Expert opinion on pharmacotherapy
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Expert Opin Pharmacother · Aug 2014
ReviewTreatment of central sensitization in patients with 'unexplained' chronic pain: an update.
Central sensitization (CS) is present in a variety of chronic pain disorders, including whiplash, temporomandibular disorders, low back pain, osteoarthritis, fibromyalgia, headache, lateral epicondylalgia among others. In spite of our increased understanding of the mechanisms involved in CS pain, its treatment remains a challenging issue. ⋯ A combination of different strategies, each targeting a different 'desensitizing' mechanism, might prove superior over monotherapies. Such combined therapy may include both bottom-up and top-down (e.g., opioids, combined μ-opioid receptor agonist and noradrenaline reuptake inhibitor drugs) strategies. Topically applied analgesic therapies have strong potential for (temporally) decreasing peripheral nociceptive input (bottom-up approach). Targeting metabolic (e.g., ketogenic diets) and neurotrophic factors (e.g., decreasing brain-derived neurotrophic factor) are promising new avenues for diminishing hyperexcitability of the CNS in central sensitization pain patients. Addressing conservative treatments, pain neuroscience education, cognitive behavioural therapy and exercise therapy are promising treatments for CS pain.
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Expert Opin Pharmacother · Aug 2014
ReviewGuanfacine extended release for the treatment of attention-deficit/hyperactivity disorder in children and adolescents.
Guanfacine extended release (GXR) is a selective α(2A)-adrenoreceptor agonist originally developed as an antihypertensive agent and now FDA approved for the treatment of attention-deficit/hyperactivity disorder (ADHD) as monotherapy and as adjunctive to psychostimulants in children and adolescents 6-17 years old. ⋯ GXR is an evidence-based treatment for ADHD in children and adolescents. Because this compound has a smaller effect size than psychostimulants for the symptoms of ADHD, it is generally considered a second-line treatment after the psychostimulants or in combination with psychostimulants. Evidence for efficacy is more robust in children than for adolescents. Because of its pharmacodynamic actions in prefrontal cortex, GXR shows considerable promise for other behavioral conditions frequently comorbid with ADHD and potential promise for emotional and behavioral dysregulation secondary to traumatic stress.
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Expert Opin Pharmacother · Aug 2014
ReviewNew formulations of bupivacaine for the treatment of postoperative pain: liposomal bupivacaine and SABER-Bupivacaine.
Although generally considered both safe and effective, local anesthetics are often used in conjunction with opioids postoperatively in part because of the limited duration of drug action of local anesthetics. Much interest exists in extending the duration of local anesthetics' effects, which may reduce the requirement for opioid pain medications that are frequently associated with side effects, including nausea and vomiting, pruritus and respiratory depression. ⋯ Clinical trials involving liposomal bupivacaine and SABER-Bupivacaine indicate that both safely prolong analgesia, while decreasing opioid requirements when compared with placebo. However, additional clinical studies are necessary to better determine the efficacy and cost-effectiveness of these long-acting local anesthetic formulations.
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Expert Opin Pharmacother · Aug 2014
ReviewDronabinol and chronic pain: importance of mechanistic considerations.
Although medicinal cannabis has been used for many centuries, the therapeutic potential of delta-9-tetrahydrocannabinol (Δ9-THC; international non-proprietary name = dronabinol) in current pain management remains unclear. Several pharmaceutical products with defined natural or synthesized Δ9-THC content have been developed, resulting in increasing numbers of clinical trials investigating the analgesic efficacy of dronabinol in various pain conditions. Different underlying pain mechanisms, including sensitization of nociceptive sensory pathways and alterations in cognitive and autonomic processing, might explain the varying analgesic effects of dronabinol in chronic pain states. ⋯ We suggest a mechanism-based approach beyond measurement of subjective pain relief to evaluate the therapeutic potential of dronabinol in chronic pain management. Development of objective mechanistic diagnostic biomarkers reflecting altered sensory and cognitive processing in the brain is essential to evaluate dronabinol induced analgesia, and to permit identification of responders and/or non-responders to dronabinol treatment.
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Expert Opin Pharmacother · Aug 2014
EditorialEnd-stage renal disease with atrial fibrillation: uncharted territory in the modern world of anticoagulants.
End-stage renal disease (ESRD) and atrial fibrillation are increasingly common concurrent findings among many patients. Coexisting ESRD and atrial fibrillation can further exacerbate each disease process; thus, evidence-based medicine protocols are needed for the treatment of patients with both ESRD and new-onset atrial fibrillation to clarify the appropriate anticoagulant management of such patients. ⋯ Unlike many disease processes that have ample evidence available in order to better manage the patient, in the patient with end-stage kidney disease and new onset of atrial fibrillation, the situation becomes much more complicated. We believe randomized controlled trials for both the classical and the newer oral anticoagulants could provide evidence-based medicine protocols for the treatment of patients with ESRD and new-onset atrial fibrillation.