This document provides guidance on clinical development of new pain medications. It discusses general considerations like pharmacokinetic and dose response studies. It recommends study designs for exploring efficacy in acute and chronic pain, including appropriate patient populations, endpoints, and trial duration. Safety evaluation over long term use is also addressed. Special populations like children, elderly, and those with renal or hepatic impairment require tailored study approaches.
The presentation enhances the reader to get comprehensive view about Pain ( physiology of pain, assessment of pain and Management of pain). This will help you to management pain effectively.
plain for treatment of patient with chronic pain, psychiatry and psychology are two approaches very important to have a proper treatment for pain disorders
The presentation enhances the reader to get comprehensive view about Pain ( physiology of pain, assessment of pain and Management of pain). This will help you to management pain effectively.
plain for treatment of patient with chronic pain, psychiatry and psychology are two approaches very important to have a proper treatment for pain disorders
Lemessa Jira pain managment in surgical patient pptLemessa jira
Poor pain management in surgical settings is known to be associated with slower
recovery, greater morbidity, longer lengths of stay, lower patient satisfaction, and higher
costs of care, suggesting that optimal pain care in these settings is of utmost importance
in promoting acute illness management, recovery, and adaptation
definition of pain - classification - categories and different clinical types of pain - assessment of pain and how to manage using pharmacological and non-pharmacological intervention
In this presentation I have tried to explain in brief about pain management, different types of pain, its diagnostic criteria, its physiology, and its treatment approaches both pharmacological and non pharmacological
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
Lemessa Jira pain managment in surgical patient pptLemessa jira
Poor pain management in surgical settings is known to be associated with slower
recovery, greater morbidity, longer lengths of stay, lower patient satisfaction, and higher
costs of care, suggesting that optimal pain care in these settings is of utmost importance
in promoting acute illness management, recovery, and adaptation
definition of pain - classification - categories and different clinical types of pain - assessment of pain and how to manage using pharmacological and non-pharmacological intervention
In this presentation I have tried to explain in brief about pain management, different types of pain, its diagnostic criteria, its physiology, and its treatment approaches both pharmacological and non pharmacological
a detailed description of pain and therpaeutic options available and clinical assessment of pain, approach to the patient with pain, assessment of intensity of pain, nsaids and opioids, tca. WHO pain ladder, chronic opioid therapy
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docxgerardkortney
ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
Topical Specialist & Compound Pharmacy Study in Jacksonville FL Dr Manish Bansal MD explains the quality of life effects of various transdermal pain therapies. A multicenter prospective cohort study.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. Flow of presentation
1) Introduction
2) Scope
3) General considerations for clinical development
4) Specific Considerations for clinical development
5) Clinical safety evaluation
6) Studies in special populations
4. Introduction
Pain is a complex process involving interactions between
peripheral and central nervous system pathways with various
neurobiological mechanisms being involved.
International Association for the Study of Pain(IASP) defines
pain as an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage .
5.
6. Classification of Pain
• Acute
• Chronic
On the basis of
duration of pain
• Nociceptive-somatic and visceral
• Neuropathic-central and peripheral
• Mixed
On the basis of
mechanisms
• Mild
• Moderate
• Severe
On the basis of
pain intensity
7.
8.
9.
10. Scope
To provide guidance on the clinical development of new
medicinal products intended for the treatment of nociceptive,
neuropathic or mixed pain.
Requirements with regard to study design, duration, target
patient population and outcome measures.
11. General Considerations for clinical
development
Clinical Pharmacology
Pharmacokinetics
Pharmacodynamics
Interaction studies
12. Exploratory studies
Healthy subjects with a controlled pain stimulus are used to test
therapeutic activity of NME.
STUDY DESIGNS:
Randomized parallel group design
Cross-over designs
Randomized withdrawal studies
13. Dose-Response Studies
Appropriate starting dose and titration schedule
Time to onset of effect,
Time to peak-effect and
Duration of effect
Ceiling effects also be evaluated
Depending on the active substance, identification of the highest
tolerated dose might not always be possible as it may depend on
pain intensity and/or duration of treatment (e.g. with opioids).
14. Confirmatory efficacy studies (acute and
chronic pain)
Study designs:
Choice of comparator (monotherapy trials)
Add-on treatments and combination treatments
Trial population:
Inclusion criteria-subjects that are homogenous with respect
to diagnosis and pain intensity
Exclusion criteria-Patients with significant pain disorders other
than the target disease or with disorders that could interfere
with pain assessments
Patients with anxiety or depression
15. Cont.…
Rescue medication: should have an appropriate speed of onset
and duration of effect .
Need for rescue medication may be defined as a trial endpoint
in some study designs (e.g. dose requirement, time to rescue or
time to non-trial analgesia as appropriate).
Primary endpoints:
Mean differences of pain intensity (PID) at specific time points,
or in long-term studies the weekly averages of the daily
measurement compared to baseline.
Analysis of the area under the time-analgesic effect curve for
pain intensity (SPID) or pain relief (TOTPAR).
17. Clinical Efficacy
Methods to assess efficacy
Pain measurement-Pain intensity (PI) is still the key measure of
efficacy of an analgesic drug and should always be reported.
Various scales used are as follows:
Visual analogue scale (VAS)
Numeric rating scale (NRS)
Verbal rating scale (VRS)
McGill Pain Questionnaire (MPQ, SF-MPQ)
Neuropathic Pain Scale (NPS)
Neuropathic Pain Symptom Inventory (NPSI)
18.
19. Cont.…
Measurement of physical functioning
Patient reported outcome measures (PROs)
Health-related quality of life (HRQOL) tools (SF-36 Health Survey)
Measurement of emotional functioning
Basal psychological and psychosocial evaluation with appropriate
measures (e.g. BDI, POMS, HADS, MOS-264 SS) Measurement
of Global Improvement and satisfaction with treatment
Clinical Global Impression of Change (CGI-C)
20. Specific Considerations for clinical development
ACUTE PAIN
The clinical trial requirements depend on:
a)Mechanism of action
b) The intended patient population
Study duration may vary from hours to weeks in acute pain trials,
depending on the pain model or clinical situation being studied.
The full range of pain intensities for which the product is intended
to be indicated (i.e. mild, moderate, severe) should be studied in
the confirmatory clinical trials.
21. General principles for the data requirements to support
different indications :
If only a single pain model is studied the approvable indication will
in principle be limited to the specific condition studied unless
extrapolation to other conditions can be clearly justified.
To justify a general indication for the treatment of acute pain,
efficacy needs to be demonstrated independently in models of both
somatic and visceral pain, or in models of somatic pain and mixed
somatic/visceral pain.
If models of just somatic or just visceral pain are studied, the
indication will normally be restricted accordingly.
22. Examples of pain models appropriate to be used in efficacy studies in acute pain
Pain Intensity mild to moderate Moderate to severe
(in general NRS ≤ 6, VAS ≤ 60 mm) (in general NRS ≥4, VAS ≥ 40 mm)
Somatic pain Tooth extraction
Minor cutaneous surgery
Surgical removal of impacted 8th
teeth
Major orthopedic surgery
Major skeletal trauma
Dressing changes in burns pain
Pain model Visceral pain Primary dysmenorrhea Acute pancreatitis
Renal / biliary colic
Both somatic and
visceral pain
Minimally invasive (laparoscopic)
abdominal/gynecological surgery
Abdominal / thoracic surgery
23. Chronic Pain
General principles for data requirements to support different type of
indications in chronic pain
If an appropriate single pain model is studied the indication will normally be
limited to the specific condition studied (e.g. CLBP). If the condition is one in which
pain is typically mixed it will be necessary to demonstrate an effect on both
nociceptive and neuropathic components.
If models of just neuropathic pain are studied, the indication will be restricted
accordingly.
To justify a general indication for the treatment of chronic pain, compelling
evidence of efficacy in both neuropathic and nociceptive pain components has to
be provided.
+
24. Efficacy studies in chronic pain
Patient population
Patients with at least moderate to severe pain (typically VAS ≥ 40
mm or NRS ≥ 4)
If the expected safety profile of the drug is benign, patients with
mild to moderate chronic pain
Patients have exhibited symptoms for more than 3 months with
no substantial recent change in pain severity
Patients duration of pain, stability of symptoms before enrolment
and pain medication history
25. Cont.…
Efficacy endpoints
Pain measurement
Measurement of physical functioning
Measurement of emotional functioning
Measurement of Global Improvement and satisfaction with
treatment
Evaluation of stimulus evoked pain (allodynia or hyperalgesia)
with standardized quantitative sensory testing by calibrated
devices
26. Cont.…
Trial design- Randomized controlled parallel group design
For a sustained therapeutic effect in chronic pain treatment period
of at least 12 weeks, excluding titration period is required.
Run in periods should ensure a high standard of non-
pharmacological management (e.g. psychological and behavioural
support) and reasonably stable symptom severity for an
appropriate duration prior to randomization.
Long term efficacy data- Randomized withdrawal study design
27. Clinical safety evaluation
Monitoring of adverse events (AEs) as per ICH/EU E1A
For drugs intended for long-term treatment, repeated use in acute
pain or for which off label long term use is plausible safety data of
at least 12 months duration is required.
Potential safety issues relating to the delivery system (e.g.
transdermal, intranasal, buccal) should be evaluated.
For drugs with CNS effects special attention should be paid to
undesirable effects such as alertness and cognition.
28. Cont.…
For new medicinal products of an established class the main
class related safety concerns should be thoroughly analyzed,
in particular those AEs that limit tolerability such as
constipation for opioids or dyspepsia for NSAIDs.
For centrally acting analgesics such as opioids special
attention should be given to respiratory effects, drug
tolerance and dependence .
29. Cont.…
Withdrawal reactions, dependence, abuse and misuse
In some of the short-term and long-term clinical trials, treatment
should be stopped abruptly or gradually as appropriate the
known pharmacology, and patients followed for a suitable
duration to record rebound and/or withdrawal phenomena.
Misuse refers to use of a drug for its intended therapeutic effect
but in an inappropriate way.
Abuse refers to use for non-therapeutic purposes.
Physical dependence is associated with the development of
tolerance and withdrawal symptoms due to rapid reduction in
exposure while psychological dependence focuses on elements
like compulsion, impaired control or craving
30. Studies in special populations
Children
Trial design: Rescue-analgesic trials
Primary endpoint: Differences in analgesic use between treatment
groups
Secondary endpoint: Pain scores
Pain assessment: Behavioural Observational Scales (e.g. FLACC or
CHEOPS for procedural or postsurgical pain)
For term and preterm neonates (e.g. CRIES, NFCS or PIPP)
31.
32.
33. Cont…
For all CNS active agents administered in term and preterm
neonates a long term neurodevelopmental follow-up to 2
years of age is requested as a standard requirement
34. Cont.…
Elderly
Musculoskeletal diseases and cancer largely contributes to diseases of
older persons.
Particular attention should be given to the safety profile in elderly
subjects.
For sedative/hypnotic agents or drugs with important CNS effects
separate dose response studies are recommended in the elderly (ICH E7).
The very elderly (>75 years old) as they represent a large target
population in both acute and chronic pain. For known drug classes,
subgroup analyses of the whole elderly population in the overall database
are in general sufficient.
Editor's Notes
Acute pain is considered adaptive ,short duration and declines with the healing of the 85 underlying injury or disease (e.g. post-surgical pain)
Chronic pain is generally regarded as maladaptive with 89 lack of survival value to the organism. Psychological, genetic4,5,6, environmental or socioeconomic
For locally acting products trials should include pain models representing the intended use of the product (e.g. ankle sprains as a model for an NSAID containing cream or gel).
In dysmenorrhea, in which pain is regularly recurrent and of predictable intensity, a crossover design with at least 4 treatment periods is recommended; parallel designs are also acceptable.
For trials in which the medicinal product is administered by an invasive procedure (e.g. spinal or epidural injection), a placebo group may not be appropriate due to ethical concerns.
In studies evaluating efficacy in acute pain following surgery or trauma, patients are likely to have concomitant sedative medication.