Clinical and preclinical perspectives on Chemotherapy-Induced Peripheral Neuropathy (CIPN): a narrative review.

This review provides an update on the current clinical and preclinical understanding of chemotherapy induced peripheral neuropathy (CIPN). The overview of the clinical syndrome includes a review of its assessment, diagnosis and treatment. CIPN is caused by several widely-used chemotherapeutics including paclitaxel, oxaliplatin, bortezomib. Severe CIPN may require dose reduction, or cessation, of chemotherapy, impacting on patient survival. While CIPN often resolves after chemotherapy, around 30% of patients will have persistent problems, impacting on function and quality of life. Early assessment and diagnosis is important, and we discuss tools developed for this purpose. There are no effective strategies to prevent CIPN, with limited evidence of effective drugs for treating established CIPN. Duloxetine has moderate evidence, with extrapolation from other neuropathic pain states generally being used to direct treatment options for CIPN. The preclinical perspective includes a discussion on the development of clinically-relevant rodent models of CIPN and some of the potentially modifiable mechanisms that have been identified using these models. We focus on the role of mitochondrial dysfunction, oxidative stress, immune cells and changes in ion channels from summary of the latest literature in these areas. Many causal mechanisms of CIPN occur simultaneously and/or can reinforce each other. Thus, combination therapies may well be required for most effective management. More effective treatment of CIPN will require closer links between oncology and pain management clinical teams to ensure CIPN patients are effectively monitored. Furthermore, continued close collaboration between clinical and preclinical research will facilitate the development of novel treatments for CIPN.

Pain management in patients with vascular disease.

Vascular disease covers a wide range of conditions, including arterial, venous, and lymphatic disorders, with many of these being more common in the elderly. As the population ages, the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population. Pain management can be complex, as there are often multiple co-morbidities to be considered. An understanding of the underlying pain mechanisms is helpful in the logical direction of treatment, particularly in chronic pain states, such as phantom limb pain or complex regional pain syndrome. Acute pain management for vascular surgery presents a number of challenges, including coexisting anticoagulant medication, that may preclude the use of regional techniques. Within the limited evidence base, there is a suggestion that epidural analgesia provides better pain relief and reduced respiratory complications after major vascular surgery. For carotid endarterectomy, there is again some evidence supporting the use of local anaesthetic analgesia, either by infiltration or by superficial cervical plexus block. Chronic pain in vascular disease includes post-amputation pain, for which well-known risk factors include high pain levels before amputation and in the immediate postoperative period, emphasizing the importance of good pain control in the perioperative period. Complex regional pain syndrome is another challenging chronic pain syndrome with a wide variety of treatment options available, with the strongest evidence being for physical therapies. Further research is required to gain a better understanding of the underlying pathophysiological mechanisms in pain associated with vascular disease and the best analgesic approaches to manage it.

Cancer treatment-related neuropathic pain: proof of concept study with menthol--a TRPM8 agonist.

PURPOSE: Effective treatment of neuropathic pain without unacceptable side effects is challenging. Cancer sufferers increasingly live with long-term treatment-related neuropathic pain, resulting from chemotherapy-induced peripheral neuropathy (CIPN) or surgical scars. This proof-of-concept study aimed to determine whether preclinical evidence for TRPM8 ion channels in sensory neurons as a novel analgesic target could be translated to clinical benefit in patients with neuropathic pain, using the TRPM8 activator menthol. PATIENTS AND METHODS: Patients with problematic treatment-related neuropathic pain underwent a baseline assessment using validated questionnaires, psychophysical testing, and objective functional measures. The painful area was treated with topical 1 % menthol cream twice daily. Assessments were repeated at 4-6 weeks. The primary outcome was the change in Brief Pain Inventory total scores at 4-6 weeks. Secondary outcomes included changes in function, mood and skin sensation. RESULTS: Fifty-one patients (female/male, 32/19) were recruited with a median age of 61 (ranging from 20 to 89). The commonest aetiology was CIPN (35/51), followed by scar pain (10/51). Thirty-eight were evaluable on the primary outcome. Eighty-two per cent (31/38) had an improvement in total Brief Pain Inventory scores (median, 47 (interquartile range, 30 to 64) to 34 (6 to 59), P < 0.001). Improvements in mood (P = 0.0004), catastrophising (P = 0.001), walking ability (P = 0.008) and sensation (P < 0.01) were also observed. CONCLUSION: This proof-of-concept study indicates that topical menthol has potential as a novel analgesic therapy for cancer treatment-related neuropathic pain. Improvements in patient-rated measures are supported by changes in objective measures of physical function and sensation. Further systematic evaluation of efficacy is required.

Translational medicine: cancer pain mechanisms and management.

Cancer-induced bone pain (CIBP) is a major clinical problem with up to 85% of patients with bony metastases having pain, often associated with anxiety and depression, reduced performance status, and a poor quality of life. Malignant bone disease creates a chronic pain state through sensitization and synaptic plasticity within the spinal cord that amplifies nociceptive signals and their transmission to the brain. Fifty per cent of patients are expected to gain adequate analgesia from palliative radiotherapy within 4-6 weeks of treatment. Opioid analgesia does make a useful contribution to the management of CIBP, especially in terms of suppressing tonic background pain. However, CIBP remains a clinical challenge because the spontaneous and movement-related components are more difficult to treat with opioids and commonly used analgesic drugs, without unacceptable side-effects. Recently developed laboratory models of CIBP, which show congruency with the clinical syndrome, are contributing to an improved understanding of the neurobiology of CIBP. This chronic pain syndrome appears to be unique and distinct from other chronic pain states, such as inflammatory or neuropathic pain. This has clear implications for treatment and development of future therapies. A translational medicine approach, using a highly iterative process between the clinic and the laboratory, may allow improved understanding of the underlying mechanisms of CIBP to be rapidly translated into real clinical benefits in terms of improved pain management.

The effect of conduction block on the spinal release of immunoreactive-neuropeptide Y (ir-NPY) in the neuropathic rat.

Peripheral nerve injury may result in significant changes in neuropeptide production and the development of neuropathic pain behaviour. Rats with a chronic constriction injury of one sciatic nerve were used to study the spinal release of immunoreactive neuropeptide Y (ir-NPY), using the antibody-coated microprobe technique. Previous work has shown an increase in NPY synthesis by large to medium-sized primary afferent neurones, as well as a new area of ir-NPY release in the deep dorsal horn on the side of nerve injury, when compared to uninjured rats. The stimulus for spontaneous ir-NPY release was unclear, but may have been due to ectopic neuronal discharges developing after nerve injury. This study used local anaesthetic to block all electrical input from the injured nerve. No change was found in the new zone of spontaneous release of ir-NPY in the deep dorsal horn ipsilateral to nerve injury. It appears therefore, that ir-NPY is released from the central termination of primary afferent neurones, without regulation from neuronal activity in the primary afferent neurones themselves.

Primary afferent-evoked release of immunoreactive galanin in the spinal cord of the neuropathic rat.

We have determined if peripheral nerve stimulation altered the increased spontaneous release of immunoreactive (ir)-galanin that is found in the superficial dorsal horn of the spinal cord of neuropathic rats. Using the antibody microprobe technique to study the localized sites of ir-galanin release in vivo, we found that high intensity electrical stimulation of the injured nerve resulted in a further increase in ir-galanin release in the superficial dorsal horn, with no significant persistence of ir-galanin after release. Release of ir-galanin at stimulus strengths sufficient to activate C fibres, in an area of the spinal cord thought to be concerned with nociceptive transmission, indicates a possible role for this peptide in the spinal modulation of pain after peripheral nerve injury.

Spontaneous release of immunoreactive neuropeptide Y from the central terminals of large diameter primary afferents of rats with peripheral nerve injury.

Microprobes bearing immobilized antibodies to the C-terminus of neuropeptide Y were used to measure the release of this neuropeptide in the spinal cords of rats with a unilateral peripheral neuropathy and in sham-operated animals. All neuropathic animals showed the characteristic behavioural syndrome and were studied at 14 days postsciatic nerve loose-ligation. An extensive spontaneous release of immunoreactive neuropeptide Y was detected in the spinal cords of the neuropathic rats and, compared to sham-operated rats, a new zone of release was found in the deep dorsal horn. Electrical stimulation of large diameter primary afferents proximal to the nerve ligature produced widespread release of neuropeptide Y in the dorsal horn which persisted for up to 1 h poststimulation. It is possible that ectopic impulses arising in the injured nerve were responsible for the spontaneous central release of neuropeptide Y and this neuropeptide may play a role in the central response to peripheral nerve injury.

The effect of a peripheral mononeuropathy on immunoreactive (ir)-galanin release in the spinal cord of the rat.

The pattern of ir-galanin release in the spinal cord of rats with a peripheral mononeuropathy was studied. On the side of the cord ipsilateral to the nerve injury enhanced ir-galanin release was found in the superficial dorsal horn. It is probable that, after nerve injury, some primary afferent neurons spontaneously release galanin from their central terminals.

The release of immunoreactive neuropeptide Y in the spinal cord of the anaesthetized rat and cat.

The release of immunoreactive (ir-) neuropeptide Y (NYP) was studied in the anaesthetized rat and cat by means of microprobes bearing immobilized antibodies to the C terminus of NPY. An extensive basal release of ir-NYP was detected throughout the dorsal and upper ventral horn of the rat. This spontaneous release was not significantly altered by sectioning the spinal cord at the thoraco-lumbar junction nor by electrical stimulation of peripheral nerves. Since NPY is virtually absent in primary afferents it is probable that spontaneous release within the spinal cord comes from active NPY-containing intrinsic spinal neurones. In the spinal cat spontaneous release of ir-NPY was detected in the mid-dorsal horn and this was unaltered by peripheral noxious thermal or noxious mechanical stimuli. As in the rat, release from intrinsic spinal neurones is most probable. The extensive spontaneous release of ir-NPY in both species suggests a widespread role in spinal cord function.