Consalvo Mattia

Traditional acupuncture in migraine: A controlled, randomized study

Objective.— To check the effectiveness of a true acupuncture treatment according to traditional Chinese medicine (TCM) in migraine without aura, comparing it to a standard mock acupuncture protocol, an accurate mock acupuncture healing ritual, and untreated controls.

Mechanism-Based Treatment in Chronic Neuropathic Pain: The Role of Antidepressants

Antidepressant drugs have been widely used for many years to treat neuropathic pain, despite the rationale for their use was still unclear. We review recent insights into their mechanism of action, focusing on central and peripheral analgesic actions. Beside the traditional monoaminergic hypothesis, other pharmacological actions have been studied: antidepressants interfere with the opioid system, interact with the NMDA receptors, and inhibit ion channel activity. Firm evidence from randomised controlled trials demonstrated that TCAs are the most effective drugs for treatment of different neuropathic pain conditions. They exhibit the lowest number needed to treat compare with all other drugs investigated. SSRIs failed to provide an adequate analgesia, due to their high selectivity. SSRIs are clearly less effective than TCAs (NNT: 6.7 vs 2.4) supporting the hypothesis that a balanced inhibition of noradrenaline and serotonin reuptake is more effective in relieving pain. On the basis of initial results Venlafaxine seems to be the most promising of the newer antidepressants as analgesic. Newer antidepressants show a better side effects profile, but further investigation are warranted to clarify their potential role in management of pain. Neuropathic pain remains a challenging condition to treat, as all currently available drugs fail to achieve adequate pain relief in a significant proportion of patients. TCAs should be currently considered the first choice in treatment of neuropathic pain and the gold standard against which to compare other potential new treatments.

Antidepressants in Chronic Neuropathic Pain

This review presents available clinical studies and new insights into mechanisms of analgesic effect and possible new routes of administration of antidepressant drugs. Older TCAs continue to be superior treatments. We focused on recent findings on newer antidepressants as analgesics. Their use should be supported by further controlled trials.

Once-daily tramadol in rheumatological pain

New once-daily formulations of tramadol have been recently marketed in various countries. This review focuses on the matrix systems used in sustained-release formulations to control drug delivery, the pharmacokinetics and pharmacodynamic profile and the available clinical trials on once-daily tramadol. Four controlled clinical studies with a limited number of patients have shown that once-daily tramadol is safe and effective for up to 12 weeks in rheumatological pain treatment, with a favourable side effects profile. Once-daily tramadol has established efficacy superior to that of placebo for pain management and functional improvement in patients with osteoarthritis. Two randomised clinical trials demonstrated similar rates of efficacy between immediate-release and once-daily sustained-release formulation, without significant differences in the use of escape medications and the number of nights woken. Once-daily tramadol offers the advantage of a reduced dosing regimen that improves patient compliance.

Traumatic aortic arch false aneurysm after blunt chest trauma in a motocross rider

This article details a case report of a traumatic aortic arch false aneurysm after blunt chest trauma. Thoracic aorta false aneurysms are a rare and life-threatening complication of aortic surgery, infection, genetic disorders and trauma.

The unsolved case of “bone-impairing analgesics”: The endocrine effects of opioids on bone metabolism

The current literature describes the possible risks for bone fracture in chronic analgesics users. There are three main hypotheses that could explain the increased risk of fracture associated with central analgesics, such as opioids: 1) the increased risk of falls caused by central nervous system effects, including sedation and dizziness; 2) reduced bone mass density caused by the direct opioid effect on osteoblasts; and 3) chronic opioid-induced hypogonadism. The impact of opioids varies by sex and among the type of opioid used (less, for example, for tapentadol and buprenorphine). Opioid-associated androgen deficiency is correlated with an increased risk of osteoporosis; thus, despite that standards have not been established for monitoring and treating opioid-induced hypogonadism or hypoadrenalism, all patients chronically taking opioids (particularly at doses ≥100 mg morphine daily) should be monitored for the early detection of hormonal impairment and low bone mass density.

Building a diagnostic algorithm on localized neuropathic pain (LNP) and targeted topical treatment: focus on 5% lidocaine-medicated plaster

Within the broad definition of neuropathic pain, the refinement of clinical diagnostic procedures has led to the introduction of the concept of localized neuropathic pain (LNP). It is characterized by consistent and circumscribed area(s) of maximum pain, which are associated with negative or positive sensory signs and/or spontaneous symptoms typical of neuropathic pain. This description outlines the clinical features (currently lacking in guidelines and treatment recommendations) in patients for whom topical targeted treatment with 5% lidocaine-medicated plaster is suggested as first-line therapy. Few epidemiologic data are present in the literature but it is generally estimated that about 60% of neuropathic pain conditions are localized, and therefore identifiable as LNP. A mandatory clinical criterion for the diagnosis of LNP is that signs and symptoms must be present in a clearly identified and defined area(s). Cartographic recordings can help to define each area and to assess variations. The diagnosis of LNP relies on careful neurological examination more than on pain questionnaires, but it is recognized that they can be extremely useful for recording the symptom profiles and establishing a more targeted treatment. The most widely studied frequent/relevant clinical presentations of LNP are postherpetic neuralgia, diabetic neuropathy, and neuropathic postoperative pain. They successfully respond to treatment with 5% lidocaine-medicated plaster with equal if not better pain control but with fewer side effects versus conventional systemic treatments. Generally, the more localized the pain (ie, the area of an A4 sheet of paper) the better the results of topical treatment. This paper proposes an easy-to-understand algorithm to identify patients with LNP and to guide targeted topical treatments with 5% lidocaine medicated plaster.

Non-analgesic effects of opioids: The interaction of opioids with bone and joints

Opioid consumption is associated with a wide range of side effects. Potential interference of opioids with bone and joint activity has emerged in the last few years. Opioids increase the risk of fracture, especially in elderly patients. Moreover, opioids interfere with the endocrine system, and their chronic use is a recognized risk factor for osteoporosis. Pathogenetic mechanisms at the basis of the interference of opioids with bones and joints are analysed in this review.

Emerging therapies in metastatic bone pain

Introduction: Current treatment for metastatic bone pain is mainly palliative. Recent insights into the molecular mechanisms involved in bone metastases have led to the identification of promising therapeutic targets. This review offers an update of preclinical and clinical data on new drugs for metastatic bone pain. Areas covered: Biphosphonates are the gold standard of bone-targeted therapy in bone metastases, for their anti-resorptive and analgesic effects. New drugs aim at breaking the ‘vicious cycle’ of bone metastatic disease, due to the bidirectional interaction between cancer cells and bone microenvironment. Osteoprotegerin, RANK/RANKL interaction, cathepsin K, the Wnt/beta-catenin pathway and sclerostin are emerging targets for modulation of cancer-induced bone desorption. Other promising targets are those expressed in cancer cells that metastasize to bone, including Src, nerve growth factor, endothelin A, TGF-beta and CXCR4. Interesting therapeutic options include targets on nociceptors that innervate the bone, such as TPRV1, Trk and cannabinoid receptors. Expert opinion: Emerging therapies promise, in the next 10 years, a significant expansion in the array of therapeutic options for bone metastases. Most of these drugs are still in an early phase of development. Further clinical trials are needed to support the evidence of their efficacy and tolerability profile.

Tapentadol prolonged release for patients with multiple myeloma suffering from moderate-to-severe cancer pain due to bone disease

Context Myeloma bone disease (MBD) is a devastating complication of multiple myeloma that leads to severe pain. Objectives The aim of this study was to evaluate the efficacy and tolerability of tapentadol prolonged release (PR) in the management of patients with MBD suffering from moderate-to-severe cancer pain. Methods A 12-week prospective study was carried out in 25 opioid-naïve MBD patients. Patients initially received twice-daily doses of tapentadol PR 50 mg. Doses were then managed to maintain adequate relief or dose-limiting toxicity. The following parameters were recorded at weekly intervals for 4 weeks, and then at weeks 8 and 12: pain, opioid-related adverse effects, use of other analgesics, DN4 (Douleur Neuropathique 4) score. Quality of life (SF-36 [36-item short-form health survey]) was measured at baseline and at final evaluation. Results Of 25 patients, 22 completed the study. Pain intensity significantly decreased from baseline to all the week intervals (P<0.01). Quality of life significantly improved with respect to all SF-36 subscale parameters (P<0.01), and so did both the physical and mental status (P<0.01). Tapentadol PR significantly reduced DN4 mean value (P<0.01) and the number of patients with neuropathic component (DN4 ≥4) (P<0.01). After 8 weeks of treatment, all patients were negative for the DN4 score. Tapentadol PR was well tolerated, and the use of other analgesics was reduced during the study period. Conclusion Tapentadol PR started in doses of 100 mg/day was effective and well tolerated in opioid-naïve MBD patients with moderate-to-severe pain. Tapentadol PR can be considered a first-choice opioid in cancer patients suffering from mixed pain with a neuropathic component.