pain Measurement/methods
- Quality-Adjusted Life Years
- Self Administration/economics
- United States
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Affiliation(s)
- E Losina
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - G Michl
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - J E Collins
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - D J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia.
| | - J M Jordan
- Thurston Arthritis Research Center and the Division of Rheumatology, Allergy and Immunology, University of North Carolina, Chapel Hill, USA.
| | - E Yelin
- University of California, San Francisco, San Francisco, CA, USA.
| | - A D Paltiel
- Yale School of Public Health, New Haven, CT, USA.
| | - J N Katz
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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47
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Malik RA. Wherefore Art Thou, O Treatment for Diabetic Neuropathy? INTERNATIONAL REVIEW OF NEUROBIOLOGY 2016; 127:287-317. [PMID: 27133154 DOI: 10.1016/bs.irn.2016.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
As of March 2016, we continue to advocate the diagnosis of diabetic neuropathy using a simple foot examination or monofilament, which identifies only those with severe neuropathy and hence risk of foot ulceration. Given the fact that the 5-year mortality rate of diabetic patients with foot ulceration is worse than that of most common cancers, surely we should be identifying patients at an earlier stage of neuropathy to prevent its progression to a stage with such a high mortality? Of course, we lament that there is no licensed treatment for diabetic neuropathy. Who is to blame? As researchers and carers, we have a duty of care to our patients with diabetic neuropathy. So, we have to look forward not backwards, and move away from our firmly entrenched views on the design and conduct of clinical trials for diabetic neuropathy. Relevant organizations such as Neurodiab, the American Diabetes Association and the Peripheral Nerve Society have to acknowledge that they cannot continue to endorse a bankrupt strategy. The FDA needs an open and self-critical dialogue with these organizations, to give pharmaceutical companies at least a fighting chance to deliver effective new therapies for diabetic neuropathy.
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Affiliation(s)
- R A Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar.
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48
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Xu XJ, Liu L, Yao SK. Nerve growth factor and diarrhea-predominant irritable bowel syndrome (IBS-D): a potential therapeutic target? J Zhejiang Univ Sci B 2016; 17:1-9. [PMID: 26739521 PMCID: PMC4710835 DOI: 10.1631/jzus.b1500181] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/07/2015] [Indexed: 02/05/2023]
Abstract
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder characterized by recurrent abdominal pain or discomfort associated with abnormal bowel habits. Diarrhea-predominant IBS (IBS-D) is a major subtype of IBS, the predominant manifestations of which are abdominal pain and diarrhea. The pathogenesis of IBS-D remained unknown until recently. The effects of psychosocial stress, central hypervigilance, neuroendocrine abnormality, disturbed gastrointestinal motility, mucosal immune activation, intestinal barrier dysfunction, visceral hypersensitivity (VH), altered gut flora, and genetic susceptibility may be involved in its development. Recently, increased attention has been placed on the neural-immune-endocrine network mechanism in IBS-D, especially the role of various neuroendocrine mediators. As a member of the neurotrophin family, nerve growth factor (NGF) has diverse biological effects, and participates in the pathogenesis of many diseases. Basic studies have demonstrated that NGF is associated with inflammatory- and stress-related VH, as well as stress-related intestinal barrier dysfunction. The aim of this study is to summarize recent literature and discuss the role of NGF in the pathophysiology of IBS-D, especially in VH and intestinal barrier dysfunction, as well as its potential as a therapeutic target in IBS-D.
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Affiliation(s)
- Xiao-juan Xu
- Gastroenterology Department, China-Japan Friendship Hospital, Beijing 100029, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100073, China
| | - Liang Liu
- Jinan Central Hospital Affiliated to Shandong University, Jinan 250014, China
| | - Shu-kun Yao
- Gastroenterology Department, China-Japan Friendship Hospital, Beijing 100029, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100073, China
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Abstract
Neurotrophins (NTs) belong to a family of trophic factors that regulate the survival, growth and programmed cell death of neurons. In mammals, there are four structurally and functionally related NT proteins, viz. nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin 3 and neurotrophin 4. Most research on NTs to date has focussed on the effects of NGF and BDNF signalling via their respective cognate high affinity neurotrophic tyrosine kinase viz TrkA and TrkB receptors. Apart from the key physiologic roles of NGF and BDNF in peripheral and central nervous system function, NGF and BDNF signalling via TrkA and TrkB receptors respectively have been implicated in mechanisms underpinning neuropathic pain. Additionally, NGF and BDNF signalling via the low-affinity pan neurotrophin receptor at 75 kDa (p75NTR) may also contribute to the pathobiology of neuropathic pain. In this review, we critically assess the role of neurotrophins signalling via their cognate high affinity receptors as well as the low affinity p75NTR in the pathophysiology of peripheral neuropathic and central neuropathic pain. We also identify knowledge gaps to guide future research aimed at generating novel insight on how to optimally modulate NT signalling for discovery of novel therapeutics to improve neuropathic pain relief.
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