LAM KID

[Pain management in rheumatology]

NAGY Katalin

OCTOBER 20, 2011

LAM KID - 2011;1(02)

[Pain is the most common symptom in rheumatology, which can be of mechanical or inflammatory origin, acute and chronic, nociceptive, neuropathic and psychogenic. Pain can be relieved by analgesics, nonsteroidal anti-inflammatory drugs, opioids, adjuvants and special drugs depending on the etiology, for example a gout attack can be stopped by colchicine. For pain relief, we use therapeutic guidelines of the World Health Organization (WHO), which recommends the use of analgesics, NSAIDs and adjuvants as the first step, weaker opioids as the second, and strong opioids as the third step. In rheumatology, the first step's drugs are generally used. If possible, NSAIDs should be administered briefly, potentially combined with analgesics and muscle relaxants. If pain management is insufficient, tramadol should be given. Pain relief in rheumatology also include the use of local and intraarticular injections, physiotherapy, TENS and balneotherapy. Complex therapies that combine the above mentioned methods is often more effective than the use of medications only.]

COMMENTS

0 comments

Further articles in this publication

LAM KID

[Inhibition of receptor activator of nuclear kappa-B ligand: pathophysiology and preclinical data]

LAKATOS Péter, NÁDASI Edit

[Bone remodeling is a lifelong process, in which the balanced functions of osteoclasts and osteoblasts have a key role. In certain conditions, for example during the dramatical hormonal changes in the postmenopausal period, the upset of this balance leads to a pathologically increased bone loss. Such conditions lead to an increased bone loss, which results in an increased risk of fractures. Bone resorption is primarily regulated by a member of the tumor necrosis factor family, receptor activator of nuclear factor κB ligand, which plays a central role in the development, function and survival of osteoclasts. Catabolic effects of this ligand is inhibited by another member of the tumor necrosis factor family, osteoprotegerin, which binds to the ligand and prevents its interaction with its receptor, the receptor activator of nuclear factor κB. Osteoclast activity is at least partly dependent on the relative balance of the ligand and osteoprotegerin. It has been shown in a number of animal models that inhibition of the ligand markedly decreases bone resorption and increases cortical and cancellous bone volume, density and strength, without having any significant effect on other organs. On the basis of these findings, inhibition of receptor activator of nuclear κB ligand is a promising therapy of conditions characterised by increased bone loss. In phase 3 clinical trials, denosumab therapy significantly increased bone mineral density at various regions of the skeleton and significantly decreased the levels of bone turnover markers compared with placebo and alendronate therapy, and significantly decreased the incidence of new vertebral, total hip and nonvertebral fractures compared with placebo. On the basis of these findings, denosumab therapy offers a novel, revolutionary solution for the treatment of postmenopausal osteoporosis.]

LAM KID

[Pain relief in metastatic bone disease]

BOÉR Katalin

[Metastatic bone disease is a hallmark of distant relapse of a number of solid tumours. The treatment of bone metastases is palliative, the main goal is to relieve pain, whereas it’s also important to reduce the risk of bone fractures, prolong survival and maintain the physical activity of patients. Pain is one of the most common symptoms of bone metastases, and state-of-the-art pain relief has an important role in maintaining the patients’ quality of life. Therapies to control pain include drug therapy, radiotherapy, surgery, systemic oncotherapy, such as chemotherapy and/or hormone therapy, multibone radioisotope therapy and administration of bisphosphonates. Regarding the relief of pain caused by malignant tumours, the guidelines developed by the World Health Organization should be followed. The algorithm of pain relief starts with assessment of the pain’s intensity and includes both pharmacological and nonpharmacological interventions. Analgesics used for pain relief include nonopioids, opioids and adjuvant agents. The pain can be efficiently relieved with the combined use of modern analgesics in the great majority of patients.]

LAM KID

[Pain relief in the neurologist’s view]

KOMOLY Sámuel

[Pain, on the basis of its anatomical origin, can be nociceptive (somatic, visceral) or neuropathic, that is, occuring as a direct consequence of a lesion or disease affecting the somatosensory system. The past few years’ epidemiological studies showed that chronic neuropathic pain affects 7-8% of the general population. Diagnosis of neuropathic pain can be established without instrumental examinations, with the help of validated tests that can be used by any physician. Neuropathic pain greatly deteriorates the patients’ quality of life, and the effect of traditional analgesics is insufficient for its treatment. Thus, it is important to know those treatment procedures and drugs that have been proved to be efficient for relieving neuropathic pain.]

LAM KID

[Osteoid osteoma]

MAGYAR Péter, KOVÁCS Balázs

LAM KID

[Connections of bone turnover and energy homeostasis in women]

BUDAY BARBARA, PACH Péter, LITERÁTI-NAGY Botond, VECSEI Zsuzsa, KORÁNYI LÁSZLÓ

[BACKGROUND - A new discovery of the past decade has been the previously unknown relationship between the bone metabolic unit and energy homeostasis. On the basis of data from previous animal and clinical studies, osteocalcin has been considered the major mediator of this relationship. Cathepsin K is a cysteine protease type osteolytic enzyme, which has a role in bone resorption, and which is a pharmaceutical target in the treatment of osteoporosis and bone metastasis. According to data from animal studies, its deficiency or selective inhibition decreases the differentiation of preadipocytes, body weight and serum levels of insulin and glucose in obese mice. The aim of our study was to elucidate the role of cathepsin K in the human bone - metabolic axis in women (n=66). PATIENTS AND METHODS - 21 healthy and 45 glucose intolerant women were examined. OGTT, IVGTT and hyperinsulinaemic euglycaemic clamp were performed to assess carbohydrate homeostasis, insulin secretion, whole-body and muscle glucose utilization (M-1 and M-3). Circulating levels of bone markers and adipokines were measured, and DEXA was used to measure BMD, fat and muscle mass. RESULTS - Cathepsin K levels showed a significant (p<0.05), negative correlation with BMI, body fat percent and OGTT glucose and insulin area under the curve (AUC), and a positive correlation with M values. No correlation was found between cathepsin K levels and IVGTT measurements. CONCLUSION - Cathepsin K - in women - is not only a participant of the bone metabolism - energy homeostasis axis. Its role in human glucose homeostasis differs from what could be expected on the basis of animal experiments, because increasing cathepsin K levels indicate, paradoxically, improving metabolic state in women. Our data suggest that insulin regulation of cathepsin K is mediated by the incretin system.]

All articles in the issue

Related contents

Journal of Nursing Theory and Practice

[Associated factors of independency in older adults with cognitive impairment living in a long term care institute]

KOVÁCS Éva, JÓNÁSNÉ SZTRUHÁR Izabella, KARÓCZI Csilla Kata, VASS Zsolt, FARKAS Lilla

[Aim of the research: Functional independence determines the elderly’s health and quality of life. In them cross-sectional study the authors analysed the associations between functional abilities (balance, gait, functional mobility, cognitive abilities), age, BMI and comorbidities and independency in older adults with cognitive impairment. Research and sampling methods: 110 elderly people were measured. Self-sufficiency was measured by the Katz-index, balance, and gait by the Tinetti Test and functional mobility by the Timed Up and Go Test. Correlations between variables were analysed with the Spearman’s rank-order correlation. Results: There was strong association between balance (r=0,557), gait (r=0,515), functional mobility (r=-0,647), and independency. It means the better the balance, gait, and functional mobility is, the higher the independency is. There was weak association between age, BMI, cognitive abilities, comorbidities and independency. Conclusion: Results show that preserving of the functional independence in older adults with cognitive impairment is a multidisciplinary task: physiotherapists and nurses should work together to complete doctors’ curative work of chronic diseases.]

Clinical Neuroscience

[Pain sensitivity changes in schizophrenic patients and animal models - Part II.]

TUBOLY Gábor, HORVÁTH Györgyi

[Diminished pain sensitivity in schizophrenic patients has been reported for more than 50 years, however little is known about the substrate and the basic mechanisms underlying altered pain sensitivity in this disease, therefore, relevant animal models are of decisive importance in the study of psychiatric diseases. The authors report a review consisting of two parts focusing on pain sensitivity changes in patients and in different animal models which proved the eligibility as schizophrenia models and pain sensitivities have also been determined. The second part of this article analyzed the results regarding knock out mice as schizophrenia models. These data proved that several genes have significant role in the pathomechanism of schizophrenia; therefore deficiency in one gene does not produce animals showing all signs of this disease. As regards the pain sensitivity changes, only a few data are available with controversial results. Data originated from complex chronic animal models indicate that they might be more adequate methods for studying the mechanisms of schizophrenia including the pain-sensitivity changes.]

Lege Artis Medicinae

[Pathomechanism, symptoms, differential diagnosis and therapy of fibromyalgia]

KELEMEN Judit

[Fibromyalgia is a chronic, non-inflammatory pain syndrome characterised by diffuse muscle pain and increased tenderness of specific tender points. The exact cause or pathomechanism of the disease is unknown. In the background, nociception and the pain processing pathways of the central nervous system are suspected as dysfunctional. The disease occurs primarily in middle-aged women. Occurence of fibromyalgia is between 1-4%, increasing up to 20% in a rheumatology clinic. In Canada, the cost of treatment of fibromyalgia was 350 million $ in 1993. Unfortunately, in Hungary no similar data is available. It is frequently joined by different vegetative and functional symptoms. One characteristic feature is insomnia, causing typical morning fatigue in patients. Effective therapy has yet to be found, although successful treatment may be achieved with drug therapy (amitryptilin), psychotherapy and aerobics with supplemental electro- and hydrotherapy. Patient education and involvement is also important for good therapeutic results and for the ability to return to work as soon as possible.]

LAM KID

[Pain relief in metastatic bone disease]

BOÉR Katalin

[Metastatic bone disease is a hallmark of distant relapse of a number of solid tumours. The treatment of bone metastases is palliative, the main goal is to relieve pain, whereas it’s also important to reduce the risk of bone fractures, prolong survival and maintain the physical activity of patients. Pain is one of the most common symptoms of bone metastases, and state-of-the-art pain relief has an important role in maintaining the patients’ quality of life. Therapies to control pain include drug therapy, radiotherapy, surgery, systemic oncotherapy, such as chemotherapy and/or hormone therapy, multibone radioisotope therapy and administration of bisphosphonates. Regarding the relief of pain caused by malignant tumours, the guidelines developed by the World Health Organization should be followed. The algorithm of pain relief starts with assessment of the pain’s intensity and includes both pharmacological and nonpharmacological interventions. Analgesics used for pain relief include nonopioids, opioids and adjuvant agents. The pain can be efficiently relieved with the combined use of modern analgesics in the great majority of patients.]

Lege Artis Medicinae

[The pain-trigger role of cytokines in the nervous system – the direct analgesic effect of anti-cytokine therapy ]

HODINKA László, VERECKEI Edit

[Nociceptive, neuropathic and central me­chanisms are involved in the perception, transmission and processing of chronic pain and shaping of cerebral pain image. Alar­mins – molecules alarming defence and signing the presence of pathogens and tissue damage - trigger a series of pathogenic events resulting in inflammatory pain stimuli. Proinflammatory cytokines play a determining role in the pain perception at the level of the nervous system. Continuous inflammatory stimuli while sensitizing the periferic and central neurons activate the pain-related cerebral areas and develop the complex pain image, the pain matrix. Ce­reb­ral functional connections are operating in networks and can be visualized by functional MRI. Cytokines activate the neurons directly or indirectly by other neuromediators. Cytokine receptors are expressed on no­ciceptors and even on higher-level neurons and on various non-neural cells, such as microglia and astrocytes. The most ubiquitous cytokines are the Tumour Necrosis Factor and Interleukin 6 in the nervous sys­tem. The signaling pathways are the Nuclear Factor κB and the Janus-kinase enzyme system. The proinflammatory cytokines and the Janus-kinase are therefore primary therapeutic targets. Anti-cytokine biologicals and small molecular kinase inhibitors decrease the pain and improve functional activity in rheumatoid arthritis. Decrease of pain was more pronounced than expected only from the decrease of the clinical biomarkers of inflammation. The early and ra­pid painkiller effect of targeted biological and chemical-biological response modifiers is attributed to their direct analgesic effect on the brain.]