Effect of pharmacotherapy on fibromyalgia: an overview of systematic reviews / Efeito da farmacoterapia na fibromialgia: uma overview de revisões sistemáticas

Fibromyalgia is a debilitating and chronic pain processing disorder, in which the proportion of patients who achieve good results with pharmacotherapy is small. However, choosing the best available evidence on pharmacotherapy can optimize patient clinical outcomes. Objective: This overview aimed to identify in systematic reviews the effects of pharmacotherapy on fibromyalgia, considering the quality of the reviews and the efficacy of the outcomes. Methods: This search was performed in seven databases: PubMed, Web of Science, COCHRANE, Lilacs, Embase, Scopus and IPA. The methodological quality was evaluated using A MeaSurement Tool to Assess Systematic Reviews 2. The protocol was registered in the PROSPERO database (CRD42018095943). Results: A total of 63 systematic reviews were selected after reading full texts, but only 8 of them were of moderate to high quality and were included in this overview. All included reviews were published in English, between 2012 and 2018, performed meta-analysis, used the American College of Rheumatology (1990) diagnostic criteria for fibromyalgia, and jointly assessed pain improvement, adverse reactions, and withdrawal. Most reviews included only randomized controlled trials. Of the fourteen drugs addressed in systematic reviews evaluated, duloxetine, milnacipran, and pregabalin showed evidence of improvement in pain (Moderate: ≤30%) and other fibromyalgia symptoms, as depression and fatigue. However, these medications presented significant withdrawals due to adverse reactions (mainly nausea, headache, dizziness and constipation). The rate of treatment withdrawal reached 36%. Conclusion: Few studies have high quality and sufficient evidence on the effect of medicines on fibromyalgia, resulting in a lack of support for prescribers to choose drugs that meet criteria for need, effectiveness, safety and compliance.

Fibromialgia é um distúrbio de processamento da dor debilitante e crônico, em que a proporção de pacientes que obtêm bons resultados com a farmacoterapia é pequena. No entanto, escolher a melhor evidência disponível sobre a farmacoterapia pode otimizar os resultados clínicos do paciente. Objetivo: Esta overview teve como objetivo identificar em revisões sistemáticas os efeitos da farmacoterapia na fibromialgia, considerando a qualidade das revisões e a eficácia dos resultados. Métodos: Esta busca foi realizada em sete bases de dados: PubMed, Web of Science, COCHRANE, Lilacs, Embase, Scopus e IPA. A qualidade metodológica foi avaliada usando A MeaSurement Tool to Assess Systematic Reviews 2. O protocolo foi registrado no PROSPERO (CRD42018095943). Resultados: Um total de 63 revisões sistemáticas foram selecionadas após a leitura de textos completos, mas apenas 8 delas eram de qualidade moderada a alta e foram incluídas nesta overview. Todas as revisões incluídas foram publicadas em inglês, entre 2012 e 2018, realizaram meta-análises, utilizaram os critérios de diagnósticos do American College of Rheumatology (1990) para fibromialgia e avaliaram conjuntamente a melhora da dor, reações adversas e retiradas. A maioria das revisões incluiu apenas ensaios clínicos randomizados. Dos quatorze medicamentos abordados nas revisões sistemáticas avaliadas, duloxetina, milnaciprano e pregabalina mostraram evidências de melhora da dor (moderada: ≤30%) e de outros sintomas da fibromialgia como depressão e fadiga. No entanto, esses medicamentos apresentaram retiradas significativas devido a reações adversas (principalmente náusea, cefaleia, tontura e constipação). A taxa de abandono ao tratamento chegou a 36%. Conclusão: Poucos estudos apresentam evidências suficientes e de alta qualidade sobre o efeito dos medicamentos na fibromialgia, resultando na falta de apoio para os prescritores escolherem medicamentos que atendam aos critérios de necessidade, eficácia, segurança e adesão.

Recapitulation of Retinal Damage in Zebrafish Larvae Infected with Zika Virus.

Zebrafish are increasingly being utilized as a model to investigate infectious diseases and to advance the understanding of pathogen-host interactions. Here, we take advantage of the zebrafish to recapitulate congenital ZIKV infection and, for the first time, demonstrate that it can be used to model infection and reinfection and monitor anti-viral and inflammatory immune responses, as well as brain growth and eye abnormalities during embryonic development. By injecting a Brazilian strain of ZIKV into the yolk sac of one-cell stage embryos, we confirmed that, after 72 h, ZIKV successfully infected larvae, and the physical condition of the virus-infected hosts included gross morphological changes in surviving embryos (84%), with a reduction in larval head size and retinal damage characterized by increased thickness of the lens and inner nuclear layer. Changes in locomotor activity and the inability to perceive visual stimuli are a result of changes in retinal morphology caused by ZIKV. Furthermore, we demonstrated the ability of ZIKV to replicate in zebrafish larvae and infect new healthy larvae, impairing their visual and neurological functions. These data reinforce the deleterious activity of ZIKV in the brain and visual structures and establish the zebrafish as a model to study the molecular mechanisms involved in the pathology of the virus.

An Overview of the Methodologies and the Quality of Studies on Pharmacotherapy for the Treatment of Fibromyalgia.

BACKGROUND: It is often unclear whether systematic reviews and primary studies are de-signed to elucidate the efficacy or effectiveness of interventions. This may compromise the use of the information in clinical or policy decisions. OBJECTIVE: This overview aimed to evaluate the methodological profiles of studies on fibromyalgia pharmacotherapy in terms of the quality and nature of the interventions (efficacy versus effective-ness). METHODS: The protocol was registered in the International Prospective Register of Systematic Re-views database. Seven databases were searched for relevant publications. Systematic reviews inves-tigating the effectiveness or efficacy of fibromyalgia pharmacotherapy were included. Methodolog-ical quality was investigated using A MeaSurement Tool to Assess Systematic Reviews (AM-STAR), and efficacy andeffectiveness were evaluated using Rating of Included Trials on the Effica-cy-effectiveness Spectrum (RITES). RESULTS: In this overview, 4,107 studies were initially identified. 8 systematic reviews and 34 prima-ry studies remained after overlaps were removed. Of the eight systematic reviews, 4.76% (n=3) and 7.93% (n=5) were of moderate and high quality, respectively. An analysis of systematic reviews clearly showed the criteria "participants characteristics" and "trial setting" with the most frequent answers as scales 1 and 2 (strong emphasis on efficacy or rather strong emphasis on efficacy), re-spectively. RITES analysis revealed that the most frequent response was "strong emphasis on effi-cacy" in 68% (92/136) of primary studies. CONCLUSION: This analysis showed, in both systematic reviews and primary studies, a predominantly strong emphasis on efficacy, suggesting the need for methodological quality improvement in future studies, especially those designed to provide evidence related to effectiveness. The protocol for this overview has been registered in the International Prospective Register of Sys-tematic Reviews (PROSPERO; CRD42018095943).

Recapitulation of retinal damage in zebrafish larvae infected with Zika virus

Zebrafish are increasingly being utilized as a model to investigate infectious diseases and to advance the understanding of pathogen–host interactions. Here, we take advantage of the zebrafish to recapitulate congenital ZIKV infection and, for the first time, demonstrate that it can be used to model infection and reinfection and monitor anti-viral and inflammatory immune responses, as well as brain growth and eye abnormalities during embryonic development. By injecting a Brazilian strain of ZIKV into the yolk sac of one-cell stage embryos, we confirmed that, after 72 h, ZIKV successfully infected larvae, and the physical condition of the virus-infected hosts included gross morphological changes in surviving embryos (84%), with a reduction in larval head size and retinal damage characterized by increased thickness of the lens and inner nuclear layer. Changes in locomotor activity and the inability to perceive visual stimuli are a result of changes in retinal morphology caused by ZIKV. Furthermore, we demonstrated the ability of ZIKV to replicate in zebrafish larvae and infect new healthy larvae, impairing their visual and neurological functions. These data reinforce the deleterious activity of ZIKV in the brain and visual structures and establish the zebrafish as a model to study the molecular mechanisms involved in the pathology of the virus.

Mapping the technological landscape of SARS, MERS, and SARS-CoV-2 vaccines.

PURPOSE: The last two decades have seen the emergence of several viral outbreaks. Some of them are the severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and severe acute respiratory syndrome 2 (SARS-CoV2) - the cause of the coronavirus disease 2019 (COVID-19). Ever, vaccines for emergency use have been authorized for the control and prevention of COVID-19. Currently, there is an urgent need to develop a vaccine for prophylaxis of COVID-19 and for other future epidemics. METHODS: This review describes patented vaccines for SARS and MERS-CoV and vaccines developed and approved for emergency use against the new coronavirus (COVID-19). The European Patent Office and the World Intellectual Property Organization were the patent databases used using specific terms. In addition, another search was carried out in the Clinical Trials in search of ongoing clinical studies focused on the COVID-19 vaccine. RESULTS: The patent search showed that most vaccines are based on viral vector platforms, nucleic acids, or protein subunits. The review also includes an overview of completed and ongoing clinical trials for SARS-CoV-2 in several countries. CONCLUSION: The information provided here lists vaccines for other types of coronavirus that have been used in the development of vaccines for COVID-19.

Technological Scenario for Masks in Patent Database During Covid-19 Pandemic.

Since January 2020, the World Health Organization announces COVID-19 outbreak a case of public health emergency of international interest, and declaring it a pandemic on March. Due to the high transmission of this disease, rate precautions have been implemented, such as the use of masks by the population, personal protective equipment (PPE), and safety protocols, mainly to health workers. Thus, we performed a patent review to evaluate the current patents related to the protective mask. The review was carried out in the patent database in the period of May 2019 to May 2020. After the process of screening and eligibility, 563 patents were selected for our analysis according to the aim of the study which used masks such as a PPE against dust particles and pathogens, mostly when it is about airborne transmission, such as viruses and bacteria. Here, an overview of the main materials used in the mask manufacturing and their efficiency was described. The results of the review showed that most of the masks used cotton, nylon, silver fiber fabrics, among others as fabrics to develop the masks. It also makes an analysis of masks composed of nanotechnology which provide high filtration efficiency. Moreover, the review also brought possibilities of masking the population, which already have been done in countries such as China and Korea and ways of sterilization for reuse of PPE during COVID-19 outbreak. Thus, this review can further researchers in the developing of masks to decrease the spread of a pandemic disease. Graphical abstract.

Knockdown of miR-26a in zebrafish leads to impairment of the anti-inflammatory function of TnP in the control of neutrophilia

Our recent data show the valuable potential of TnP for the development of a new and safe anti-inflammatory drug due to its ability to control the traffic and activation of leukocytes in response to inflammation. Although there is considerable knowledge surrounding the cellular mechanisms of TnP, less is known about the mechanistic molecular role of TnP underlying its immunomodulatory functions. Here, we conducted investigations to identify whether miRNAs could be one of the molecular bases of the therapeutic effect of TnP. Using a zebrafish model of neutrophilic inflammation with a combination of genetic gain- and loss-of-function approaches, we showed that TnP treatment was followed by up-regulation of only four known miRNAs, and mature dre-miR-26a-1, herein referred just as miR-26a was the first most highly expressed. The knockdown of miR-26a ubiquitously resulted in a significant reduction of miR-26a in embryos, accompanied by impaired TnP immunomodulatory function observed by the loss of the control of the removal of neutrophils in response to inflammation, while the overexpression increased the inhibition of neutrophilic inflammation promoted by TnP. The striking importance of miR-26a was confirmed when rescue strategies were used (morpholino and mimic combination). Our results identified miR-26a as an essential molecular regulator of the therapeutic action of TnP, and suggest that miR-26a or its targets could be used as promising therapeutic candidates for enhancing the resolution of inflammation.

SARS, MERS and SARS-CoV-2 (COVID-19) treatment: a patent review.

INTRODUCTION: Coronavirus has been responsible for several virus outbreaks since 2003, caused by SARS-CoV-1, MERS-CoV, and currently SARS-CoV-2 (COVID-19), the causative agent of coronavirus disease in 2019. COVID-19 has become a global public health emergency because of its high virulence and mortality capacity. This patent review aims to provide an overview of the patents that present possible treatments for SARS-CoV-1, SARS-CoV-2 and MERS-CoV. AREAS COVERED: To treat SARS, MERS and SARS-CoV-2, researchers have filed patents for a number of therapeutic agents. Most of the treatments found were protease inhibitors aimed at proteases such as PLpro, 3 CLpro, RNA helicase, and Spike protein, or used monoclonal antibodies and interferons. In addition, the use of Chinese folk medicine and its multitude of medicinal plants with strong antiviral properties was reinforced. Thus, these therapies used in previous epidemics can serve as an aid in the new pandemic by SARS-CoV-2 and be a starting point for new treatments. EXPERT OPINION: The various antiviral alternatives presented in this review offer therapeutic options to fight coronavirus infections. If shown to be effective, these drugs may be extremely important in the current pandemic.

Coriandrum sativum Extract Prevents Alarm Substance-Induced Fear- and Anxiety-Like Responses in Adult Zebrafish.

Anxiety disorders appear to involve distinct neurobiological mechanisms and several medications are available against this mental health problem. However, pharmacological therapeutic approaches display undesirable side effects for patients, particularly when long-term therapy is required. Some evidences have suggested that Coriandrum sativum extract (CSE) provide sedative and anxiolytic effects. We investigate if CSE could attenuate anxiety-like behaviors induced by novelty and alarm substance exposures in zebrafish. Adult zebrafish were injected with vehicle, clonazepam, or CSE (25, 50 or 100 mg/kg) and submitted to novel tank test. At the end, saline or alarm substance was added and anxiety-like responses were recorded. Twenty-four hours after, fish were submitted to the light/dark test. Novelty associated with alarm substance exposure decreased distance traveled and total time mobile in novel tank, and CSE (at 50 and 100 mg/kg) prevented these alterations similarly to clonazepam. Alarm substance reduced the time spent in white compartment (p = 0.0193 as compared with vehicle group). Clonazepam and CSE prevented this anxiogenic effect of alarm substance. CSE presents anxiolytic effects against alarm substance-induced locomotor and anxiogenic responses similarly to clonazepam. These data corroborate with the use of this plant in traditional medicine and provides a putative new pharmacological intervention for anxiety disorders.

Alcoholic monoterpenes found in essential oil of aromatic spices reduce allergic inflammation by the modulation of inflammatory cytokines.

Allergic inflammation is a response of the body against pathogens by cytokine release and leucocyte recruitment. Recently, there was an increase in morbimortality associated with allergic inflammation, especially asthma. The treatment has many adverse effects, requiring the search for new therapies. Monoterpenes are natural products with anti-inflammatory activity demonstrated in several studies and can be an option to inflammation management. Thus, we investigated the effects of citronellol, α-terpineol and carvacrol on allergic inflammation. The model of asthma was established by OVA induction in male Swiss mice. The monoterpenes were administered (25, 50 or 100 mg/kg, i.p.) 1 h before induction. After 24hs, the animals were sacrificed to leucocytes and TNF-α quantification. Monoterpenes significantly decrease leucocyte migration and TNF-α levels, possibly by modulation of COX, PGE2 and H1 receptor, as demonstrated by molecular docking. These findings indicate that alcoholic monoterpenes can be an alternative for treatment of allergic inflammation and asthma.

Zebrafish as an alternative method for determining the embryo toxicity of plant products: a systematic review.

The toxicological assessment of plant products and pharmaceutical chemicals is a necessary requirement to ensure that all compounds are safe to be exposed to humans. Many countries are trying to reduce the use of animals; thus, alternative techniques, such as ex vivo tests, in vitro assays, and ex uteri embryos, are used. Toxicological assays using zebrafish embryos are an advantageous technique because they are transparent, have rapid embryonic development, and do not require invasive techniques. This paper comprehensively reviews how toxicity testing with plant products is conducted in zebrafish embryos. The search terms zebra fish, Danio rerio, zebrafish, zebra danio, Brachydanio rerio, zebrafish, and embryos were used to search for English-language articles in PUBMED, SCOPUS, and WEB OF SCIENCE. Twelve articles on plant product toxicity studies using zebrafish were selected for reading and analysis. After analyzing the articles and comparing with results in mammals, it was possible to prove the similarity among the results and thus corroborate the further development of zebrafish as a valid tool in toxicity tests.

Anti-nociceptive effect of stigmasterol in mouse models of acute and chronic pain.

Stigmasterol is a common sterol found in plants, but the anti-nociceptive effect of this compound and its mechanism of action are not fully explored. Thus, in the present study, the anti-nociceptive effect of stigmasterol was investigated in acute and chronic models of pain and its mechanism of action. We used adult male albino Swiss mice (25-35 g) to observe the anti-nociceptive effect of stigmasterol in acetic-acid writhing test or in complete Freund's adjuvant injection, surgical incision in hind paw, or partial sciatic nerve ligation. Moreover, we investigate the involvement of opioid receptors (naloxone, 2 mg/kg, intraperitoneally) in stigmasterol anti-nociceptive effect and stigmasterol action on acetylcholinesterase activity. Some possible adverse effects caused by stigmasterol were also investigated. Stigmasterol (0.3-3 mg/kg, orally) exhibited an anti-nociceptive effect on acetic-acid-induced writhing test. Furthermore, it markedly attenuated the mechanical allodynia caused by surgical incision (after acute treatment with stigmasterol, preventive and curative effects were observed) and partial sciatic nerve ligation (after acute treatment with stigmasterol) and complete Freund's adjuvant (after acute or repeated treatment with stigmasterol). The anti-nociceptive effect of stigmasterol was not reversed by naloxone. Moreover, stigmasterol did not alter in vitro acetylcholinesterase activity in spinal cord or brain samples. Also, stigmasterol did not cause gastric ulcers or alter the gastrointestinal transit of mice. Taken together, these results support the potential anti-nociceptive effect of stigmasterol in different models of pain.

Anti-inflammatory and antioxidant effects of Aloe saponaria Haw in a model of UVB-induced paw sunburn in rats.

Ultraviolet B (UVB) irradiation mainly affects biological tissues by inducing an increase in reactive oxygen species (ROS) production which leads to deleterious outcomes for the skin, including pain and inflammation. As a protective strategy, many studies have focused on the use of natural products. The aim of this study was to investigate the effects of Aloe saponaria on nociceptive, inflammatory, and oxidative parameters in a model of UVB-induced sunburn in adult male Wistar rats. Sunburned animals were topically treated with vehicle (base cream), 1% silver sulfadiazine (positive control) or A. saponaria (10%) once a day for 6days. UVB-induced nociception (allodynia and hyperalgesia), inflammation (edema and leukocyte infiltration) and oxidative stress (increases in H2O2, protein carbonyl levels and lipid peroxidation and a decrease in non protein thiol content) were reduced by both A. saponaria and sulfadiazine topical treatment. Furthermore, A. saponaria or its constituents aloin and rutin reduced the oxidative stress induced by H2O2 in skin homogenates in vitro. Our results demonstrate that topical A. saponaria treatment displayed anti-nociceptive and anti-inflammatory effects in a UVB-induced sunburn model, and these effects seem to be related to its antioxidant components.

Antinociceptive and anti-inflammatory effects of Aloe saponaria Haw on thermal injury in rats.

ETHNOPHARMACOLOGICAL RELEVANCE: In Brazil, the plant Aloe saponaria Haw, popularly known as "babosa pintadinha", has been empirically used for its potential effect on thermal injury. Because there are no scientific data confirming its popular use, the aim of the present study was to investigate the effects of Aloe saponaria on nociceptive and inflammatory parameters in a rat model of thermal injury. MATERIALS AND METHODS: Adult male Wistar rats were subjected to a thermal injury or sham procedure (immersion in water at 70 or 37°C, respectively, for 5 or 8s). Burned animals were topically treated with vehicle (base cream), sulfadiazine 1% (positive control) or Aloe saponaria cream (0.3%-30%) once a day for 2 or 6 days. Each day, 30min before the treatment, we measured nociceptive (static and dynamic mechanical allodynia, thermal allodynia and spontaneous pain) and inflammatory (paw edema) parameters. Moreover, enzymatic indicators of leukocyte infiltration into burned tissue were also determined 2 or 6 days after the thermal injury. RESULTS: The thermal injury (fist and second-degree) procedure, but not the sham procedure, induced nociception and inflammation from 1 to 6 days after the injury. The topical treatment with Aloe saponaria cream (10%) reduced nociceptive behaviors from day 1 to 6 (peak at day 2), edema at days 5 and 6 (peak at day 6) and myeloperoxidase, N-acetyl-glucosaminidase and eosinoperoxidase activities at day 6. The antinociceptive and anti-inflammatory effects of Aloe saponaria were obtained with doses of 3%-30%, with maximal inhibition obtained with a dose of 10% (reductions of 39±9%, 41±9%, 31±7%, 83±7% and 23±2% for static and dynamic mechanical allodynia, thermal allodynia, spontaneous pain and paw edema, respectively). CONCLUSION: Our results demonstrate that topically applied Aloe saponaria presented antinociceptive and anti-inflammatory effects in rats subjected to a thermal injury, which supports its traditional use for burn injuries.

Identification of the plant steroid α-spinasterol as a novel transient receptor potential vanilloid 1 antagonist with antinociceptive properties.

The transient receptor potential vanilloid 1 (TRPV1) receptor is relevant to the perception of noxious information and has been studied as a therapeutic target for the development of new analgesics. The goal of this study was to perform in vivo and in vitro screens to identify novel, efficacious, and safe TRPV1 antagonists isolated from leaves of the medicinal plant Vernonia tweedieana Baker. All of the fractions and the hydroalcoholic extract produced antinociception in mice during the capsaicin test, but the dichloromethane fraction also had antioedematogenic effect. Among the compounds isolated from the dichloromethane fraction, only α-spinasterol reduced the nociception and edema induced by capsaicin injection. Moreover, α-spinasterol demonstrated good oral absorption and high penetration into the brain and spinal cord of mice. α-Spinasterol was able to displace [3H]resiniferatoxin binding and diminish calcium influx mediated by capsaicin. Oral administration of the dichloromethane fraction and α-spinasterol also produced antinociceptive effect in the noxious heat-induced nociception test; however, they did not change the mechanical threshold of naive mice. The treatment with α-spinasterol did not produce antinociceptive effect in mice systemically pretreated with resiniferatoxin. In addition, α-spinasterol and the dichloromethane fraction reduced the edema, mechanical, and heat hyperalgesia elicited by complete Freund's adjuvant paw injection. The dichloromethane fraction and α-spinasterol did not affect body temperature or locomotor activity. In conclusion, α-spinasterol is a novel efficacious and safe antagonist of the TRPV1 receptor with antinociceptive effect.

Eriodictyol: a flavonoid antagonist of the TRPV1 receptor with antioxidant activity.

The transient potential vanilloid 1 receptor (TRPV1) is a calcium-permeable channel responsible for the transduction and modulation of acute and chronic pain signaling. As such, this receptor is a potential target for the treatment of a number of pain disorders. However, AMG517, a TRPV1 antagonist, presents several clinical limitations that include the induction of severe hyperthermia. The aim of this study was to investigate the possible interaction of the flavonoid eriodictyol with the TRPV1 receptor and to determine its putative antinociceptive and hyperthermic effects. Eriodictyol was able to displace [(3)H]-resiniferatoxin binding (IC(50)=47; 21-119nM) and to inhibit calcium influx mediated by capsaicin (IC(50)=44; 16-125nM), suggesting that eriodictyol acts as a TRPV1 antagonist. Moreover, eriodictyol induced antinociception in the intraplantar capsaicin test, with maximal inhibition of 49±10 and 64±4% for oral (ID(50)=2.3; 1.1-5.7mg/kg) and intrathecal (ID(50)=2.2; 1.7-2.9nmol/site) administration, respectively. Eriodictyol did not induce any change in body temperature or locomotor activity. Orally administered eriodictyol (4.5mg/kg) prevented the nociception induced by intrathecal injections of capsaicin, as well as the non-protein thiol loss and 3-nitrotyrosine (3-NT) formation induced by capsaicin in spinal cord. Eriodictyol also reduced the thermal hyperalgesia and mechanical allodynia elicited by complete Freund's adjuvant (CFA) paw injection. In conclusion, eriodictyol acts as an antagonist of the TRPV1 receptor and as an antioxidant; it induces antinociception without some of the side effects and limitations such as hyperthermia that are expected for TRPV1 antagonists.