Hyperalgesia Clinical Trial
Official title:
Can Opioid-induced Hyperalgesia be Prevented by Gradual Dose Reduction vs. Abrupt Withdrawal of Remifentanil?
Remifentanil is a rapid-acting opioid which has been widely used in pain treatment during
surgery for the last 15 years 1. Remifentanil is rapidly eliminated (minutes) from the body
after end of infusion, and this makes it easily manageable compared to other opioids.
However, there are both experimental and clinical studies indicating that remifentanil,
after end of infusion, triggers increased pain sensation and increased opioid consumption
post-operatively. Increased post-operative opioid consumption should be avoided due to the
adverse effects of these drugs (nausea/vomiting, pruritus, dizziness, fatigue and reduced
respiratory rate). Thus, it's important to investigate relevant strategies to avoid the
increased pain sensation (opioid-induced hyperalgesia = hypersensitivity to pain stimuli)
after end of infusion of remifentanil after surgery. Several experimental and clinical
trials have been conducted in this field. Ketamine has been shown to block this effect, but
its adverse effect profile (i.a. hallucinations) makes it not suitable in normal clinical
use. In a study of healthy volunteers, it has been demonstrated that parecoxib (a COX-2
selective NSAID) can prevent remifentanil-induced hyperalgesia. Our group has previously
shown that a relatively COX-1 selective NSAID (ketorolac) can prevent hyperalgesia in an
experimental pain model.
This is of interest since NSAIDs are frequently administered as premedication before
surgery. There are several disadvantages associated with the use of COX-2 inhibitors, e.g.
the risk of myocardial infarction after long-term use (> 1 year), and potentially reduced
bone healing after orthopedic surgery. However, this has not been shown with short-term use
(days/week). The disadvantages associated with the use of e.g. ketorolac (a COX-1 inhibitor)
are i.a. increased bleeding tendency, which is unfavourable for the surgeon, and increased
risk of gastric ulcer. Therefore, it is of interest to investigate other ways of preventing
opioid-induced hyperalgesia. In a recent animal study it has been shown that gradual dose
reduction of remifentanil (vs. abrupt withdrawal of a relatively high remifentanil dose) can
prevent the development of hyperalgesia after end of infusion. In this study we will i.a.
investigate whether this is also the case in humans. In this new model, the study
participants will get remifentanil infusion with two different dose reduction regimes:
gradual reduction or abrupt withdrawal.
Status | Completed |
Enrollment | 16 |
Est. completion date | December 2012 |
Est. primary completion date | December 2012 |
Accepts healthy volunteers | Accepts Healthy Volunteers |
Gender | Male |
Age group | 18 Years to 60 Years |
Eligibility |
Inclusion Criteria: - Male - Age 18-60 - Body mass index 17-30 - Healthy volunteers Exclusion Criteria: - Use of medication; alternative medicine - Substance abuse - Allergies towards medication used in the study - Participation in other clinical studies the previous 6 months |
Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Double Blind (Subject, Investigator, Outcomes Assessor), Primary Purpose: Prevention
Country | Name | City | State |
---|---|---|---|
Norway | Oslo University Hospital | Oslo |
Lead Sponsor | Collaborator |
---|---|
Oslo University Hospital |
Norway,
Angst MS, Koppert W, Pahl I, Clark DJ, Schmelz M. Short-term infusion of the mu-opioid agonist remifentanil in humans causes hyperalgesia during withdrawal. Pain. 2003 Nov;106(1-2):49-57. — View Citation
Drdla R, Gassner M, Gingl E, Sandkühler J. Induction of synaptic long-term potentiation after opioid withdrawal. Science. 2009 Jul 10;325(5937):207-10. doi: 10.1126/science.1171759. — View Citation
Guignard B, Bossard AE, Coste C, Sessler DI, Lebrault C, Alfonsi P, Fletcher D, Chauvin M. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology. 2000 Aug;93(2):409-17. — View Citation
Hood DD, Curry R, Eisenach JC. Intravenous remifentanil produces withdrawal hyperalgesia in volunteers with capsaicin-induced hyperalgesia. Anesth Analg. 2003 Sep;97(3):810-5. — View Citation
Joly V, Richebe P, Guignard B, Fletcher D, Maurette P, Sessler DI, Chauvin M. Remifentanil-induced postoperative hyperalgesia and its prevention with small-dose ketamine. Anesthesiology. 2005 Jul;103(1):147-55. — View Citation
Koppert W, Sittl R, Scheuber K, Alsheimer M, Schmelz M, Schüttler J. Differential modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by S-ketamine and clonidine in humans. Anesthesiology. 2003 Jul;99(1):152-9. — View Citation
Lenz H, Raeder J, Draegni T, Heyerdahl F, Schmelz M, Stubhaug A. Effects of COX inhibition on experimental pain and hyperalgesia during and after remifentanil infusion in humans. Pain. 2011 Jun;152(6):1289-97. doi: 10.1016/j.pain.2011.02.007. Epub 2011 Mar 10. — View Citation
Servin FS. Remifentanil: an update. Curr Opin Anaesthesiol. 2003 Aug;16(4):367-72. — View Citation
Tröster A, Sittl R, Singler B, Schmelz M, Schüttler J, Koppert W. Modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by parecoxib in humans. Anesthesiology. 2006 Nov;105(5):1016-23. — View Citation
Vinik HR, Kissin I. Rapid development of tolerance to analgesia during remifentanil infusion in humans. Anesth Analg. 1998 Jun;86(6):1307-11. — View Citation
Type | Measure | Description | Time frame | Safety issue |
---|---|---|---|---|
Primary | Hyperalgesia measured by numeric rating scale for pain | Two pain models will be used - a heat-pain and a cold-pain model. Testing will be done before, during and after remifentanil infusion. NRS (Numeric rating Scale) will be used for pain scoring. Heat model: A computer-controlled Medoc ATS Thermal stimulator (3 x 3 cm) is applied to the left volar forearm at pre-defined areas. Cold model: In the cold test the study participant should keep his right hand in circulating cold water (3 °C) in up to 90 seconds. The pain models will be applied during three separate trials using remifentanil infusion with abrupt withdrawal, remifentanil infusion with gradual withdrawal and saline infusion(placebo). |
3 weeks | No |
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