Clinical trial NCT05311774: Efficacy of Duloxetine in Conjunction With Tramadol for Chronic Cancer Pain
Official title: Efficacy of Duloxetine in Conjunction With Tramadol for Chronic Cancer Pain
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: NA
Conditions: Cancer Pain
Keywords: duloxetine
tramadol
cancer pain
Lead sponsor: Assiut University
Sponsor class: OTHER
First posted: 2022-04-05
Enrollment: 400
Sex: ALL
Minimum age (years): 20
Maximum age (years): 70
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Cancer pain is one of the most common and problematic symptoms. Opioids are typically the most common drugs used in the treatment of cancer pain,they are limited due to their side effects.

Tramadol is a centrally acting non-opiate analgesic with low affinity for μ-opioid receptors, and is effective in the treatment of moderate to severe pain.

Neuropathic pain is typically not amenable to standard opiate therapy, and the addition of tricyclic antidepressants or/and antiepileptic drugs can offer a very effective treatment strategy in such patients.

Duloxetine is a Serotonin Norepinephrine Reuptake Inhibitor (SNRI) that has been used traditionally for its antidepressant qualities and has also analgesic benefit in the treatment of neuropathic pain. Duloxetine exerts its analgesic action through central and peripheral pain modulation .

Detailed description: Cancer pain is one of the most common and problematic symptoms.uncontrolled pain affect quality of life and daily activities .Cancer pain has two main categories nociceptive and neuropathic pain,Cancer pain is often a combination of nociceptive and neuropathic pain.

A framework for managing pain often starts with the World Health Organization (WHO) Analgesic Ladder, step 1 use non opioid analgesics, step 2 weak opioids, step 3 strong opioids, step 4 interventions non pharmacological, adjuvants can be added to any step .

Opioids are typically the most common drugs used in the treatment of cancer pain. They work by binding to μ-opioid receptors within the central nervous system, which are responsible for opioid mediated analgesia, respiratory depression, sedation, physiological dependence, and tolerance, they are limited due to their side effects as nausea, constipation, sedation, and confusion, prolonged use of opioids may lead to development of tolerance, abnormal hypersensitivity to pain.

Tramadol is a centrally acting non-opiate analgesic with low affinity for μ-opioid receptors, and is effective in the treatment of moderate to severe pain. It has been also shown to inhibit reuptake of serotonin and norepinephrine, which synergistically enhances its weak opioid mechanism of action.

This may explain the reduced incidences of abuse, respiratory depression and other adverse effects of traditional opioids in patients on long-term tramadol therapy.it is a useful drug in patients with cancer pain both with nociceptive and neuropathic pain .Neuropathic pain is typically not amenable to standard opiate therapy, and the addition of tricyclic antidepressants or/and antiepileptic drugs can offer a very effective treatment strategy in such patients.

Adjuvant analgesics are drugs primarily marketed for other indications, such as depression, but also have an important role in cancer pain management. Antidepressants, such as serotonin- norepinephrine reuptake inhibitors (duloxetine, venlafaxine) or tricyclics ( nortriptyline, amitriptyline) and anticonvulsants (pregabalin, gabapentin, carbamazepine) have efficacy in the treatment of pain, particularly neuropathic pain .Duloxetine is a Serotonin Norepinephrine Reuptake Inhibitor (SNRI) that has been used traditionally for its antidepressant qualities and has also analgesic benefit in the treatment of neuropathic pain . Duloxetine exerts its analgesic action through central and peripheral pain modulation , it enhances the effect of serotonin and norepinephrine on descending inhibitory pain pathways in the brain and spinal cord and activation of some cerebral prefrontal areas . Besides, it has been claimed that Duloxetine has an anti-nociceptive effect through Na + channel block , therefore it suppresses the neuronal cell firing resulting from peripheral injury . The most common adverse effects of duloxetine, which may lead to discontinuation of the drug, are nausea, dizziness, and somnolence .There is a possibility that duloxetine was effective in both activation of the descending pain modulatory system and the improvement of depressive mood, the effect may have partly taken place due to elevation of the pain threshold through the antidepressant effect of duloxetine . Recently, the efficacy of duloxetine has been reported in patients with chemotherapy-induced peripheral neuropathy (CIPN) and in non-cancer neuropathic pain. .

Eligibility criteria: Inclusion Criteria:

* Patients with cancer pain

  1. age from 20-70 years old.
  2. not receiving any type of analgesia before (opioid naïve, no adjuvants).

Exclusion Criteria:

1. Difficult to be assessed for pain.
2. Any contraindication for duloxetine or tramadol.

Primary outcomes:
measure: concentration of tramadol consumption
timeFrame: at one month
Secondary outcomes:
measure: concentration of tramadol consumption
timeFrame: at 2 month and 3 month
measure: - change in pain with visual analogue scale
timeFrame: at 3,6,9 and 12 days , 2 weeks,1 month,2 month,3 month
measure: type of pain that relieved better
timeFrame: at 1 month,2 month and 3 month
measure: Leeds Assessment of Neuropathic Symptoms and Signs Scale if neuropathic pain
timeFrame: at 1 month,2 month and 3 month
measure: Scale Assessing Pain Intensity and Interference (Pain, Enjoyment, General Activity)
timeFrame: at 1 month,2 month and 3 month
measure: Depression scores by the Patient Health Questionnaire
timeFrame: at 1 month,2 month and 3 month
measure: Anxiety scores by the Patient Health Questionnaire
timeFrame: at 1 month,2 month and 3 month
measure: Flanagan Quality of Life Scale
timeFrame: at 1 month,2 month and 3 month
measure: Side effects as nausea, vomiting, constipation, sedation, arrhythmia and hypertension
timeFrame: up to 3 month
Other outcomes:
Locations:
city: Assiut
country: Egypt
facility: Assiut University
Study officials:
affiliation: Assiut University
name: khaled M Fares, MD
role: STUDY_DIRECTOR
affiliation: Assiut University
name: Ahmad M Abd EL Rahman, MD
role: STUDY_DIRECTOR
affiliation: Assiut University
name: Diab F Hetta, MD
role: STUDY_DIRECTOR
References:
citation: van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage. 2016 Jun;51(6):1070-1090.e9. doi: 10.1016/j.jpainsymman.2015.12.340. Epub 2016 Apr 23.
citation: Greco MT, Roberto A, Corli O, Deandrea S, Bandieri E, Cavuto S, Apolone G. Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer. J Clin Oncol. 2014 Dec 20;32(36):4149-54. doi: 10.1200/JCO.2014.56.0383. Epub 2014 Nov 17.
citation: Ashby MA, Fleming BG, Brooksbank M, Rounsefell B, Runciman WB, Jackson K, Muirden N, Smith M. Description of a mechanistic approach to pain management in advanced cancer. Preliminary report. Pain. 1992 Nov;51(2):153-161. doi: 10.1016/0304-3959(92)90256-B.
citation: Knudsen AK, Aass N, Fainsinger R, Caraceni A, Klepstad P, Jordhoy M, Hjermstad MJ, Kaasa S. Classification of pain in cancer patients--a systematic literature review. Palliat Med. 2009 Jun;23(4):295-308. doi: 10.1177/0269216309103125. Epub 2009 Mar 13.
citation: . World Health Organization. Cancer Pain Relief. 2. Geneva: WHO; 1996. 7.
citation: Gutstein HB, Akil H. Opioid analgesics. In: Hardman JG, Limbrid E, editors. Goodman and Gilman's the Pharmacological Basis of Therapeutics. 10. New York: McGraw-Hill Professional; 2001. pp. 569-619.
citation: Alvarez V, Arttamangkul S, Williams JT. A RAVE about opioid withdrawal. Neuron. 2001 Dec 6;32(5):761-3. doi: 10.1016/s0896-6273(01)00530-x.
citation: Raffa RB, Friderichs E, Reimann W, Shank RP, Codd EE, Vaught JL. Opioid and nonopioid components independently contribute to the mechanism of action of tramadol, an 'atypical' opioid analgesic. J Pharmacol Exp Ther. 1992 Jan;260(1):275-85.
citation: Desmeules JA, Piguet V, Collart L, Dayer P. Contribution of monoaminergic modulation to the analgesic effect of tramadol. Br J Clin Pharmacol. 1996 Jan;41(1):7-12. doi: 10.1111/j.1365-2125.1996.tb00152.x.
citation: Raffa RB. Pharmacology of oral combination analgesics: rational therapy for pain. J Clin Pharm Ther. 2001 Aug;26(4):257-64. doi: 10.1046/j.1365-2710.2001.00355.x.
citation: Russell IJ, Kamin M, Bennett RM, Schnitzer TJ, Green JA, Katz WA. Efficacy of tramadol in treatment of pain in fibromyalgia. J Clin Rheumatol. 2000 Oct;6(5):250-7. doi: 10.1097/00124743-200010000-00004.
citation: Arbaiza D, Vidal O. Tramadol in the treatment of neuropathic cancer pain: a double-blind, placebo-controlled study. Clin Drug Investig. 2007;27(1):75-83. doi: 10.2165/00044011-200727010-00007.
citation: Duhmke RM, Cornblath DD, Hollingshead JR. Tramadol for neuropathic pain. Cochrane Database Syst Rev. 2004;(2):CD003726. doi: 10.1002/14651858.CD003726.pub2.
citation: Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, Gilron I, Haanpaa M, Hansson P, Jensen TS, Kamerman PR, Lund K, Moore A, Raja SN, Rice AS, Rowbotham M, Sena E, Siddall P, Smith BH, Wallace M. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015 Feb;14(2):162-73. doi: 10.1016/S1474-4422(14)70251-0. Epub 2015 Jan 7.
citation: Collins SL, Moore RA, McQuayHJ, Wiffen P. Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic review. J Pain Symptom Manage. 2000 Dec;20(6):449-58. doi: 10.1016/s0885-3924(00)00218-9.
citation: McMenamin E. Pain management principles. Curr Probl Cancer. 2011 Nov-Dec;35(6):317-24. doi: 10.1016/j.currproblcancer.2011.10.006. No abstract available.
citation: Verdu B, Decosterd I, Buclin T, Stiefel F, Berney A. Antidepressants for the treatment of chronic pain. Drugs. 2008;68(18):2611-32. doi: 10.2165/0003495-200868180-00007.
citation: Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, Kalso EA, Loeser JD, Miaskowski C, Nurmikko TJ, Portenoy RK, Rice ASC, Stacey BR, Treede RD, Turk DC, Wallace MS. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007 Dec 5;132(3):237-251. doi: 10.1016/j.pain.2007.08.033. Epub 2007 Oct 24.
citation: Quilici S, Chancellor J, Lothgren M, Simon D, Said G, Le TK, Garcia-Cebrian A, Monz B. Meta-analysis of duloxetine vs. pregabalin and gabapentin in the treatment of diabetic peripheral neuropathic pain. BMC Neurol. 2009 Feb 10;9:6. doi: 10.1186/1471-2377-9-6.
citation: Onutu AH. Duloxetine, an antidepressant with analgesic properties - a preliminary analysis. Rom J Anaesth Intensive Care. 2015 Oct;22(2):123-128.
citation: Basbaum AI, Fields HL. Endogenous pain control systems: brainstem spinal pathways and endorphin circuitry. Annu Rev Neurosci. 1984;7:309-38. doi: 10.1146/annurev.ne.07.030184.001521. No abstract available.
citation: Jones CK, Peters SC, Shannon HE. Efficacy of duloxetine, a potent and balanced serotonergic and noradrenergic reuptake inhibitor, in inflammatory and acute pain models in rodents. J Pharmacol Exp Ther. 2005 Feb;312(2):726-32. doi: 10.1124/jpet.104.075960. Epub 2004 Oct 19.
citation: Wang SY, Calderon J, Kuo Wang G. Block of neuronal Na+ channels by antidepressant duloxetine in a state-dependent manner. Anesthesiology. 2010 Sep;113(3):655-65. doi: 10.1097/ALN.0b013e3181e89a93.
citation: Nakajima K, Obata H, Iriuchijima N, Saito S. An increase in spinal cord noradrenaline is a major contributor to the antihyperalgesic effect of antidepressants after peripheral nerve injury in the rat. Pain. 2012 May;153(5):990-997. doi: 10.1016/j.pain.2012.01.029. Epub 2012 Mar 15.
citation: Allgulander C, Nutt D, Detke M, Erickson J, Spann M, Walker D, Ball S, Russell J. A non-inferiority comparison of duloxetine and venlafaxine in the treatment of adult patients with generalized anxiety disorder. J Psychopharmacol. 2008 Jun;22(4):417-25. doi: 10.1177/0269881108091588.
citation: Colleoni M, Mandala M, Peruzzotti G, Robertson C, Bredart A, Goldhirsch A. Depression and degree of acceptance of adjuvant cytotoxic drugs. Lancet. 2000 Oct 14;356(9238):1326-7. doi: 10.1016/S0140-6736(00)02821-X.
citation: McDonald MV, Passik SD, Dugan W, Rosenfeld B, Theobald DE, Edgerton S. Nurses' recognition of depression in their patients with cancer. Oncol Nurs Forum. 1999 Apr;26(3):593-9.
citation: Meyer HA, Sinnott C, Seed PT. Depressive symptoms in advanced cancer. Part 2. Depression over time; the role of the palliative care professional. Palliat Med. 2003 Oct;17(7):604-7. doi: 10.1191/0269216303pm813oa.
citation: Bouhassira D, Wilhelm S, Schacht A, Perrot S, Kosek E, Cruccu G, Freynhagen R, Tesfaye S, Lledo A, Choy E, Marchettini P, Mico JA, Spaeth M, Skljarevski V, Tolle T. Neuropathic pain phenotyping as a predictor of treatment response in painful diabetic neuropathy: data from the randomized, double-blind, COMBO-DN study. Pain. 2014 Oct;155(10):2171-9. doi: 10.1016/j.pain.2014.08.020. Epub 2014 Aug 27.
citation: Smith EM, Pang H, Cirrincione C, Fleishman S, Paskett ED, Ahles T, Bressler LR, Fadul CE, Knox C, Le-Lindqwister N, Gilman PB, Shapiro CL; Alliance for Clinical Trials in Oncology. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013 Apr 3;309(13):1359-67. doi: 10.1001/jama.2013.2813.