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Snow NJ, Kirkland MC, Downer MB, Murphy HM, Ploughman M. Transcranial magnetic stimulation maps the neurophysiology of chronic noncancer pain: A scoping review. Medicine (Baltimore) 2022; 101:e31774. [PMID: 36401490 PMCID: PMC9678597 DOI: 10.1097/md.0000000000031774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Chronic noncancer pain is a global public health challenge. It is imperative to identify biological markers ("biomarkers") to understand the mechanisms underlying chronic pain and to monitor pain over time and after interventions. Transcranial magnetic stimulation (TMS) is a promising method for this purpose. OBJECTIVES To examine differences in TMS-based outcomes between persons with chronic pain and healthy controls (HCs) and/or before versus after pain-modulating interventions and relationships between pain measures and TMS outcomes; To summarize the neurophysiological mechanisms underlying chronic pain as identified by TMS. METHODS We searched the PubMed database for literature from January 1, 1985, to June 9, 2020, with the keywords "pain" and "transcranial magnetic stimulation." Eligible items included original studies of adult human participants with pain lasting for ≥ 6 months. We completed a narrative synthesis of the study findings stratified by chronic pain etiology (primary pain, neuropathic pain, and secondary musculoskeletal pain). RESULTS The search yielded 1265 records. The final 12 articles included 244 patients with chronic pain (192 females, aged 35-65 years) and 169 HCs (89 females, aged 28-59 years). Abnormalities in TMS outcomes that reflect GABAergic and glutamatergic activities were associated with many of the disorders studied and were distinct for each pain etiology. Chronic primary pain is characterized by reduced intracortical inhibition and corticospinal excitability, chronic neuropathic pain shows evidence of increased excitation and disinhibition, and chronic secondary musculoskeletal pain involves low corticospinal excitability. DISCUSSION TMS could be a useful tool for delineating the neurophysiological underpinnings of chronic pain syndromes.
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Affiliation(s)
- Nicholas Jacob Snow
- Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland & Labrador, St. John’s, NL, Canada
| | - Megan Christine Kirkland
- Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland & Labrador, St. John’s, NL, Canada
| | - Matthew Bruce Downer
- Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland & Labrador, St. John’s, NL, Canada
| | - Hannah Margaret Murphy
- Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland & Labrador, St. John’s, NL, Canada
| | - Michelle Ploughman
- Recovery and Performance Laboratory, Faculty of Medicine, Memorial University of Newfoundland & Labrador, St. John’s, NL, Canada
- * Correspondence: Michelle Ploughman, Recovery and Performance Laboratory, Rehabilitation Research Unit of NL, Faculty of Medicine, Memorial University of Newfoundland & Labrador, Dr. Leonard A. Miller Centre, Room 400, 100 Forest Road, St. John’s, Newfoundland and Labrador A1A 1E5, Canada (e-mail: )
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Central Neuropathic Pain Syndromes: Current and Emerging Pharmacological Strategies. CNS Drugs 2022; 36:483-516. [PMID: 35513603 DOI: 10.1007/s40263-022-00914-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/31/2022]
Abstract
Central neuropathic pain is caused by a disease or lesion of the brain or spinal cord. It is difficult to predict which patients will develop central pain syndromes after a central nervous system injury, but depending on the etiology, lifetime prevalence may be greater than 50%. The resulting pain is often highly distressing and difficult to treat, with no specific treatment guidelines currently available. This narrative review discusses mechanisms contributing to central neuropathic pain, and focuses on pharmacological approaches for managing common central neuropathic pain conditions such as central post-stroke pain, spinal cord injury-related pain, and multiple sclerosis-related neuropathic pain. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids have some evidence for efficacy in central neuropathic pain. Medications from other pharmacologic classes may also provide pain relief, but current evidence is limited. Certain non-pharmacologic approaches, neuromodulation in particular, may be helpful in refractory cases. Emerging data suggest that modulating the primary afferent input may open new horizons for the treatment of central neuropathic pain. For most patients, effective treatment will likely require a multimodal therapy approach.
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Abstract
Pain is a major matter for patients with multiple sclerosis; treatment response is frequently inadequate, with a significant impact on quality of life. The estimated prevalence of pain in multiple sclerosis ranges widely (26-86%), and different subtypes of pain, mediated by specific pathophysiological mechanisms, are described. The aim of this narrative review, performed using a systematic search methodology, was to provide current, evidence-based, knowledge about the pharmacological treatment of the different kinds of pain in multiple sclerosis. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Clinical Trials database (ClinicalTrials.gov), considering publications up to November 2019. Two authors independently selected studies for inclusion, data extraction, and bias assessment. A total of 27 randomized controlled trials were identified, but in only a few cases, patients with different pain qualities were stratified. Following a mechanism-based approach, treatment of paroxysmal pain and painful tonic spasms should be based on sodium-channel blockers, whereas treatment of ongoing extremity pain should be based on gabapentinoids and antidepressants.
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Bendtsen L, Zakrzewska JM, Abbott J, Braschinsky M, Di Stefano G, Donnet A, Eide PK, Leal PRL, Maarbjerg S, May A, Nurmikko T, Obermann M, Jensen TS, Cruccu G. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol 2019; 26:831-849. [DOI: 10.1111/ene.13950] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022]
Affiliation(s)
- L. Bendtsen
- Department of Neurology Faculty of Health and Medical Sciences Danish Headache Center Rigshospitalet‐Glostrup University of Copenhagen Glostrup Denmark
| | - J. M. Zakrzewska
- Pain Management Centre National Hospital for Neurology and Neurosurgery London UK
- Eastman Dental Hospital UCLH NHS Foundation Trust London UK
| | - J. Abbott
- Trigeminal Neuralgia Association UK Oxted Surrey UK
| | | | - G. Di Stefano
- Department of Human Neuroscience Sapienza University Rome Italy
| | - A. Donnet
- Headache and Pain Department CHU La Timone APHM Marseille France
| | - P. K. Eide
- Department of Neurosurgery Oslo University Hospital‐Rikshospitalet Oslo Norway
- Institute of Clinical Medicine Faculty of Medicine University of Oslo Oslo Norway
| | - P. R. L. Leal
- Department of Neurosurgery Faculty of Medicine of Sobral Federal University of Ceará Sobral Brazil
- University of Lyon 1 Lyon France
| | - S. Maarbjerg
- Department of Neurology Faculty of Health and Medical Sciences Danish Headache Center Rigshospitalet‐Glostrup University of Copenhagen Glostrup Denmark
| | - A. May
- Department of Systems Neuroscience Universitäts‐Krankenhaus Eppendorf Hamburg Germany
| | - T. Nurmikko
- Neuroscience Research Centre Walton Centre NHS Foundation Trust Liverpool UK
| | - M. Obermann
- Center for Neurology Asklepios Hospitals Schildautal Seesen Germany
| | - T. S. Jensen
- Department of Neurology and Danish Pain Research Center Aarhus University Hospital University of Aarhus Aarhus C Denmark
| | - G. Cruccu
- Department of Human Neuroscience Sapienza University Rome Italy
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Di Stefano G, Maarbjerg S, Truini A. Trigeminal neuralgia secondary to multiple sclerosis: from the clinical picture to the treatment options. J Headache Pain 2019; 20:20. [PMID: 30782116 PMCID: PMC6734488 DOI: 10.1186/s10194-019-0969-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/06/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Trigeminal neuralgia is one of the most characteristic and difficult to treat neuropathic pain conditions in patients with multiple sclerosis. The present narrative review addresses the current evidence on diagnostic tests and treatment of trigeminal neuralgia secondary to multiple sclerosis. METHODS We searched for relevant papers within PubMed, EMBASE and the Cochrane Database of Systematic Reviews, taking into account publications up to December 2018. RESULTS Trigeminal neuralgia secondary to multiple sclerosis manifests with facial paroxysmal pain triggered by typical manoeuvres; neurophysiological investigations and MRI support the diagnosis, providing the definite evidence of trigeminal pathway damage. A dedicated MRI is required to identify pontine demyelinating plaques. In many patients with multiple sclerosis, neuroimaging and surgical evidence suggests that neurovascular compression might act in concert with the pontine plaque through a double-crush mechanism. Although no placebo-controlled trials have been conducted in these patients, according to expert opinion the first-line therapy for trigeminal neuralgia secondary to multiple sclerosis relies on sodium-channel blockers, i.e. carbamazepine and oxcarbazepine. The sedative and motor side effects of these drugs frequently warrant an early consideration for neurosurgery. Surgical procedures include Gasserian ganglion percutaneous techniques, gamma knife radiosurgery and microvascular decompression in the posterior fossa. CONCLUSIONS The relatively poor tolerability of the centrally-acting drugs carbamazepine and oxcarbazepine highlights the need to develop new selective and better-tolerated sodium-channel blockers. Prospective studies based on more advanced neuroimaging techniques should focus on how trigeminal anatomical abnormalities may be able to predict the efficacy of microvascular decompression.
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Affiliation(s)
- Giulia Di Stefano
- Department of Human Neurosciences, Sapienza University, Viale Università 30, 00185 Rome, Italy
| | - Stine Maarbjerg
- Danish Headache Center, Department of Neurology, Rigshospitalet - Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Truini
- Department of Human Neurosciences, Sapienza University, Viale Università 30, 00185 Rome, Italy
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de Leeuw TG, Mangiarini L, Lundin R, Kaguelidou F, van der Zanden T, Pasqua OD, Tibboel D, Ceci A, de Wildt SN. Gabapentin as add-on to morphine for severe neuropathic or mixed pain in children from age 3 months to 18 years - evaluation of the safety, pharmacokinetics, and efficacy of a new gabapentin liquid formulation: study protocol for a randomized controlled trial. Trials 2019; 20:49. [PMID: 30646965 PMCID: PMC6334401 DOI: 10.1186/s13063-018-3169-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 12/30/2018] [Indexed: 01/07/2023] Open
Abstract
Background Gabapentin has shown efficacy in the treatment of chronic neuropathic or mixed pain in adults. Although pediatric pain specialists have extensive experience with gabapentin for the treatment of neuropathic pain, its use is off-label. Its efficacy and safety in this context have never been shown. The aim of this trial is to compare gabapentin with placebo as add-on to morphine for the treatment of severe chronic mixed or neuropathic pain in children. This trial is part of the European Union Seventh Framework Programme project Gabapentin in Paediatric Pain (GAPP) to develop a pediatric use marketing authorization for a new gabapentin suspension. Methods/design The GAPP-2 study is a randomized, double-blind, placebo-controlled, multicenter superiority phase II study in children with severe chronic neuropathic or mixed pain. Its primary objective is to evaluate the efficacy of a gabapentin liquid formulation as adjunctive therapy to morphine. Sixty-six eligible children 3 months to 18 years of age with severe pain (pain scores ≥ 7), stratified in three age groups, will be randomized to receive gabapentin (to an accumulating dose of 45 to 63 mg/kg/day, dependent on age) or placebo, both in addition to morphine, for 12 weeks. Randomization will be preceded by a short washout period, and treatment will be initiated by a titration period of 3 weeks. After the treatment period, medication will be tapered during 4 weeks. The primary endpoint is the average pain scores in the two treatment groups (average of two measures each day for 3 days before the end-of-study visit [V10] assessed by age-appropriate pain scales (Face, Legs, Activity, Cry, Consolability scale; Faces Pain Scale–Revised; Numeric Rating Scale). Secondary outcomes include percentage responders to treatment (subjects with 30% reduction in pain scale), number of episodes of breakthrough pain, number of rescue interventions, number of pain-free days, participant dropouts, quality of life (Pediatric Quality of Life Inventory), and acceptability of treatment. Outcomes will be measured at the end-of-study visit after 12 weeks of treatment at the optimal gabapentin dose. Groups will be compared on an intention-to-treat basis. Discussion We hope to provide evidence that the combination of morphine and gabapentin will provide better analgesia than morphine alone and will be safe. We also aim to obtain confirmation of the recommended pediatric dose. Trial registration EudractCT, 2014-004897-40. Registered on 7 September 2017. ClinicalTrials.gov, NCT03275012. Registered on 7 September 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3169-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas G de Leeuw
- Department of Anesthesia and Pain Medicine, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Laura Mangiarini
- Consorzio per Valutazione Biologiche e Farmacologiche, Pavia, Italy
| | | | - Florentia Kaguelidou
- Department of Pediatric Pharmacology and Pharmacogenetics, AP-HP, Hôpital Robert Debré, F-75019, Paris, France.,Inserm, CIC 1426, F-75019, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, EA 08, F-75010, Paris, France
| | - Tjitske van der Zanden
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | | | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Adriana Ceci
- Consorzio per Valutazione Biologiche e Farmacologiche, Pavia, Italy
| | - Saskia N de Wildt
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.,Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands
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Di Stefano G, Truini A, Cruccu G. Current and Innovative Pharmacological Options to Treat Typical and Atypical Trigeminal Neuralgia. Drugs 2018; 78:1433-1442. [PMID: 30178160 PMCID: PMC6182468 DOI: 10.1007/s40265-018-0964-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Trigeminal neuralgia is a representative neuropathic facial pain condition, characterised by unilateral paroxysmal pain in the distribution territory of one or more divisions of the trigeminal nerve, triggered by innocuous stimuli. A subgroup of patients with trigeminal neuralgia [TN (previously defined as atypical TN)] also suffer from concomitant continuous pain, i.e. a background pain between the paroxysmal attacks. The aim of this review is to provide current, evidence-based, knowledge about the pharmacological treatment of typical and atypical TN, with a specific focus on drugs in development. We searched for relevant papers within PubMed, EMBASE, the Cochrane Database of Systematic Reviews and the Clinical Trials database (ClinicalTrials.gov), taking into account publications up to February 2018. Two authors independently selected studies for inclusions, data extraction, and bias assessment. Carbamazepine and oxcarbazepine are the first-choice drugs for paroxysmal pain. When sodium channel blockers cannot reach full dosage because of side effects, an add-on treatment with lamotrigine or baclofen should be considered. In patients with atypical TN, both gabapentin and antidepressants are expected to be efficacious and should be tried as an add-on to oxcarbazepine or carbamazepine. Although carbamazepine and oxcarbazepine are effective in virtually the totality of patients, they are responsible for side effects causing withdrawal from treatment in an important percentage of cases. A new, better tolerated, Nav1.7 selective state-dependent, sodium channel blocker (vixotrigine) is under development. Future trials testing the effect of combination therapy in patients with TN are needed, especially in patients with concomitant continuous pain and in TN secondary to multiple sclerosis.
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Affiliation(s)
- G Di Stefano
- Department of Human Neuroscience, Sapienza University, viale Università 30, 00185, Rome, Italy
| | - A Truini
- Department of Human Neuroscience, Sapienza University, viale Università 30, 00185, Rome, Italy
| | - G Cruccu
- Department of Human Neuroscience, Sapienza University, viale Università 30, 00185, Rome, Italy.
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8
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Recommandations pour le diagnostic et la prise en charge de la névralgie trigéminale classique. Neurochirurgie 2018; 64:285-302. [DOI: 10.1016/j.neuchi.2018.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 03/20/2018] [Accepted: 04/08/2018] [Indexed: 12/26/2022]
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Zakrzewska JM, Wu J, Brathwaite TSL. A Systematic Review of the Management of Trigeminal Neuralgia in Patients with Multiple Sclerosis. World Neurosurg 2017; 111:291-306. [PMID: 29294398 DOI: 10.1016/j.wneu.2017.12.147] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with trigeminal neuralgia (TN) and multiple sclerosis (MS) are often treated with medications or a surgical procedure. However, there is little evidence that such treatments result in 50% pain reduction and improvement in quality of life. The aim of this systematic review is to evaluate the clinical effectiveness of treatments in patients with MS and trigeminal neuralgia. METHODS We searched Medline, EMBASE, and the Cochrane Collaboration database from inception until October 2016. Two authors independently selected studies for inclusions, data extraction, and bias assessment. RESULTS All studies were of low quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. For medical management, 10 studies were included, of which one was a randomized controlled trial. Two studies were on the use of misopropol, unique to patients with MS. For surgical therapy, 26 studies with at least 10 patients and a minimum of 2 years follow-up were included. All types of surgical procedures are reported and the results are poorer for TN with MS, with 50% having a recurrence by 2 years. The main complication was sensory loss. Many patients had to undergo further procedures to become pain free and there were no agreed prognostic factors. CONCLUSIONS There was insufficient evidence to support any 1 medical therapy and so earlier surgery may be preferable. A patient with TN and MS has therefore to make a decision based on low-level evidence, beginning with standard drug therapy and then choosing a surgical procedure.
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Affiliation(s)
- Joanna M Zakrzewska
- Facial Pain Unit, Eastman Dental Hospital, UCLH NHS Foundation Trust, London, United Kingdom.
| | - Jianhua Wu
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, United Kingdom
| | - Tricia S-L Brathwaite
- Department of Oral & Maxillofacial Surgery, Eastman Dental Hospital, UCLH NHS Foundation Trust, London
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10
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Abstract
INTRODUCTION Unique among the different neuropathic pain conditions, trigeminal neuralgia frequently has an excellent response to some selected drugs, which, on the other hand, often entail disabling side effects. Physicians should be therefore acquainted with the management of these drugs and the few alternative options. Areas covered: This article, based on a systematic literature review, describes the pharmacological options, and indicates the future perspectives for treating trigeminal neuralgia. The article therefore provides current, evidence-based knowledge about the pharmacological treatment of trigeminal neuralgia, and suggests a practical approach to the various drugs, including starting dose, titration and side effects. Expert commentary: Carbamazepine and oxcarbazepine are the reference standard drugs for treating patients with trigeminal neuralgia. They are effective in most patients. The undesired effects however cause withdrawal from treatment or a dosage reduction to an insufficient level in many patients. Sodium channel blockers selective for the sodium channel 1.7 (Nav1.7) receptor, currently under development, might be an alternative, better-tolerated pharmacological option in the next future.
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Affiliation(s)
- Giulia Di Stefano
- a Department of Neurology and Psychiatry , University Sapienza , Roma , Italy
| | - Andrea Truini
- a Department of Neurology and Psychiatry , University Sapienza , Roma , Italy
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Abstract
Practicing clinicians come across uses of pharmacologic agents that may not always be listed in the usual references. For example, glycerin injection for nerve block, H2 antagonists in colorectal cancer, or colchicine for systemic sclerosis may represent novel, hard-to-find clinical applications. If you have encountered a new and/or unusual use of a drug, submit the information to this Hospital Pharmacy feature. Send three copies, double-spaced, 1,000 words or less, to: Thomas G. Burnakis, PharmD, Baptist Medical Center, 800 Prudential Drive, Jacksonville, FL 32207.
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Affiliation(s)
- Thomas G. Burnakis
- Department of Pharmacy, Baptist Medical Center, 800 Prudential Drive, Jacksonville, FL 32207
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12
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French guidelines for diagnosis and treatment of classical trigeminal neuralgia (French Headache Society and French Neurosurgical Society). Rev Neurol (Paris) 2017; 173:131-151. [DOI: 10.1016/j.neurol.2016.12.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 12/19/2016] [Indexed: 12/19/2022]
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Otero-Romero S, Sastre-Garriga J, Comi G, Hartung HP, Soelberg Sørensen P, Thompson AJ, Vermersch P, Gold R, Montalban X. Pharmacological management of spasticity in multiple sclerosis: Systematic review and consensus paper. Mult Scler 2016; 22:1386-1396. [DOI: 10.1177/1352458516643600] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 03/01/2016] [Indexed: 11/16/2022]
Abstract
Background and objectives: Treatment of spasticity poses a major challenge given the complex clinical presentation and variable efficacy and safety profiles of available drugs. We present a systematic review of the pharmacological treatment of spasticity in multiple sclerosis (MS) patients. Methods: Controlled trials and observational studies were identified. Scientific evidence was evaluated according to pre-specified levels of certainty. Results: The evidence supports the use of baclofen, tizanidine and gabapentin as first-line options. Diazepam or dantrolene could be considered if no clinical improvement is seen with the previous drugs. Nabiximols has a positive effect when used as add-on therapy in patients with poor response and/or tolerance to first-line oral treatments. Despite limited evidence, intrathecal baclofen and intrathecal phenol show a positive effect in severe spasticity and suboptimal response to oral drugs. Conclusion: The available studies on spasticity treatment offer some insight to guide clinical practice but are of variable methodological quality. Large, well-designed trials are needed to confirm the effectiveness of antispasticity agents and to produce evidence-based treatment algorithms.
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Affiliation(s)
- Susana Otero-Romero
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain/Preventive Medicine and Epidemiology Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Giancarlo Comi
- Neurological Department, Institute of Experimental Neurology (INSPE), Scientific Institute Hospital San Raffaele, University Vita-Salute San Raffaele, Milan, Italy
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Per Soelberg Sørensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alan J Thompson
- Department of Brain Repair & Rehabilitation, Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Patrick Vermersch
- Université Lille, INSERM, CHU Lille, Lille Inflammation Research International Center (LIRIC) UMR 995, Lille, France
| | - Ralf Gold
- Department of Neurology, Ruhr University, St. Josef-Hospital, Bochum, Germany
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia (Cemcat), Department of Neurology-Neuroimmunology, Vall d’Hebron University Hospital, Barcelona, Spain
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14
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Yuan M, Zhou HY, Xiao ZL, Wang W, Li XL, Chen SJ, Yin XP, Xu LJ. Efficacy and Safety of Gabapentin vs. Carbamazepine in the Treatment of Trigeminal Neuralgia: A Meta-Analysis. Pain Pract 2016; 16:1083-1091. [PMID: 26891784 DOI: 10.1111/papr.12406] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 09/05/2015] [Indexed: 01/27/2023]
Abstract
To evaluate the safety and efficacy of gabapentin in comparison with carbamazepine in the treatment of trigeminal neuralgia, a meta-analysis of randomized controlled trials was performed. Two reviewers independently selected studies, assessed study quality, and extracted data. Sixteen randomized controlled trials that included 1,331 patients were assessed. The meta-analysis showed that the total effective rate of gabapentin therapy group was similar with carbamazepine therapy group (OR = 1.600, 95% CI 1.185, 2.161, P = 0.002). While the effective rate of gabapentin therapy for 4 weeks was higher than that of carbamazepine therapy (OR = 1.495, 95% CI 1.061, 2.107, P = 0.022, heterogeneity: x2 = 7.12, P = 0.625, I2 = 0.0%), the life satisfaction improvement is also better in the gabapentin therapy group after a 4-week treatment (SMD = 0.966, 95% CI 0.583, 1.348, P < 0.001). Furthermore, our meta-analysis suggested that the adverse reaction rate of gabapentin therapy group was significantly lower than that of carbamazepine therapy group (OR = 0.312, 95% CI 0.240, 0.407, P < 0.001). In conclusion, present trials comparing gabapentin with carbamazepine are all poor in terms of methodological quality. Based on the available evidence, it is not possible to draw conclusions regarding the efficacy and side effects of gabapentin being superior to carbamazepine.
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Affiliation(s)
- Min Yuan
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huang-Yan Zhou
- Department of Immunology and Pathogenic Biology, The Basic Medical College of Nanchang University, Nanchang, Jiangxi, China
| | - Zhi-Long Xiao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wei Wang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xue-Li Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Shen-Jian Chen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiao-Ping Yin
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Li-Jun Xu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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15
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Termsarasab P, Thammongkolchai T, Frucht SJ. Spinal-generated movement disorders: a clinical review. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2015; 2:18. [PMID: 26788354 PMCID: PMC4711055 DOI: 10.1186/s40734-015-0028-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/24/2015] [Indexed: 12/25/2022]
Abstract
Spinal-generated movement disorders (SGMDs) include spinal segmental myoclonus, propriospinal myoclonus, orthostatic tremor, secondary paroxysmal dyskinesias, stiff person syndrome and its variants, movements in brain death, and painful legs-moving toes syndrome. In this paper, we review the relevant anatomy and physiology of SGMDs, characterize and demonstrate their clinical features, and present a practical approach to the diagnosis and management of these unusual disorders.
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Affiliation(s)
- Pichet Termsarasab
- />Department of Neurology, Movement Disorder Division, Icahn School of Medicine at Mount Sinai, New York, USA
- />Department of Medicine, Neurology Division, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Steven J. Frucht
- />Department of Neurology, Movement Disorder Division, Icahn School of Medicine at Mount Sinai, New York, USA
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Khan N, Woodruff TM, Smith MT. Establishment and characterization of an optimized mouse model of multiple sclerosis-induced neuropathic pain using behavioral, pharmacologic, histologic and immunohistochemical methods. Pharmacol Biochem Behav 2014; 126:13-27. [PMID: 25223977 DOI: 10.1016/j.pbb.2014.09.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/25/2014] [Accepted: 09/06/2014] [Indexed: 11/19/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) that causes debilitating central neuropathic pain in many patients. Although mouse models of experimental autoimmune encephalomyelitis (EAE) have provided insight on the pathobiology of MS-induced neuropathic pain, concurrent severe motor impairments confound quantitative assessment of pain behaviors over the disease course. To address this issue, we have established and characterized an optimized EAE-mouse model of MS-induced neuropathic pain. Briefly, C57BL/6 mice were immunized with MOG35-55 (200μg) and adjuvants comprising Quil A (45μg) and pertussis toxin (2×250ng). The traditionally used Freund's Complete Adjuvant (FCA) was replaced with Quil A, as FCA itself induces CNS neuroinflammation. Herein, EAE-mice exhibited a mild relapsing-remitting clinical disease course with temporal development of mechanical allodynia in the bilateral hindpaws. Mechanical allodynia was fully developed by 28-30days post-immunization (p.i.) and was maintained until study completion (52-60days p.i.), in the absence of confounding motor deficits. Single bolus doses of amitriptyline (1-7mg/kg), gabapentin (10-50mg/kg) and morphine (0.1-2mg/kg) evoked dose-dependent analgesia in the bilateral hindpaws of EAE-mice; the corresponding ED50s were 1.5, 20 and 1mg/kg respectively. At day 39 p.i. in EAE-mice exhibiting mechanical allodynia in the hindpaws, there was marked demyelination and gliosis in the brain and lumbar spinal cord, mirroring these pathobiologic hallmark features of MS in humans. Our optimized EAE-mouse model of MS-associated neuropathic pain will be invaluable for future investigation of the pathobiology of MS-induced neuropathic pain and for efficacy profiling of novel molecules as potential new analgesics for improved relief of this condition.
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MESH Headings
- Amines/therapeutic use
- Amitriptyline/therapeutic use
- Animals
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Brain/pathology
- Cyclohexanecarboxylic Acids/therapeutic use
- Demyelinating Diseases/pathology
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Encephalomyelitis, Autoimmune, Experimental/chemically induced
- Encephalomyelitis, Autoimmune, Experimental/complications
- Encephalomyelitis, Autoimmune, Experimental/drug therapy
- Encephalomyelitis, Autoimmune, Experimental/pathology
- Female
- Gabapentin
- Gait
- Gliosis/pathology
- Hyperalgesia/chemically induced
- Hyperalgesia/complications
- Hyperalgesia/drug therapy
- Mice
- Morphine/therapeutic use
- Multiple Sclerosis/complications
- Multiple Sclerosis/drug therapy
- Myelin-Oligodendrocyte Glycoprotein
- Neuralgia/complications
- Neuralgia/drug therapy
- Peptide Fragments
- Pertussis Toxin
- Quillaja Saponins
- gamma-Aminobutyric Acid/therapeutic use
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Affiliation(s)
- Nemat Khan
- The University of Queensland, Center for Integrated Preclinical Drug Development, St Lucia Campus, Brisbane, Queensland 4072, Australia; School of Pharmacy, The University of Queensland, Pharmacy Australia Center of Excellence, Woolloongabba, Brisbane, Queensland 4102, Australia
| | - Trent M Woodruff
- The School of Biomedical Sciences, University of Queensland, St Lucia Campus, Brisbane, Queensland 4072, Australia
| | - Maree T Smith
- The University of Queensland, Center for Integrated Preclinical Drug Development, St Lucia Campus, Brisbane, Queensland 4072, Australia; School of Pharmacy, The University of Queensland, Pharmacy Australia Center of Excellence, Woolloongabba, Brisbane, Queensland 4102, Australia.
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17
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Khan N, Smith MT. Multiple sclerosis-induced neuropathic pain: pharmacological management and pathophysiological insights from rodent EAE models. Inflammopharmacology 2014; 22:1-22. [PMID: 24234347 PMCID: PMC3933737 DOI: 10.1007/s10787-013-0195-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 10/22/2013] [Indexed: 01/05/2023]
Abstract
In patients with multiple sclerosis (MS), pain is a frequent and disabling symptom. The prevalence is in the range 29-86 % depending upon the assessment protocols utilised and the definition of pain applied. Neuropathic pain that develops secondary to demyelination, neuroinflammation and axonal damage in the central nervous system is the most distressing and difficult type of pain to treat. Although dysaesthetic extremity pain, L'hermitte's sign and trigeminal neuralgia are the most common neuropathic pain conditions reported by patients with MS, research directed at gaining insight into the complex mechanisms underpinning the pathobiology of MS-associated neuropathic pain is in its relative infancy. By contrast, there is a wealth of knowledge on the neurobiology of neuropathic pain induced by peripheral nerve injury. To date, the majority of research in the MS field has used rodent models of experimental autoimmune encephalomyelitis (EAE) as these models have many clinical and neuropathological features in common with those observed in patients with MS. However, it is only relatively recently that EAE-rodents have been utilised to investigate the mechanisms contributing to the development and maintenance of MS-associated central neuropathic pain. Importantly, EAE-rodent models exhibit pro-nociceptive behaviours predominantly in the lower extremities (tail and hindlimbs) as seen clinically in patients with MS-neuropathic pain. Herein, we review research to date on the pathophysiological mechanisms underpinning MS-associated neuropathic pain as well as the pharmacological management of this condition. We also identify knowledge gaps to guide future research in this important field.
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Affiliation(s)
- Nemat Khan
- Centre for Integrated Preclinical Drug Development and School of Pharmacy, The University of Queensland, Level 3, Steele Building, St. Lucia Campus, Brisbane, QLD 4072 Australia
| | - Maree T. Smith
- Centre for Integrated Preclinical Drug Development and School of Pharmacy, The University of Queensland, Level 3, Steele Building, St. Lucia Campus, Brisbane, QLD 4072 Australia
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18
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Solaro C, Tanganelli P, Messmer Uccelli M. Pharmacological treatment of pain in multiple sclerosis. Expert Rev Neurother 2014; 7:1165-74. [PMID: 17868015 DOI: 10.1586/14737175.7.9.1165] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pain is a common symptom in multiple sclerosis (MS) and was recently estimated to be experienced by up to 75% of patients. Nociceptive and neuropathic pain in MS may be present concurrently and at different stages of the disease and may be associated with other symptoms. Evidence for treating pain in MS is limited. Many clinical features of pain are often unrecognized by clinicians and are difficult for patients to describe. Treatment is often based on anecdotal reports and clinical experience. We present a review of treatment options for pain in MS that should serve to update current knowledge, highlight shortcomings in clinical research and provide indications towards achieving evidence-based treatment of pain in MS.
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Affiliation(s)
- Claudio Solaro
- ASL 3 Hospitals, Department of Neurology, Via Oliva 22, Genoa 16153, Italy.
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19
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Toosy A, Ciccarelli O, Thompson A. Symptomatic treatment and management of multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2014; 122:513-562. [PMID: 24507534 DOI: 10.1016/b978-0-444-52001-2.00023-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.
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Affiliation(s)
- Ahmed Toosy
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Olga Ciccarelli
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Alan Thompson
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK.
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20
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Abstract
The onset of multiple sclerosis (MS) in childhood and adolescence is being increasingly recognized. Relative to MS in adults, little is known about the diagnostic evaluation, clinical course, outcome, and management of MS in children. To remedy some of these deficiencies, pediatric MS clinics have been created in several countries to provide specialized care to, and to study, affected children. Research is currently underway to investigate the pathobiologic features of childhood-onset MS, to study the mechanisms of myelin inflammation and repair, to evaluate patient outcomes collaboratively between the different clinics, and to increase knowledge of pediatric MS for children living with the disease. It is hoped that, through an understanding of the earliest aspects of the MS disease process, critical insights will be gained about the genesis of MS.
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21
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Affiliation(s)
- Alexander D Rae-Grant
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.
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22
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Neuropathic pain in animal models of nervous system autoimmune diseases. Mediators Inflamm 2013; 2013:298326. [PMID: 23737643 PMCID: PMC3662183 DOI: 10.1155/2013/298326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/09/2013] [Indexed: 12/19/2022] Open
Abstract
Neuropathic pain is a frequent chronic presentation in autoimmune diseases of the nervous system, such as multiple sclerosis (MS) and Guillain-Barre syndrome (GBS), causing significant individual disablement and suffering. Animal models of experimental autoimmune encephalomyelitis (EAE) and experimental autoimmune neuritis (EAN) mimic many aspects of MS and GBS, respectively, and are well suited to study the pathophysiology of these autoimmune diseases. However, while much attention has been devoted to curative options, research into neuropathic pain mechanisms and relief has been somewhat lacking. Recent studies have demonstrated a variety of sensory abnormalities in different EAE and EAN models, which enable investigations of behavioural changes, underlying mechanisms, and potential pharmacotherapies for neuropathic pain associated with these diseases. This review examines the symptoms, mechanisms, and clinical therapeutic options in these conditions and highlights the value of EAE and EAN animal models for the study of neuropathic pain in MS and GBS.
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24
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Krzyzanowska A, Avendaño C. Behavioral testing in rodent models of orofacial neuropathic and inflammatory pain. Brain Behav 2012; 2:678-97. [PMID: 23139912 PMCID: PMC3489819 DOI: 10.1002/brb3.85] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 07/10/2012] [Accepted: 07/13/2012] [Indexed: 11/12/2022] Open
Abstract
Orofacial pain conditions are often very debilitating to the patient and difficult to treat. While clinical interest is high, the proportion of studies performed in the orofacial region in laboratory animals is relatively low, compared with other body regions. This is partly due to difficulties in testing freely moving animals and therefore lack of reliable testing methods. Here we present a comprehensive review of the currently used rodent models of inflammatory and neuropathic pain adapted to the orofacial areas, taking into account the difficulties and drawbacks of the existing approaches. We examine the available testing methods and procedures used for assessing the behavioral responses in the face in both mice and rats and provide a summary of some pharmacological agents used in these paradigms to date. The use of these agents in animal models is also compared with outcomes observed in the clinic.
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Affiliation(s)
- Agnieszka Krzyzanowska
- Department of Anatomy, Histology and Neuroscience, Autonoma University of Madrid, Medical School Madrid, Spain
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25
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De Santi L, Annunziata P. Symptomatic cranial neuralgias in multiple sclerosis: Clinical features and treatment. Clin Neurol Neurosurg 2012; 114:101-7. [DOI: 10.1016/j.clineuro.2011.10.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 10/29/2011] [Accepted: 10/30/2011] [Indexed: 11/15/2022]
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Abstract
INTRODUCTION Multiple sclerosis (MS) is an inflammatory, demyelinating, central nervous system disease that frequently causes pain. AREAS COVERED This article reviews the current literature and describes the therapeutic options for treating MS-related pain. The reader will be provided with current, evidence-based knowledge about the treatment of MS-related pain, and the review will take a practical approach to the various drugs for treating pain, including starting dose, titration and side effects. EXPERT OPINION Only cannabinoids have been assessed in randomized, controlled trials. Because of the concern regarding the risk of abuse and psychiatric adverse events, published guidelines as well as expert recommendations suggest using them as second-line therapy only. Hence, current treatment should be based on the general principles for treating peripheral neuropathic pain, taking into account drug-induced adverse effects.
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Affiliation(s)
- Andrea Truini
- University of Rome-La Sapienza, Department of Neurology and Psychiatry, Viale Università 30, 00185 Rome, Italy.
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27
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Thibault K, Calvino B, Pezetl S. Characterisation of sensory abnormalities observed in an animal model of multiple sclerosis: A behavioural and pharmacological study. Eur J Pain 2012; 15:231.e1-16. [DOI: 10.1016/j.ejpain.2010.07.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 06/17/2010] [Accepted: 07/12/2010] [Indexed: 10/19/2022]
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Ogawa K, Takasu K, Shinohara S, Yoneda Y, Kato A. Pharmacological characterization of lysophosphatidic acid-induced pain with clinically relevant neuropathic pain drugs. Eur J Pain 2011; 16:994-1004. [DOI: 10.1002/j.1532-2149.2011.00096.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2011] [Indexed: 11/06/2022]
Affiliation(s)
| | - K. Takasu
- Pain and Neurology, Discovery Research Laboratories; Shionogi & Co., Ltd; Shiga; Japan
| | - S. Shinohara
- Pain and Neurology, Discovery Research Laboratories; Shionogi & Co., Ltd; Shiga; Japan
| | - Y. Yoneda
- Laboratory of Molecular Pharmacology, Division of Pharmaceutical Sciences; Kanazawa University Graduate School of Natural Science and Technology; Ishikawa; Japan
| | - A. Kato
- Pain and Neurology, Discovery Research Laboratories; Shionogi & Co., Ltd; Shiga; Japan
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30
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Abstract
Multiple sclerosis (MS) is an inflammatory, demyelinating, autoimmune disease of the CNS. There are currently a number of disease-modifying medications for MS that modulate or suppress the immune system; however, these medications do not directly relieve MS symptoms, which include visual deficits, gait problems, sensory deficits, weakness, tremor, spasticity and pain, among others. Pain is a common symptom in MS which has recently been estimated to be experienced by more than 40% of patients. Nociceptive pain occurs as an appropriate physiological response transmitted to a conscious level when nociceptors in bone, muscle or any body tissue are activated, warning the organism of tissue damage. Neuropathic pain is initiated as a direct consequence of a lesion or disease affecting the somatosensory system, with no physiological advantage. Nociceptive and neuropathic pain in MS may be present concurrently and at different stages of the disease, and may be associated with other symptoms. Central neuropathic pain has been reported to be among the most common pain syndromes in MS. It is described as constant, often spontaneous, burning occurring more frequently in the lower limbs. Treatment typically includes tricyclic antidepressants and antiepileptic medications, although studies have been conducted in relatively small samples and optimal dosing has not been confirmed. Cannabinoids have been among the few treatments studied in well designed, randomized, placebo-controlled trials for central neuropathic pain. In the largest of these trials, which included 630 subjects, a 15-week comparison between Delta9-tetrahydrocannabinol and placebo was performed. More patients receiving active treatment perceived an improvement in pain than those receiving placebo, although approximately 20% of subjects reported worsening of pain while on active treatment. Trigeminal neuralgia, while affecting less than 5% of patients with MS, is the most studied pain syndrome. The pain can be extreme and is typically treated with carbamazepine, although adverse effects can mimic an MS exacerbation. Painful topic spasms occur in approximately 11% of the MS population and are treated with antispasticity medications such as baclofen and benzodiazepines. Gabapentin has also demonstrated efficacy, but all studies have included small sample sizes. In general, evidence for treating pain in MS is limited. Many clinical features of pain are often unrecognized by clinicians and are difficult for patients to describe. Treatment is often based on anecdotal reports and clinical experience. We present a review of treatment options for pain in MS, which should serve to update current knowledge, highlight shortcomings in clinical research and provide indications towards achieving evidence-based treatment of pain in MS.
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Abstract
Trigeminal neuralgia occurs in approximately 1-2% of patients suffering from multiple sclerosis. Its pathophysiology is common to idiopathic forms and resides in altered properties of the sensory axonal membrane at the root entry zone into the pons, leading to parossistic firing. Antiepileptic drugs of the sodium channel blocker type, such as carbamazepine, lamotrigine, and phenytoin are highly effective in controlling pain. However, side effects on the CNS may, at higher doses, severely worsen the already impaired neurologic conditions in multiple sclerosis patients. Baclofen, a presynaptic muscle relaxant is also beneficial in trigeminal pain. Whatever the drug, habituation and loss of efficacy are likely to occur sooner or later. Symptomatic, neurolesive surgery is indicated in cases resistant or intolerant to medical therapy. Radiofrequency thermorhizotomy, either monitored by trigeminal evoked potentials or not, is the recommended procedure, as it may be considered the most reliable as far as localization and degree of lesion are concerned.
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Affiliation(s)
- Massimo Leandri
- Interuniversity Centre for Pain Neurophysiology, Via Dodecaneso 35, I-16132, Genova, Italy.
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32
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Solaro C, Boehmker M, Tanganelli P. Pregabalin for treating paroxysmal painful symptoms in multiple sclerosis: a pilot study. J Neurol 2009; 256:1773-4. [PMID: 19579001 DOI: 10.1007/s00415-009-5203-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Accepted: 05/28/2009] [Indexed: 01/13/2023]
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Cruccu G, Gronseth G, Alksne J, Argoff C, Brainin M, Burchiel K, Nurmikko T, Zakrzewska JM. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol 2008. [DOI: 10.1111/j.1468-1331.2008.02185.x epub 2008 aug 21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Cruccu G, Gronseth G, Alksne J, Argoff C, Brainin M, Burchiel K, Nurmikko T, Zakrzewska JM. AAN-EFNS guidelines on trigeminal neuralgia management. Eur J Neurol 2008; 15:1013-28. [PMID: 18721143 DOI: 10.1111/j.1468-1331.2008.02185.x] [Citation(s) in RCA: 400] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Several issues regarding diagnosis, pharmacological treatment, and surgical treatment of trigeminal neuralgia (TN) are still unsettled. The American Academy of Neurology and the European Federation of Neurological Societies launched a joint Task Force to prepare general guidelines for the management of this condition. After systematic review of the literature the Task Force came to a series of evidence-based recommendations. In patients with TN MRI may be considered to identify patients with structural causes. The presence of trigeminal sensory deficits, bilateral involvement, and abnormal trigeminal reflexes should be considered useful to disclose symptomatic TN, whereas younger age of onset, involvement of the first division, unresponsiveness to treatment and abnormal trigeminal evoked potentials are not useful in distinguishing symptomatic from classic TN. Carbamazepine (stronger evidence) or oxcarbazepine (better tolerability) should be offered as first-line treatment for pain control. For patients with TN refractory to medical therapy early surgical therapy may be considered. Gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. Microvascular decompression may be considered over other surgical techniques to provide the longest duration of pain freedom. The role of surgery versus pharmacotherapy in the management of TN in patients with multiple sclerosis remains uncertain.
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Affiliation(s)
- G Cruccu
- Department of Neurological Sciences, La Sapienza University, Rome, Italy.
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35
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Abstract
While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.
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36
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Abstract
Central neuropathic pain is a painful condition, often severe, that occurs in a person who is already affected by an injury or disease of the brain or spinal cord. This dual insult is especially threatening to the quality of life of a person and their ability to perform even the most basic of tasks. Despite this high level of suffering there are relatively few trials investigating the management of central neuropathic pain. However, two randomised placebo-controlled studies have recently emerged demonstrating efficacy of pregabalin in reducing central neuropathic pain due to spinal cord injury and central poststroke pain. Pregabalin, an anticonvulsant, has been shown to be efficacious in the management of peripheral neuropathic pain of various causes and now may have a role to play in central neuropathic pain.
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Affiliation(s)
- Paul Gray
- Royal Brisbane and Women's Hospital, Multidisciplinary Pain Centre, Herston, 4029, Australia.
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37
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Obermann M, Yoon MS, Sensen K, Maschke M, Diener HC, Katsarava Z. Efficacy of Pregabalin in the Treatment of Trigeminal Neuralgia. Cephalalgia 2007; 28:174-81. [DOI: 10.1111/j.1468-2982.2007.01483.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This prospective, open-label study aimed to evaluate the efficacy of pregabalin treatment in patients suffering from trigeminal neuralgia with and without concomitant facial pain. Fifty-three patients with trigeminal neuralgia (14 with concomitant chronic facial pain) received pregabalin (PGB) 150-600 mg daily and were prospectively followed for 1 year. The primary outcome was number of patients pain free or with reduction of pain intensity by > 50% and of attack frequency by > 50% after 8 weeks. Secondary outcome was sustained pain relief after 1 year. Thirty-nine patients (74%) improved after 8 weeks with a mean dose of 269.8 mg/day (range 150-600 mg/day) PGB: 13 (25%) experienced complete pain relief and 26 (49%) reported pain reduction > 50%, whereas 14 (26%) did not improve. Patients without concomitant facial pain showed better response rates (32 of 39, 82%) compared with patients with concomitant chronic facial pain (7 of 14, 50%, P = 0.020). Concomitant chronic facial pain appears to be a clinical predictor of poor treatment outcome. PGB appears to be effective in the treatment of trigeminal neuralgia.
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Affiliation(s)
- M Obermann
- Department of Neurology, University of Duisburg-Essen, Essen
| | - MS Yoon
- Department of Neurology, University of Duisburg-Essen, Essen
| | - K Sensen
- Department of Neurology, University of Duisburg-Essen, Essen
| | - M Maschke
- Department of Neurology, University of Duisburg-Essen, Essen
- Department of Neurology and Neurophysiology, Bruederkrankenhaus Trier, Germany
| | - HC Diener
- Department of Neurology, University of Duisburg-Essen, Essen
| | - Z Katsarava
- Department of Neurology, University of Duisburg-Essen, Essen
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38
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Solaro C, Restivo D, Mancardi GL, Tanganelli P. Oxcarbazepine for treating paroxysmal painful symptoms in multiple sclerosis: a pilot study. Neurol Sci 2007; 28:156-8. [PMID: 17603770 DOI: 10.1007/s10072-007-0811-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 05/07/2007] [Indexed: 10/23/2022]
Abstract
Oxcarbazepine (OXC) is an anitepileptic medication recently approved as monotherapy for partial onset seizure and demonstrated to be useful in the treatment of several neuropathic pain. We performed an open-label pilot study of OXC (dosage 600-1200 mg/day) in 12 multiple sclerosis (MS) patients suffering painful paroxysmal symptoms. Eight subjects were female and 4 male, with a mean age of 43.6 years, mean disease duration of 7.3 years and mean score at the EDSS of 3.2. Ten patients had a relapsing-remitting disease course, 1 had secondary progressive and 1 had primary progressive course. Painful paroxysmal symptoms (PPS) were defined as transient painful symptoms in any area of the body, with abrupt onset, brief duration, from a few seconds to a few minutes, with repetitive and stereotyped features. The subjective level of the PPS was scored using a three-point scale (0-3). The mean dosage of OXC was 1033 mg daily. Nine patients experienced a complete and sustained recovery within 1 month from treatment initiation (T0 vs. T1, p>0.05). Two patients dropped out of the study due to adverse effects: 1 case of nausea and dizziness, 1 case of C. hyponatraemia. The medication was well tolerated in the majority of the subjects. The study results provide a new possibility for treating painful symptoms in MS, but efficacy on PPS must be confirmed in a larger study.
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Affiliation(s)
- C Solaro
- Department of Neurology ASL 3 Genovese, Via Oliva 22, I-16123, Genova, Italy.
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Management of neuropathic orofacial pain. ACTA ACUST UNITED AC 2007; 103 Suppl:S32.e1-24. [PMID: 17379152 DOI: 10.1016/j.tripleo.2006.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Accepted: 10/16/2006] [Indexed: 12/13/2022]
Abstract
Current management of painful trigeminal neuropathies relies on pharmacological (topical and systemic), surgical, and complementary modalities. There is, however, a lack of quality research relating to the effectiveness of these modalities. In this review we analyze the available data that relates to the therapy of trigeminal neuralgia, postherpetic neuralgia, and posttraumatic neuropathies and provide clinical guidelines. The review focuses on medical management, as well as surgical and other interventions for painful neuropathies.
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Siniscalchi A, Gallelli L, Scornaienghi D, Mancuso F, De Sarro G. Topiramate therapy for symptomatic trigeminal neuralgia. Clin Drug Investig 2007; 26:113-5. [PMID: 17163241 DOI: 10.2165/00044011-200626020-00006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- A Siniscalchi
- Department of Neuroscience, Neurology Division, Annunziata Hospital, Cosenza, Italy
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Henze T, Rieckmann P, Toyka KV. Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society. Eur Neurol 2006; 56:78-105. [PMID: 16966832 DOI: 10.1159/000095699] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 07/12/2006] [Indexed: 01/13/2023]
Abstract
Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.
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Affiliation(s)
- T Henze
- Reha-Zentrum Nittenau, Rehabilitationszentrum fur Neurologie, Nittenau, Germany.
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Abstract
Trigeminal neuralgia is a chronic pain syndrome of still unestablished origin. Its diagnosis depends on clinical grounds. Drug therapy initially helps a great majority of patients. The choice of drugs is quite large, but truly effective compounds with a tolerable side effect profile remain few. Carbamazepine (or oxcarbazepine) and lamotrigine appear to be the most effective, followed by baclofen. Several patients require further nonpharmacological treatment for which no evidence-based recommendation is possible. In the future, neuromodulation may be brought to bear, as in other chronic pain syndromes.
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Affiliation(s)
- Sergio Canavero
- Turin Advanced Neuromodulation Group, Cso Einaudi 2 10128, Turin, Italy.
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Crayton HJ, Rossman HS. Managing the symptoms of multiple sclerosis: a multimodal approach. Clin Ther 2006; 28:445-60. [PMID: 16750459 DOI: 10.1016/j.clinthera.2006.04.005] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) may experience numerous symptoms, including spasticity, fatigue, cognitive dysfunction, depression, bladder dysfunction, bowel dysfunction, sexual dysfunction, and pain. OBJECTIVE This article reviews the pharmacologic and nonpharmacologic interventions used to manage the symptoms of MS and discusses how interventions for a particular MS symptom may have an impact on other symptoms. METHODS The English-language literature was reviewed through November 2005 using MEDLINE and the Cochrane Database of Systematic Reviews, with no restriction on year. The search terms included multiple sclerosis, disease-modifying therapies, adverse events, and combinations of multiple sclerosis with terms such as spasticity, fatigue, depression, mood disorders, pain, bladder dysfunction, bowel dysfunction, sexual dysfunction, cognitive dysfunction, and quality of life. RESULTS The numerous options for the treatment of MS symptoms have shown varying degrees of efficacy and tolerability. Certain symptoms, if left untreated, may precipitate exacerbation of others. For example, spasticity may lead to pain and bladder and bowel dysfunction, whereas fatigue can compromise cognitive function. Similarly, the adverse effects of treatments for certain symptoms may further compromise other aspects of function. For example, the use of antidepressants may lead to sexual dysfunction, and treatments for spasticity and pain may cause sedation, which can worsen fatigue, cognitive dysfunction, and depressed mood. CONCLUSIONS MS is associated with numerous symptoms that can be adversely affected by each other and by therapeutic interventions. Careful clinical monitoring and individualization of pharmacologic and non-pharmacologic therapies are recommended to manage the symptoms of MS, with the goals of improving or maintaining function and preserving the patient's quality of life.
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Affiliation(s)
- Heidi J Crayton
- Georgetown University Hospital, Washington, District of Columbia 20007, USA.
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Abstract
The onset of multiple sclerosis is being increasingly recognized in children and adolescents. There are now approved immunomodulatory therapies for adults with multiple sclerosis. Treatment early in the disease course appears to have a greater impact on disease outcome, an issue of particular importance for children who face decades of multiple sclerosis disease activity. This review summarizes the multiple sclerosis therapies currently available, efficacy data available from studies of these medications in adults and limited information on the use of these medications in children. Future directions in multiple sclerosis therapeutics and specific issues relating to pediatric multiple sclerosis are discussed.
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Affiliation(s)
- Brenda Banwell
- University of Toronto, Pediatric Multiple Sclerosis Clinic, ON, Canada.
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Svendsen KB, Bach FW. Chapter 49 Pain in multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2006; 81:731-745. [PMID: 18808871 DOI: 10.1016/s0072-9752(06)80053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Pandey CK, Raza M, Tripathi M, Navkar DV, Kumar A, Singh UK. The comparative evaluation of gabapentin and carbamazepine for pain management in Guillain-Barré syndrome patients in the intensive care unit. Anesth Analg 2005; 101:220-5, table of contents. [PMID: 15976235 DOI: 10.1213/01.ane.0000152186.89020.36] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the effects of gabapentin and carbamazepine for pain relief in 36 Guillain-Barré syndrome patients. Patients were randomly assigned to receive gabapentin 300 mg, carbamazepine 100 mg, or matching placebo 3 times a day for 7 days. Fentanyl 2 microg/kg was used as a supplementary analgesic on patient demand. The pain score was recorded by using a numeric pain rating scale of 0-10, and sedation was recorded with a Ramsay sedation scale of 1-6 before medications were given and then at 6-h intervals throughout the study period. Total daily fentanyl consumption was recorded each day for each patient. The results of the study demonstrated that patients in the gabapentin group had significantly lower (P < 0.05) median numeric pain rating scale scores (3.5, 2.5, 2.0, 2.0, 2.0, 2.0, and 2.0) compared with patients in the placebo group (6.0, 6.0, 6.0, 6.0, 6.0, 6.0, and 6.0) and the carbamazepine group (6.0, 6.0, 5.0, 4.0, 4.0, 3.5, and 3.0). There was no significant difference in fentanyl consumption between the gabapentin and carbamazepine groups on Day 1 (340.1 +/- 34.3 microg and 347.5 +/- 38.0 microg, respectively), but consumption was significantly less in these 2 groups compared with the placebo group (590.4 +/- 35.0 microg) (P < 0.05). For the rest of the study period, there was a significant difference in fentanyl consumption among all treatment groups, and it was minimal in the gabapentin group (P < 0.05). We conclude that gabapentin is more effective than carbamazepine for decreasing pain and fentanyl consumption.
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Affiliation(s)
- Chandra Kant Pandey
- Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.
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Restivo DA, Tinazzi M, Patti F, Palmeri A, Maimone D. Botulinum toxin treatment of painful tonic spasms in multiple sclerosis. Neurology 2003; 61:719-20. [PMID: 12963779 DOI: 10.1212/01.wnl.0000080081.74117.e4] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- D A Restivo
- Department of Neurology, Garibaldi Hospital, Catania, Italy.
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Kapur N, Kamel IR, Herlich A. Oral and craniofacial pain: diagnosis, pathophysiology, and treatment. Int Anesthesiol Clin 2003; 41:115-50. [PMID: 12872029 DOI: 10.1097/00004311-200341030-00010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Neeraj Kapur
- Department of Anesthesiology, Temple University Hospital, Philadelphia, PA 19140, USA
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Abstract
Pregabalin (S-[+]-3-isobutylgaba) was designed as a lipophilic GABA (gamma-aminobutyric acid) analogue substituted at the 3'-position in order to facilitate diffusion across the blood-brain barrier. It was originally developed as an anticonvulsant agent, however it has been shown to be effective in the treatment of several disorders including hyperalgesia and behavioural disorders. Although its exact mode of action remains unclear, pregabalin interacts with the same binding site and has a similar pharmacological profile as its predecessor, gabapentin (1-[aminomethyl] cyclohexane acetic acid). Its main site of action appears to be on the alpha(2)delta subunit of voltage-dependent calcium channels, widely distributed throughout the peripheral and central nervous system. Pregabalin appears to produce an inhibitory modulation of neuronal excitability. In healthy volunteers, it is rapidly absorbed with peak blood concentrations within 1 h and it has a bioavailability of approximately 90%. In preclinical trials of anticonvulsant activity, pregabalin is three to ten times more potent than gabapentin. It is well-tolerated and associated with dose-dependent adverse effects (ataxia, dizziness, headache and somnolence) that are mild-to-moderate and usually transient. There are no known pharmacokinetic drug-drug interactions reported to date. Preliminary animal and human studies showed beneficial effects in both ethological and conflict models of anxiety, as well as having some sleep-modulating properties. In Phase II and III trials, pregabalin shows promising anxiolytic action when compared to placebo in generalised anxiety disorder, social phobia and panic disorder.
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Noseworthy JH. Treatment of multiple sclerosis and related disorders: what's new in the past 2 years? Clin Neuropharmacol 2003; 26:28-37. [PMID: 12567162 DOI: 10.1097/00002826-200301000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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