The journal of pain : official journal of the American Pain Society
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Like other types of neuropathic pain, postherpetic neuralgia (PHN) can be resistant to many types of pharmacologic and interventional therapies. Although many analgesic agents have been used for the treatment of other types of neuropathic pain, tricyclic antidepressants, antiepileptic drugs, opioids, and lidocaine patch appear to demonstrate relative analgesic efficacy for the treatment of pain from PHN. There are fewer studies on the use of interventional options for the treatment of pain from PHN. The majority of interventional therapies show equivocal analgesic efficacy although some data indicate that intrathecal methylprednisolone may be effective. Further randomized, controlled trials will be needed to confirm the analgesic efficacy of analgesic and interventional therapies to determine their role in the overall treatment of patients with PHN. ⋯ This article reviews the analgesic options for the treatment of PHN and suggests that tricyclic antidepressants, membrane stabilizers, opioids, and lidocaine patch may demonstrate analgesic efficacy in this group of patients. These data may potentially help clinicians who attempt to provide analgesia in patients with PHN.
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Hypogonadotrophic hypogonadism is characteristically induced in men by intrathecal, transdermal, or sustained-action opioids. Although women receiving intrathecal opioids have similar changes, often accompanied by amenorrhea, hypogonadotrophic hypogonadism has not been documented in women receiving sustained-action, transdermal, or oral opioids. Dehydroepiandrosterone sulfate deficiency, indicating adrenal inhibition, is present in most men and women chronically consuming sustained-action oral or transdermal opioids. We recorded menstrual histories and measured gonadotrophin, androgen, and estradiol levels in 47 women ages 30 to 75 years who were consuming sustained-action oral or transdermal opioids for control of nonmalignant pain and in 68 non-opioid-consuming control subjects. Testosterone, estradiol, and dehydroepiandrosterone sulfate values were 48% to 57% lower in opioid-consuming women with intact ovarian tissue than in control subjects (P < .01-.05). Luteinizing hormone and follicle-stimulating hormone values averaged 30% lower in premenopausal and 70% lower in postmenopausal opioid consumers (P < .001). Among oophorectomized women not consuming estrogen, free testosterone levels were 39% lower in opioid consumers (P < .05), indicating impaired adrenal androgen production. Additional lowering of free testosterone levels was associated independently with oral estrogen replacement and low body mass index. Menses had often ceased soon after beginning sustained-action opioid therapy. Our observations document hypogonadotrophic hypogonadism plus decreased adrenal androgen production in most women consuming sustained-action oral or transdermal opioids. ⋯ These observations demonstrate profound inhibition of ovarian sex hormone and adrenal androgen production among women chronically consuming sustained-action opioids. Related consequences include altered menstrual flow, probable reduced fertility, and possible contributions to opioid-associated depression, osteoporosis, and hyperalgesia. Measurements of bone density, estradiol, and free testosterone may guide appropriate therapy.
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Herpes zoster causes substantial morbidity, especially among older adults. Although the acute cutaneous manifestations can be painful and troublesome, the most important consequence of herpes zoster (shingles) is the chronic pain syndrome known as postherpetic neuralgia (PHN). Previous studies have suggested that declining varicella-zoster virus (VZV)-specific cell-mediated immune (CMI) responses account for the increased frequency of herpes zoster seen in older adults. This led to the idea that immunization designed to boost VZV-specific CMI responses might reduce the risk of herpes zoster. This hypothesis was tested in a large, randomized, placebo-controlled clinical trial called the Shingles Prevention Study (SPS). Compared with the placebo group, herpes zoster vaccine recipients had a 61.1% reduction in zoster "burden of illness" (an index incorporating incidence and severity of herpes zoster); a 66.5% reduction in the incidence of postherpetic neuralgia; and a 51.3% reduction in the incidence of herpes zoster. The incidence of serious adverse events was not different between the overall vaccine and placebo populations. The most frequently encountered adverse event among vaccine recipients was local reactogenicity, with self-limited and generally mild tenderness, warmth, or erythema occurring at the injection site in about one-half of vaccine recipients. The zoster vaccine was approved by the US Food and Drug Administration in 2006 and is indicated for prevention of herpes zoster in immunocompetent persons aged 60 years and older. ⋯ The herpes zoster vaccine provides physicians with an effective means for reducing a patient's risk for developing shingles and its attendant complications. No significant safety concerns regarding the vaccine have been identified. Indications for use of the attenuated-virus vaccine in special subpopulations continue to evolve.
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Randomized Controlled Trial Comparative Study
Lumiracoxib 400 mg compared with celecoxib 400 mg and placebo for treating pain following dental surgery: a randomized, controlled trial.
This randomized, double-blinded, double-dummy, parallel-group, single-center study compared a single dose of the novel selective COX-2 inhibitor lumiracoxib (400 mg), with celecoxib (400 mg) or placebo in dental pain. Patients > or =17 years with moderate-to-severe dental pain were recruited after surgical extraction of 2 or more partially or fully bony impacted molars. Pain intensity was measured using the categorical scale and the primary efficacy variable was the summed pain intensity difference over 8 hours after dosing (SPID-8). Patient disposition and demographics were comparable between lumiracoxib 400 mg (n = 156), celecoxib 400 mg (n = 156), and placebo (n = 52) groups. Lumiracoxib was statistically superior (P < .001) to both celecoxib and placebo in reducing pain intensity (SPID-8; least-squares means: 8.31, lumiracoxib; 4.26, celecoxib; -1.87, placebo). Significantly more patients treated with lumiracoxib (58.9%) considered treatment to be good or excellent compared with celecoxib and placebo (42.3% and 5.7%, respectively; P = .001). Lumiracoxib was superior to celecoxib and placebo for all other secondary efficacy variables. All treatments were well-tolerated. In conclusion, 400 mg lumiracoxib was well-tolerated and provided significantly superior analgesia to 400 mg celecoxib or placebo in patients with moderate-to-severe pain after dental surgery. ⋯ In a randomized, double-blinded, double-dummy, parallel-group, single-center study, a single dose of the novel selective COX-2 inhibitor lumiracoxib (400 mg) was well-tolerated and provided significantly superior analgesia to 400 mg celecoxib or placebo in patients with moderate-to-severe dental pain after surgical extraction of impacted molars.
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Accurate evaluation of pain plays a critical role in identifying new interventions for the treatment and prevention of herpes zoster and postherpetic neuralgia (PHN). Different types of pain and other sensory symptoms are found in patients with herpes zoster, and these vary greatly with respect to their presence, location, duration, intensity, and quality. The results of recent studies of herpes zoster and PHN and the development of new methods for assessing neuropathic pain provide a foundation for diagnosing and assessing the pain associated with herpes zoster. We review the results of recent research to identify the essential components that must be considered in developing an evidence-based description of pain associated with herpes zoster and PHN. ⋯ Comprehensive assessments of pain are necessary for clinical research on the epidemiology, natural history, pathophysiologic mechanisms, treatment, and prevention of pain in herpes zoster and PHN.