Margarita M. Puig

Synergism between paracetamol and nonsteroidal anti-inflammatory drugs in experimental acute pain

Abstract The antinociception induced by the intraperitoneal coadministration of combinations of paracetamol with the nonsteroidal anti‐inflammatory drugs (NSAIDs) diclofenac, ibuprofen, ketoprofen, meloxicam, metamizol, naproxen, nimesulide, parecoxib and piroxicam was studied by isobolographic analysis in the acetic acid abdominal constriction test of mice (writhing test). The effective dose that produced 50% antinociception (ED50) was calculated from the log dose–response curves of fixed ratio combinations of paracetamol with each NSAID. By isobolographic analysis, this ED50 was compared to the theoretical additive ED50 calculated from the ED50 of paracetamol and of each NSAID alone obtained from ED50 dose–response curves. As shown by isobolographic analysis, all the combinations were synergistic, the experimental ED50s being significantly smaller than the theoretically calculated ED50s. The results of this study demonstrate potent interactions between paracetamol and NSAIDs and validate the clinical use of combinations of these drugs in the treatment of pain conditions.

Opioid-induced hyperalgesia in a murine model of postoperative pain : Role of nitric oxide generated from the inducible nitric oxide synthase

Background: Opioid-induced delayed hyperalgesia and allodynia have been reported in human and animal models. The authors evaluated the influence of different opioids used during clinical anesthesia on nociceptive sensitivity and incisional pain in mice. The role of the inducible nitric oxide synthase on surgical pain and opioid-induced pronociception also was investigated. Methods: CD1 mice were used to study the efficacy of opioids inducing pronociception and enhancing incisional pain. The implication of nitric oxide generated from the inducible nitric oxide synthase was investigated using knockout mice (C57/BL6) for its gene. Mice underwent right hind paw surgery under sevoflurane anesthesia combined with subcutaneous administration of saline or the opioids fentanyl (0.05 mg/kg), alfentanil (1 mg/kg), and remifentanil (0.04 mg/kg). Nociception was evaluated daily for 7 days using paw-pressure, plantar, and von Frey tests. Results: The antinociceptive effect of opioids was followed by long-lasting thermal hyperalgesia and mechanical allodynia (each lasting between 2 and 7 days), but not mechanical hyperalgesia. Intraoperative infusion of opioids significantly enhanced incisional pain in all tests. The most prominent effects were observed with remifentanil. The inducible nitric oxide synthase gene deletion attenuated both remifentanil- and incision-induced pronociceptive effects. In mutant mice for the inducible nitric oxide synthase gene, remifentanil was still efficient in enhancing incisional pain, but the global pronociceptive effect was attenuated significantly as compared with wild-type mice. Conclusions: The authors’ study demonstrates that the intraoperative administration of fentanyl or remifentanil enhances the extent and duration of postoperative pain. The results suggest a role of the nitric oxide systems in the cause of acute postoperative pain and opioid-induced pronociception.

Pronociceptive effects of remifentanil in a mouse model of postsurgical pain: effect of a second surgery.

Background:Remifentanil anesthesia enhances postoperative pain in animals and humans. The authors evaluated the impact of the dose (&mgr;g · kg−1 · min−1) and duration of remifentanil infusion, and the effects of a second surgery on postoperative pain sensitization. Methods:Mice received different doses of remifentanil over 30 or 60 min. The authors assessed thermal (Hargreaves) and mechanical hyperalgesia (von Frey) at 2, 4, 7, and 10 days. In other experiments, mice had a plantar incision during sevoflurane with or without remifentanil anesthesia that was repeated 27 days later, when nociceptive thresholds returned to baseline. Linear mixed models were used for statistical analysis. Results:Remifentanil induced dose-dependent pronociceptive effects with calculated ED50s of 1.7 (95% confidence interval, 1.3–2.1) and 1.26 (1.0–1.6) &mgr;g · kg−1 · min−1 for thermal and mechanical hyperalgesia, respectively, which lasted longer with higher doses (P < 0.001). The duration of infusion did not alter the pronociceptive effects of remifentanil when administered at a constant dose of infusion. When given during surgery, high (2.66 &mgr;g · kg−1 · min−1) or low (0.66 &mgr;g · kg−1 · min−1) remifentanil increased the extent (P < 0.05) and duration (P < 0.01) of thermal and mechanical hyperalgesia. The latter was further enhanced after a second surgery performed in the same experimental conditions (P < 0.05). Surgery or remifentanil infusion, each one individually, induced significant mechanical hyperalgesia, which was greater when repeated (P < 0.05). Conclusions:In this model of incisional pain, remifentanil induces pronociceptive effects, which are dose dependent but unaltered by the duration of administration. A second surgery performed on the same site and experimental conditions induces greater postoperative hyperalgesia that is enhanced when remifentanil is used as an anesthetic.

Expression of Opioid Receptors During Peripheral Inflammation

Opioid receptors (OR) and their mRNA are present in the central and peripheral nervous system of mammals. In this review we examine the behavioral effects of opioids and the expression of their receptors during peripheral inflammation in two experimental models: the rat paw and the mouse intestine. Inflammation increased the antinociceptive (paw) and the inhibitory effects of opioids in the gut (transit, permeability and plasma extravasation) by interaction with OR located at peripheral sites. Based on agonist efficacy, micro > delta >> kappa-OR mediate the antinociceptive and antitransit effects of opioids during inflammation. Intestinal permeability is modulated by delta = micro >> kappa-OR, while kappa > delta >> micro-OR are involved in the inhibition of plasma extravasation. Intestinal inflammation increased the transcription of micro and delta-OR (but not kappa) genes in the gut, thus explaining the enhanced antitransit and antisecretory effects of micro and delta-OR agonists; however, the increased inhibitory effects of kappa-OR agonists on plasma extravasation could result from post-transcriptional regulation of the receptor. Similarly, the increased expression of peripheral micro-OR observed in the rat paw during inflammation, occurs at post-transcriptional levels and is related to an increased axonal transport from the dorsal root ganglia to peripheral terminals. The sites and mechanisms implicated in the increased transcription of micro and delta-OR during intestinal inflammation are under investigation.

Dexketoprofen-induced antinociception in animal models of acute pain: Synergy with morphine and paracetamol

The antinociceptive activity of dexketoprofen was studied in mice using the acetic acid writhing test (acute tonic pain), the tail flick test (acute phasic pain) and the formalin assay (inflammatory pain). Isobolographic analysis was used to study the antinociceptive interactions between morphine and paracetamol co-administered with dexketoprofen. In the writhing test, the intraperitoneal administration of dexketoprofen or ketoprofen resulted in parallel dose-response curves with equal efficacy, but higher relative potency for dexketoprofen. In the tail flick test, the curves were parallel with similar efficacy and potency. The administration of morphine or paracetamol in both tests resulted in dose-response curves not parallel with that of dexketoprofen, which showed a potency between morphine and paracetamol. In the formalin assay, the antinociceptive activity of morphine during phase I was 122, 295 and 1695 times higher than dexketoprofen, ketoprofen and paracetamol, respectively. Isobolographic analysis demonstrated that the combination of sub-analgesic doses of dexketoprofen with morphine or with paracetamol was strongly synergic in all three tests. Synergistic drug combinations should improve effective pharmacological treatment of pain, minimizing drug specific adverse effects. These findings are undoubtedly worthy of additional controlled clinical trials in severe pain syndromes.

The pro-nociceptive effects of remifentanil or surgical injury in mice are associated with a decrease in delta-opioid receptor mRNA levels: Prevention of the nociceptive response by on-site delivery of enkephalins

Abstract The ultra‐short‐acting mu‐opioid receptor (MOR) agonist remifentanil enhances postsurgical pain when used as main anesthetic in animal models and man. Although the mechanism/s involved are poorly characterized, changes in opioid receptor expression could be a relevant feature. Using a mouse model of postoperative pain, we assessed the expression of MOR and delta opioid receptors (DORs) and the efficacy of Herpes Simplex vector‐mediated proenkephalin release (SHPE) preventing postoperative nociceptive sensitization induced by remifentanil or surgical incision. We determined MOR and DOR expressions in the dorsal root ganglia and the spinal cord after remifentanil or surgery in CD1 mice, using real‐time PCR and Western blotting. We also assessed the effect of SHPE on nociception induced by remifentanil, surgery, and their combination (2 and 7 days after manipulation), using thermal and mechanical tests. Both remifentanil and surgery decreased DOR mRNA levels (up to days 2 and 4, respectively) in the dorsal root ganglia, but not in the spinal cord. No changes were observed in MOR mRNA, or in receptor‐protein levels (Western) of either receptor. Pre‐treatment with SHPE 7 days before manipulation prevented remifentanil‐induced thermal hyperalgesia and mechanical allodynia and the increase in incisional pain observed when surgery was performed under remifentanil anesthesia. SHPE also prevented surgically induced allodynia but not hyperalgesia, which was blocked by the additional administration of RB101, an enkephalinase inhibitor. The study suggests that down‐regulation of DOR contributes to remifentanil and surgery‐induced nociception, and that postoperative pain is completely reversed by increasing enkephalin levels in the spinal cord and the periphery.

Patients' Perception of Postoperative Pain Management : Validation of the International Pain Outcomes (IPO) Questionnaire

UNLABELLED PAIN OUT is a European Commission-funded project aiming at improving postoperative pain management. It combines a registry that can be useful for quality improvement and research using treatment and patient-reported outcome measures. The core of the project is a patient questionnaire-the International Pain Outcomes questionnaire-that comprises key patient-level outcomes of postoperative pain management, including pain intensity, physical and emotional functional interference, side effects, and perceptions of care. Its psychometric quality after translation and adaptation to European patients is the subject of this validation study. The questionnaire was administered to 9,727 patients in 10 languages in 8 European countries and Israel. Construct validity was assessed using factor analysis. Discriminant validity assessment used Mann-Whitney U tests to detect mean group differences between 2 surgical disciplines. Internal consistency reliability was calculated as Cronbachs alpha. Factor analysis resulted in a 3-factor structure explaining 53.6% of variance. Cronbachs alpha at overall scale level was high (.86), and for the 3 subscales was low, moderate, or high (range, .53-.89). Significant mean group differences between general and orthopedic surgery patients confirmed discriminant validity. The psychometric quality of the International Pain Outcomes questionnaire can be regarded as satisfactory. PERSPECTIVE The International Pain Outcomes questionnaire provides an instrument for postoperative pain assessment and improvement of quality of care, which demonstrated good psychometric quality when translated into a variety of languages in a large European and Israeli patient population. This measure provides the basis for the first comprehensive postoperative pain registry in Europe and other countries.

Isoflurane Requirements During Combined General/Epidural Anesthesia for Major Abdominal Surgery

We evaluated the effects of bupivacaine on the requirements for thiopental and isoflurane during combined general/epidural anesthesia. Sixty patients scheduled for colon resection were randomly distributed into six groups that received, before the induction of anesthesia, an epidural (T9-10) bolus (8 mL) followed by an infusion (8 mL/h) of saline (Groups 1 and 4), bupivacaine 0.0625% plus fentanyl 2 &mgr;g/mL (Groups 2 and 5), or bupivacaine 0.125% plus fentanyl 2 &mgr;g/mL (Groups 3 and 6). We evaluated the amount of thiopental needed to abolish the eyelid reflex and the percentage of isoflurane required to maintain the bispectral index (BIS) between 50 and 60 (Groups 1–3) or the mean arterial blood pressure (MAP) within 20% of basal values (Groups 4–6). All groups required similar doses of thiopental (5 mg/kg); the time of evaluation, but not epidural treatment, had a significant effect (P < 0.0001) on BIS and MAP. After tracheal intubation, MAP and BIS increased by 18% and 49%, respectively (P < 0.05). In the bupivacaine groups, isoflurane requirements similarly decreased by 35% (P < 0.03). For BIS and MAP, the epidural treatment (P < 0.02) and type of evaluation (P < 0.03) had a significant effect; MAP was lower (P < 0.05) with 0.125% bupivacaine. We conclude that epidural bupivacaine does not alter the thiopental dose, but it decreases isoflurane requirements by 35%. This study demonstrates that both doses of bupivacaine and fentanyl induce similar isoflurane-sparing effects. However, patients receiving 0.125% bupivacaine showed lower values of MAP when compared with controls, and thus bupivacaine 0.0625% should be favored during combined anesthesia.

Endorphin Levels in Cerebrospinal Fluid of Patients with Postoperative and Chronic Pain

The authors measured endorphin levels in the cerebrospinal fluid (CSF) of 12 patients with chronic pain due to lumbar disc syndrome and eight patients with acute postoperative pain. These were compared with CSF endorphin levels in 20 control patients with no history of pain. Endorphins were extracted by adsorption to a synthetic resin (Amberlite XAD-2®), eluted with methanol, and assayed using the electrically stimulated mouse vas deferens. Results were expressed as methionine-enkephalin (Met-E) equivalents, which was the standard in the bioassay. The CSF endorphin level was 0.42 ± 0.07 pmol/ml (mean ± SE) in the postoperative group, 1.44 ± 0.2 pmol/ml in the chronic pain group, and 4.36 ± 0.89 pmol/ml in the control group. CSF endorphin levels in the two pain groups differed significantly from both the control group and each other. These results suggest a correlation between pain levels and endorphin concentration in the CSF; however, in the acute postoperative pain group the influence of other factors such as anesthesia or surgical stress cannot be evaluated.

Interaction between metamizol and tramadol in a model of acute visceral pain in rats

Tramadol (TRM) and metamizol (MTZ) are drugs with complex mechanisms of action, extensively used in combination in pain management. In the present investigation we have evaluated the interaction between MTZ:TRM in the ethacrinic acid writhing test in rats. Dose—response curves (s.c.) were obtained for each drug individually, combined in fixed potency ratios (1:0.3, 1:1, 1:3), and for MTZ in presence of a fixed‐dose of TRM (3.5 mg/kg). Interactions were analysed using isobolograms, interaction indexes (INT‐I) and ANOVA. We used naloxone (1 mg/kg s.c.) to determine the opioid‐component of the effects (ED80).