Opioids in post-stroke pain: a systematic review and meta-analysis

Background: Post-stroke pain is one of the most common sequelae of stroke, which stands among the leading causes of death and adult-acquired disability worldwide. The role and clinical efficacy of opioids in post-stroke pain syndromes is still debated. Objectives: Due to the important gap in knowledge on the management of post-stroke pain, this systematic review aimed at assessing the efficacy of opioids in post-stroke pain syndromes. Methods: A literature search was conducted on databases relevant for medical scientific literature, i.e. PubMed/MEDLINE, Scopus, Web of Science and Cochrane Library databases from databases inception until August 31st, 2020 for clinical trials assessing the effects of opioids and opioid antagonists on pain reduction and pain related symptoms in patients with post-stroke pain syndromes. Studies assessing the effects of other medications (e.g., tricyclic antidepressant, pregabalin) or non - pharmacological management strategies (e.g., neurostimulation techniques) were excluded. The selected studies have been subjected to examination of the risk of bias. Results: The literature search retrieved 83,435 results. After duplicates removal, 34,285 articles were title and abstract screened. 25 full texts were assessed and 8 articles were identified to be eligible for inclusion in the qualitative summary and narrative analysis, of which three were placebo-controlled and two were dose-response. Among placebo-controlled studies, two evaluated the analgesic effect of morphine and one assessed the effects of the opioid antagonist naloxone on patients with central post-stroke pain. With regard to dose-response studies, both were on patients with central post-stroke pain, one assessing the efficacy of levorphanol, and the other on naloxone. Seven out of eight included studies showed an overall slight analgesic effect of opioids, with less consistent effects on other pain-related symptoms (e.g., mood, quality of life). The randomized controlled trials were subjected to meta-analysis and rating of the quality of evidence for the two outcomes considered according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system. The overall results are inconclusive because of the small number of studies and of patients. Conclusions: The limited number of the included studies and their heterogeneity in terms of study design do not support the efficacy of opioids in post-stroke pain and in pain-related outcomes. Large double-blind randomized clinical trials with objective assessment of pain and related symptoms are needed to further investigate this topic

Pharmacological treatment of pain and agitation in severe dementia and responsiveness to change of the Italian Mobilization-Observation-Behavior-Intensity-Dementia (I-MOBID2) Pain Scale: study protocol

Up to 80% of Alzheimer's disease (AD) patients in nursing homes experiences chronic pain and 97% develops fluctuant neuropsychiatric symptoms (NPS). Agitation, associated with unrelieved pain, is managed through antipsychotics and may increase the risk of death. Evidence is accumulating in favor of analgesia for a safer, effective therapy of agitation. The Italian version of Mobilization-Observation-Behavior-Intensity-Dementia, I-MOBID2, recently validated in the Italian setting, shows: good scale content validity index (0.89), high construct validity (Spearman rank-order correlation Rho = 0.748), reliable internal consistency (Cronbach's α coefficient = 0.751), good-excellent inter-rater (intraclass correlation coefficient, ICC = 0.778) and test-retest (ICC = 0.902) reliability, and good inter-rater and test-retest agreement (Cohen's K = 0.744) with 5.8 min completion time. This study intends to identify the responsiveness of the I-MOBID2 based on COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations, assessing the a priori hypotheses of (1) the efficacy of painkillers administered to severe AD patients after proper pain assessment and (2) the effect of reduction of the Cohen-Mansfield Agitation Inventory (CMAI) score and of agitation rescue medications. This protocol is approved by Calabria Region Ethics Committee protocol No. 31/2017 and follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines

New Trends in Migraine Pharmacology: Targeting Calcitonin Gene–Related Peptide (CGRP) With Monoclonal Antibodies

Migraine is a common neurologic disorder characterized by attacks consisting of unilateral, throbbing headache accompanied by photophobia, phonophobia, and nausea which remarkably reduces the patients’ quality of life. Not migraine-specific non-steroidal anti-inflammatory drugs (NSAIDs) are effective in patients affected by mild episodic migraine whilst in moderate or severe episodic migraine and in chronic migraineurs triptans and preventative therapies are needed. Since these treatments are endowed with serious side effects and have limited effectiveness new pharmacological approaches have been investigated. The demonstrated pivotal role of calcitonin gene-related peptide (CGRP) has fostered the development of CGRP antagonists, unfortunately endowed with liver toxicity, and monoclonal antibodies (mAbs) toward circulating CGRP released during migraine attack or targeting its receptor. Currently, four mAbs, eptinezumab, fremanezumab, galcanezumab for CGRP and erenumab for CGRP canonical receptor, have been studied in clinical trials for episodic and chronic migraine. Apart from the proven effectiveness, these antibodies have resulted well tolerated and could improve the compliance of the patients due to their long half-lives allowing less frequent administrations. This study aims at investigating the still poorly clear pathogenesis of migraine and the potential role of anti-CGRP mAbs in the scenario of prophylaxis of migraine

Effect of Gabapentin in a Neuropathic Pain Model in Mice Overexpressing Human Wild-Type or Human Mutated Torsin A

Background: DYT1 dystonia is the most common form of early-onset inherited dystonia, which is caused by mutation of torsin A (TA) belonging to the “ATPases associated with a variety of cellular activities” (AAA + ATPase). Dystonia is often accompanied by pain, and neuropathic pain can be associated to peripherally induced movement disorder and dystonia. However, no evidence exists on the effect of gabapentin in mice subjected to neuropathic pain model overexpressing human normal or mutated TA. Methods: Mice subjected to L5 spinal nerve ligation (SNL) develop mechanical allodynia and upregulation of the α2δ-1 L-type calcium channel subunit, forming a validated experimental model of neuropathic pain. Under these experimental conditions, TA is expressed in dorsal horn neurons and astrocytes and colocalizes with α2δ-1. Similar to this subunit, TA is overexpressed in dorsal horn 7 days after SNL. This model has been used to investigate (1) basal mechanical sensitivity; (2) neuropathic pain phases; and (3) the effect of gabapentin, an α2δ-1 ligand used against neuropathic pain, in non-transgenic (NT) C57BL/6 mice and in mice overexpressing human wild-type (hWT) or mutant (hMT) TA. Results: In comparison to non-transgenic mice, the threshold for mechanical sensitivity in hWT or hMT does not differ (Kruskal–Wallis test = 1.478; p = 0.4777, although, in the latter animals, neuropathic pain recovery phase is delayed. Interestingly, gabapentin (100 mg/Kg) reduces allodynia at its peak (occurring between post-operative day 7 and day 10) but not in the phase of recovery. Conclusions: These data lend support to the investigation on the role of TA in the molecular machinery engaged during neuropathic pain

Dementia and COVID-19: A Case Report and Literature Review on Pain Management

The coronavirus disease 2019 (COVID-19) pandemic imposes an unprecedented lifestyle, dominated by social isolation. In this frame, the population to pay the highest price is represented by demented patients. This group faces the highest risk of mortality, in case of severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection, and they experience rapid cognitive deterioration, due to lockdown measures that prevent their disease monitoring. This complex landscape mirrors an enhancement of neuropsychiatric symptoms (NPSs), with agitation, delirium and reduced motor performances, particularly in non-communicative patients. Due to the consistent link between agitation and pain in these patients, the use of antipsychotics, increasing the risk of death during COVID-19, can be avoided or reduced through an adequate pain treatment. The most suitable pain assessment scale, also feasible for e-health implementation, is the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) pain scale, currently under validation in the Italian real-world context. Here, we report the case of an 85-year-old woman suffering from mild cognitive impairment, subjected to off-label treatment with atypical antipsychotics, in the context of undertreated pain, who died during the pandemic from an extensive brain hemorrhage. This underscores the need for appropriate assessment and treatment of pain in demented patients

Progress in the Treatment of Migraine Attacks: From Traditional Approaches to Eptinezumab

Migraine is the second cause of disability and of lost years of healthy life worldwide. Migraine is characterized by recurrent headache attacks and accompanying disabling symptoms lasting 4–48 h. In episodic migraine, attacks occur in less than 15 days per month and in chronic migraine, in more than 15 monthly days. Whilst successful translation of pharmacological discoveries into efficacious therapeutics has been achieved in the preventative therapy of chronic migraine, treatment of acute migraine suffers the lack of effective advancements. An effective treatment affords complete freedom from pain two hours after therapy and provides the absence of the most bothersome symptom (MBS) associated with migraine after 2 h. However, available anti-migraine abortive treatments for acute attacks do not represent an effective and safe treatment for all the populations treated. In particular, the most used specific treatment is represented by triptans that offer 2-h sustained freedom from pain achieved in 18–50% of patients but they are contraindicated in coronary artery disease, stroke and peripheral vascular disease due to the vasoconstriction at the basis of their pharmacologic action. The most novel therapies, i.e., gepants and ditans, are without sufficient post-marketing data for secure use. Here, an attempt is proposed to analyse the rational basis and evidence in favour of investigating the efficacy and safety in acute migraine attacks of eptinezumab, i.e., monoclonal antibody (mAb) directed towards calcitonin gene-related peptide (CGRP) unique for intravenous infusion administration

Characterization of the role of ageing on mechanical and thermal nociception and nocifensive response to formalin test in C57BL/6 Mice

Dottorato di Ricerca in Biochimica Cellulare ed Attività dei Farmaci in Oncologia, XXVII Ciclo, a.a. 2013-2014Il dolore cronico, che riduce notevolmente la qualità della vita, interessa un vasto segmento della popolazione globale (il 25% della popolazione Europea e più di 100 milioni di cittadini Americani), diventando anche più frequente negli anziani (> 65 anni). In questa popolazione, il dolore cronico spesso viene incompreso e non opportunamente trattato (Bruckenthal & D’Arcy, 2007), anche a causa della resistenza alla maggior parte degli analgesici di elezione. Pertanto, questo progetto di dottorato è stato condotto con l’obiettivo di caratterizzare un modello di dolore cronico che potesse essere un valido strumento rappresentativo della condizione di dolore cronico nell’anziano ed il ruolo dell’invecchiamento nella nocicezione meccanica e termica e nella risposta nocifensiva in topi C57BL/6. Topi C57BL/6 di due mesi di età sono stati sottoposti al Test della Formalina (Dubuisson & Dennis, 1977): oltre a studiare il comportamento nocifensivo di licking/biting/flinching indotto dalla formalina, l’allodinia meccanica e l’edema sviluppati dagli animali in seguito alla somministrazione di formalina sono stati rispettivamente investigati tramite il Test di Von Frey (Chaplan et al., 1994) e l’utilizzo di un calibro, nel 1°, 4°, 7°, 9°, 11° e 14° giorno successivo alla somministrazione di formalina. Inoltre, è stata studiata l’efficacia del gabapentin, uno dei trattamenti di scelta per gli stati di dolore cronico come la neuropatia diabetica e la nevralgia postherpetica (Backonja et al., 1998; Rowbotham et al., 1998), sia nella risposta nocifensiva al test della formalina sia nella conseguente allodinia meccanica, fino a 4 giorni dopo l’iniezione di formalina. I risultati ottenuti hanno dimostrato la presenza di allodinia meccanica nella zampa ipsilaterale già due ore dopo la somministrazione di formalina, con il picco nel 4° giorno. Questa allodinia meccanica a lungo termine (fino a 14 giorni), nel 4° giorno successivo all’iniezione di formalina, interessa anche la zampa controlaterale, confermando l’esistenza di meccanismi centrali ritenuti alla base della seconda fase del test della formalina ed escludendo la possibilità che tale allodinia possa essere causata dall’edema evidenziato. Il gabapentin è risultato molto efficace nella seconda fase, lievemente efficace nella prima fase e nell’allodinia meccanica indotta dalla formalina 2 ore dopo la somministrazione di formalina. Tale attività non è stata evidenziata nel primo e nel quarto giorno successivo all’iniezione di formalina, verosimilmente a causa dell’emivita del farmaco. I nostri risultati caratterizzano il test della formalin come un modello rappresentativo di uno stato di dolore cronico che racchiude sia le caratteristiche infiammatorie del dolore articolare, spesso resistente al trattamento (Scaglione et al., 2014), sia gli aspetti centrali del dolore neuropatico, perciò molto utile per studiare le condizioni di dolore cronico che affliggono un crescente numero di pazienti anziani. Inoltre, il quadro fisiopatologico del dolore nell’anziano è stato approfondito per comprendere come l’invecchiamento potesse influenzare prima la nocicezione e, successivamente, lo sviluppo ed il mantenimento del dolore, dal momento che i cambiamenti nella nocicezione indotti dall’età non sono ancora ben noti (Taguchi et al., 2010). Pertanto, topi C57BL/6 giovani (2 mesi) e più anziani (6, 12 e 18 mesi) sono stati sottoposti a test comportamentali per determinare la sensibilità basale meccanica e termica (test di Von Frey (Chaplan et al., 1994), Pin-prick test (Chan et al., 1992), test di Hargreaves (Hargreaves et al., 1988), test dell’acetone (Choi et al., 1994)). Come dimostrato anche da studi longitudinali, soprattutto la sensibilità meccanica ed anche quella termica (sia al caldo che al freddo) sono risultate incrementate. I primi cambiamenti evidenti, in particolare per la sensibilità al freddo, sono stati osservati intorno ai 6 mesi di età. Fra l’età di 12 e di 18 mesi, i livelli di sensibilità hanno mostrato una sorta di plateau, con un incremento molto più lento. Poiché la nocicezione è risultata essere modificata negli animali anziani, si è deciso di esaminare l’effetto dell’età sulla risposta nocifensiva al dolore evocato (test della formalina). La risposta nocicettiva, espressa in secondi di licking/biting/flinching e come totale di eventi di licking/biting/flinching, è risultata differente nei topi anziani (6, 12, 18 mesi), presentando non più solo 2 ma 3 fasi di picco, uno spostamento temporale ed un’ampiezza variata. Inoltre, lo stato allodinico formalina-indotto è risultato più pronunciato nei topi anziani, nei quali l’allodinia meccanica ha continuato ancora a rimanere stabile al picco, mentre nei topi di due mesi il recupero stava già cominciando. Anche il processo di guarigione e l’edema della zampa sono risultati influenzati dall’età dell’animale. A livello molecolare, non sono state evidenziate differenze significative nei livelli della proteina p62, di LC3- I e di LC3-II, mentre solo i livelli di espressione di Beclin 1 sono risultati progressivamente ridotti con l’invecchiamento, in maniera statisticamente significativa. Sebbene siano necessari ulteriori esperimenti, questi risultati sembrano suggerire che la pathway dell’autofagia sia modificata e che il flusso autofagico sia probabilmente ridotto. Di fondamentale importanza è l’osservazione che il principale marker di dolore cronico, la subunità del canale del Ca2+ α2δ-1, è risultata quasi assente nei topi di 2 mesi e notevolmente up-regolata, seguendo un andamento a campana, nei topi di 6 e di 12 mesi. Questo fenomeno potrebbe essere alla base della ridotta soglia meccanica dei topi più anziani. Inoltre, una nuova banda a basso peso molecolare, che abbiamo chiamato α2δ-1*, è risultata altamente presente nei topi più anziani rispetto ai topi di due mesi, come la banda nota α2δ-1. I nostri risultati hanno dimostrato che anche l’efficacia del gabapentin (10 e 100 mg/Kg) nel test della formalina e nell’allodinia meccanica indotta dalla formalina, testato in topi C57BL/6 di 2 e 6 mesi, è risultata influenzata dall’invecchiamento. In particolare, nei topi giovani, solo la dose di 100 mg/Kg è risultata efficace in tutte le fasi del test della formalina, mentre, sia la dose più alta che la dose più bassa sono state efficaci nei topi di 6 mesi. A differenza dei topi di due mesi, i topi di 6 mesi non hanno mostrato cambiamenti significativi fra la soglia meccanica dei topi trattati con veicolo e quella dei topi trattati con il farmaco due ore dopo la somministrazione di formalina. Tuttavia, la somministrazione acuta di gabapentin è risultata più efficace sull’allodinia meccanica indotta dalla formalina nei topi di 6 che nei topi di 2 mesi, suggerendo che nei topi anziani, anche una dose più bassa di gabapentin risulta terapeutica ma l’effetto terapeutico ha più breve durata. Questo fenomeno potrebbe essere dovuto all’up-regulation della subunità α2δ-1 evidenziata nei topi anziani. In conclusione, i risultati ottenuti durante questo progetto di ricerca di dottorato caratterizzano il test della Formalina (Dubuisson & Dennis, 1977) come un valido modello di dolore cronico e dimostrano che il processo di invecchiamento influenza la soglia nocicettiva agli stimoli sia di natura meccanica che termica ed il comportamento nocifensivo in tale modello sperimentale di dolore cronico. I nostri risultati sono dotati di un notevole valore traslazionale per rispondere al bisogno, non ancora soddisfatto, di un migliore sfruttamento degli strumenti farmacologici già disponibili e di nuovi trattamenti terapeutici per la gestione del dolore cronico nei pazienti anziani.Università della Calabri

Role of CGRP pathway polymorphisms in migraine: a systematic review and impact on CGRP mAbs migraine therapy

Background!#!the interest of clinical reaseach in polymorphisms and epigenetics in migraine has been growing over the years. Due to the new era of preventative migraine treatment opened by monoclonal antibodies (mAbs) targeting the signaling of the calcitonin-gene related peptide (CGRP), the present systematic review aims at identifying genetic variants occurring along the CGRP pathway and at verifying whether these can affect the clinical features and the course of disease and the responsiveness of patients to therapy.!##!Methods!#!the literature search has been conducted consulting the most relevant scientific databases, i.e. PubMed/MEDLINE, Scopus, Web of Science, the Human Genome Epidemiology (HuGE) Published Literature database (Public Health Genomics Knowledge Base) and Clinicaltrials.gov from database inception until April 1, 2021. The process of identification and selection of the studies included in the analysis has followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) criteria for systematic reviews and meta-analyses and the guidance from the Human Genome Epidemiology Network for reporting gene-disease associations.!##!Results!#!the search has retrieved 800 results, among which only 7 studies have met the eligibility criteria for inclusion in the analysis. The latter are case-control studies of genetic association and an exploratory analysis and two polymorphisms have been detected as the most recurring: the rs3781719 (T > C) of the CALC A gene encoding CGRP and the rs7590387 of the gene encoding the receptor activity-modifying protein (RAMP) 1 (C > G). Only one study assessing the methylation pattern with regard to CGRP pathway has been found from the search. No genetic association studies investigating the possible effect of genetic variants affecting CGRP signaling on the responsiveness to the most recent pharmacological approaches, i.e. anti-CGRP(R) mAbs, gepants and ditans, have been published. According to the Human Genome Epidemiology (HuGE) systematic reviews and meta-analyses risk-of-bias score for genetic association studies, the heterogeneity between and across studies and the small sample size do not allow to draw conclusions and prompt future studies.!##!Conclusions!#!adequately powered, good quality genetic association studies are needed to understand the impact of genetic variants affecting the pathway of CGRP on migraine susceptibility and clinical manifestation and to predict the response to therapy in terms of efficacy and safety

New trends in pain research: from basic research to clinical translation

The small town of Parghelia on the Tyrrhenian coast (Calabria, Italy) recently provided an attractive setting for a two-year-awaited international meeting on “NEW TRENDS IN PAIN RESEARCH: From Basic Research to Clinical Translation” (13-15 September, 2012). The event, attended by around sixty participants, brought together young researchers, PhD students, international scientists and academics interested in sharing the latest acquisitions in the field of pain research