Department of Anaesthesia, Monash University, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia*Corresponding author
Accepted for publication: November 20, 2000
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Abstract |
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Br J Anaesth 2001; 86: 52834
Keywords: analgesics non-opioid, alphadolone; pain, post-operative
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Introduction |
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Few articles have been published describing the effect of neuroactive steroids on the spinal cord. One article reported inhibition of spontaneous and evoked electrical activity in spinal cord neurones after intravenous injection of Saffan, a veterinary steroid combination anaesthetic containing alphaxalone 9 mg ml1 and alphadolone 3 mg ml1 dissolved in Cremophor EL.11 These observations of effects on neuronal activity were not specific for any particular sensory modality. Intrathecal injection of water-soluble aminosteroid anaesthetics has been shown to cause antinociception in rats, which was a result of interaction of the drugs with spinal cord GABAA receptors.12 Subanaesthetic doses of Saffan causes powerful antinociception in rats.13 Further investigations showed that all the sedative and anaesthetic properties of the mixture were due to the alphaxalone content and all of the antinociceptive properties were due to the alphadolone content. Alphadolone caused spinally mediated antinociception by an interaction with spinal cord GABAA receptors when the drug was given intraperitoneally or intragastrically to rats without any signs of sedation, even when it was given at a very high dose.14 Therefore, we performed a pilot study to provide initial information on the tolerability and safety of the drug and initial data on its efficacy.
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Materials and methods |
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The study consisted of two parts, as shown in Fig. 1. At any time during both parts, if the patient was randomized to receive placebo, then a capsule containing lactose 250 mg was administered orally at the time of medication. If the subject was randomized to receive alphadolone, then the first patient so randomized received alphadolone acetate 25 mg orally. The patient was monitored for efficacy of the medication and side-effects. If there were no unacceptable side-effects, such as respiratory depression, severe sedation or disorientation, then the next patient randomized to receive the active treatment received a higher dose. The dose escalation planned was 25, 50, 100, 250, 500 and 1000 mg. The trial switched from the dose escalation phase to the comparison phase when there was clear evidence of efficacy. The senior author (CSG) assessed this and the study switched to part 2 without the observers knowledge. Patient and observer (AR) remained unaware of the nature of the treatment, whether placebo or alphadolone and what dose.
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There seemed to be efficacy with the 100, 250 and 500 mg doses in these patients. Thus, in the second part of the study, a double-blind comparison of placebo with alphadolone 250 mg was carried out. Patients 8, 10, 13 and 14 received alphadolone 250 mg and patients 9, 11 and 12 received placebo.
The protocol below was carried out in all patients in both parts of the study and the data were analysed for the efficacy and side-effect profile of alphadolone compared with placebo.
Protocol
Patients (n=14) scheduled for knee reconstruction surgery gave written informed consent to be included in the study after inclusion and exclusion criteria had been met. Inclusion criteria were: ASA 12; age 1870 yr; not using regular analgesics apart from paracetamol and non-steroidal anti-inflammatory drugs. All analgesic medications were withheld before surgery on the day of surgery. Subjects who had renal, hepatic or respiratory disease (other than mild asthma) and pregnant women were excluded from the study. No epidural, spinal or knee-joint local anaesthetic or opioid injections were allowed. After the patients had given informed consent, they were given an opportunity to familiarize themselves with the patient-controlled analgesia (PCA) machine and to practice completing the visual analogue scale (VAS) and verbal rating scale used for postoperative assessments.
No premedication was given. The patients were taken to the operating theatre and given a standardized anaesthetic that consisted of propofol induction followed by propofol infusion and the muscle relaxant of the anaesthetists preference. The trachea was intubated and the lungs were ventilated with a mixture of nitrous oxide and oxygen. Incremental doses of morphine (12 mg i.v.) were given as indicated by the assessment of the depth of anaesthesia by normal monitoring techniques. The amount of morphine used in the operating theatre was recorded. After surgery, muscle relaxation was reversed with atropine and neostigmine. In the recovery ward, the patient was reintroduced to the PCA machine, which contained morphine and was set to deliver a 1 mg dose with a lockout time of 5 min. The patient was discharged to the ward 30 min later.
Placebo or alphadolone was given orally with 100 ml of water 1 h after return to the ward. The following observations and measurements were made 1 h before, 30 min before and just before giving the test medication, and were repeated every 30 min thereafter until 6 h after the capsule had been given: sedation, on a four-point scale (none, mild, moderate, severe); nausea (none, mild, moderate, severe vomiting); morphine consumption during the last 30 min; 10 cm VAS for pain (no pain, most intense pain imaginable); respiratory depression score (none=respiratory rate greater than 10 b.p.m., oxygen saturation greater than 95%; mild=respiratory rate greater than 6 and less than 10 b.p.m., and oxygen saturation greater than 95%; moderate=respiratory rate less than 6 b.p.m. but oxygen saturation greater than 95%; severe=respiratory rate less than 6 b.p.m. and/or oxygen saturation less than 95%); light-headedness (none=no dizziness; mild=light dizziness but no nystagmus; moderate=feels dizzy and has nystagmus; severe=very dizzy with nausea); slurred speech (none, mild, moderate, severe); presence of confusion or disorientation; gaze-evoked nystagmus (none; mild=12 jerks; moderate=constant slow jerks; severe=fast jerks and feeling dizzy); lack of co-ordination, with two tests: (i) close eyes, touch nose with finger; (ii) touch fingers 1, 2, 3 and 4 in turn with thumb (classified as none=both tests accomplished; mild=both tests accomplished but slowly; moderate=one test achieved after two attempts; severe=failed both tests after two attempts at each).
One hour after the capsule had been given, all patients commenced physiotherapy with a continuous passive movement (CPM) machine. This machine forcibly moves the knee through an angle of 30° to 45°. Thus, after capsule administration the pain measurements were on movement, whereas before this they were at rest.
All patients had 10 ml of blood taken from a vein immediately before capsule administration and 30 min and 1, 1.5, 2, 3, 4 and 6 h after capsule administration. Blood was placed in heparinized tubes and centrifuged and the plasma was decanted for later analysis of blood alphadolone concentration by the Key Centre for Applied and Nutritional Toxicology, Royal Melbourne Institute of Technology.
Statistics
Statistical tests were applied to the data obtained in part 2 in order to compare the alphadolone and placebo treatment groups. Morphine consumption from the PCA in each half-hour period for the 6 h after drug treatment was classified as 0, 1, 2, 3 or 4 mg. The numbers of times each dose had been used in the placebo- and alphadolone-treated groups were placed in a contingency table and a 2 test was applied. The
2 test was also used to compare the groups with respect to all other scores except the VAS for pain intensity. The latter measurements at each 30 min period were transformed by dividing them by the mean of the three readings taken before capsule administration. All of the values for the alphadolone-treated group were compared with those for placebo treatment using the MannWhitney U-test. In all statistical tests, a P value less than 0.05 was considered to be statistically significant.
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Results |
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The doses of morphine received by the patients in the operating theatre, recovery ward and ward before capsule administration were not significantly different between placebo- and alphadolone-treated patients (Table 1).
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On this basis, it was decided to switch the rest of the trial (part 2) to a double-blind comparison of alphadolone 250 mg with placebo in the remaining patients. Data from placebo-treated patients (n=5) and alphadolone-treated patients (100, 250 and 500 mg, n=7) were combined for statistical comparisons.
Sedation and nausea scores
These data were entered into a contingency table (Table 2).
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Verbal rating scale for pain
Verbal rating scale scores were entered into a 4x2 contingency table (Table 3). A 2 test revealed that the alphadolone-treated patients recorded significantly lower pain scores.
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CPM duration
Each patient was put on the CPM machine 1 h after capsule administration. The patient could be taken off this machine at the discretion of the nursing staff. Thus, little can be made of these data except to rule out the possibility that the alphadolone patients were subjected to knee movements for shorter periods of time.
Table 6 shows that this was not the case.
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Discussion |
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Throughout the development of neurosteroid compounds for use in humans, researchers and developers have concentrated on the hypnotic, sedative and anticonvulsant properties of these compounds.2633 Such work has led to the development and patenting of new neurosteroids as anticonvulsants, acting as positive modulators at GABAA receptors to be used as anti-epileptics34 35 or for the treatment of migraine.36 There have been no reports of analgesic or antinociceptive effects of neurosteroids separate from their sedative and anticonvulsant properties. For example, effects on electrically evoked spinal cord neuronal activity after anaesthetic doses of intravenous Althesin (alphaxalone/alphadolone) have been reported.37 38 Anti nociception in animals has been reported after injection of sedative neurosteroids directly into the brain or spinal cord without any control measurements to exclude the effect of sedation on the observations.39 By contrast, in human experiments, subnarcotic doses of Althesin, like equivalent doses of thiopentone, produced a degree of analgesia during experimental pain elicited by pressure on the tibia.4042. It was found that Althesin alone provided insufficient analgesia for major surgery.43 It abolished the pain of uterine contractions only during the period of unconsciousness, which was followed by hypersensitivity to pain during recovery.40 41 There have been observations of gender differences and pregnancy-associated antinociception that have been attributed to steroid hormones.4446 All of these compounds caused hormonal effects as well as antinociception. Therefore, apart from data reported by Nadeson and Goodchild,1214 selective antinociceptive effects of neurosteroids were not suspected.
Experiments in rats showed that spinal cord GABAA receptors are responsible for the antinociceptive effects of subanaesthetic doses of propofol47 and Saffan (alphaxalone/alphadolone mixture).13 Unexpectedly, it was found that alphadolone was responsible for this antinociception, but only when intraperitoneal or intragastric routes of administration were used.14 This led to inactivation of the anaesthetic properties of the alphadolone, even when the compound was administered at high doses. This suggested a new use for the neurosteroid as an analgesic and that the active compound might be a metabolite.
This pilot study shows for the first time a number of properties of orally administered alphadolone in humans. Alphadolone is rapidly absorbed after oral administration and metabolized to the glucuronide. It may be well tolerated up to a dose of 500 mg orally, with no observed increase in central nervous system disturbances greater than those caused by hangover of anaesthetic and postoperative medication with morphine. No free alphadolone was detected, which may explain the lack of sedation and is in accordance with the results obtained previously in rats.13 14 This was followed by a reduced morphine requirement after operation and improved pain scores even in the presence of lower morphine use. This morphine-sparing and improved pain relief occurred in the presence of movement of the joint. Thus, we conclude that orally administered alphadolone may possess useful analgesic properties in humans and that these properties are worthy of more detailed investigation.
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