Mannitol Cream for Post Herpetic Neuralgia (MannitolPHN)

Mannitol Cream in the Treatment of Post-herpeticNeuralgia;a Randomized Placebo-Controlled Crossover Pilot Study

30% mannitol cream has shown its ability to reduce the activation of the Capsaicin (TRPV1) (Transient Receptor Potential Vanilloid 1) receptor, a likely cause of the pain of post-herpetic neuralgia (PHN). This randomized placebo-controlled crossover study compares PHN pain one week before, for one week on the randomly assigned mannitol versus placebo cream and, after a three day washout, for one week on the other cream. Following this crossover study, participants receive mannitol cream for three months. Pain levels will be checked to assess whether continued use of this cream significantly reduces the pain levels associated with PHN. If pain persists beyond 3 months, participants will be offered mannitol and menthol cream for one month following which their pain levels will be checked.

Study Overview

• Status: Completed
• Conditions: Neuralgia, Postherpetic
• Intervention / Treatment: Drug: Mannitol cream; Drug: Placebo

Detailed Description

Pain levels: 0 to 10 Numerical Rating Scale (NRS), medication and alcohol intake will be checked daily for one week prior to randomization in 20 participants with post herpetic neuralgia, lasting more than three months. Following this 10 will be randomized to apply 30% mannitol in vehicle cream and 10 to apply vehicle cream alone for one week during which daily pain levels and use of medication and alcohol will be measured together with the mode of application (rubbing in or applying it to cling wrap then applying the cream coated cling wrap to the skin in cases of severe allodynia). After a three day washout period, they will be given the cream they did not receive previously for one week. The same variables will be recorded daily. The data collected in the first 24 days will be used to generate a power analysis. Following this, all subjects will receive the 30% mannitol cream to apply for three months. Their pain levels, medication intake and method of application will be measured once a month for three months. T-tests will compare the pain levels for mannitol and placebo users before and after one week of the use of each cream to see if the mannitol cream provides better short term pain relief than placebo. Repeated measures ANOVA (Analysis Of VAriance) will compare pain levels before using the mannitol cream and monthly for three months to assess the long-term effects of mannitol cream. Variables collected at each visit, which will not be used for statistical purposes in the current very small pilot project but may be used in a later study, include: application method, effect and side effects of the cream, medication and alcohol use, PHQ - 9 (Personal Health Questionnaire, 9 questions), and questions from the brief pain inventory score. At three months, a satisfaction score will be added to the database. If pain persists beyond 3 months, participants will be offered mannitol and menthol cream for one month, following which their pain levels, PHQ - 9 and brief pain inventory scores will be checked.

• Study Type: Interventional
• Enrollment (Actual): 20
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• Canada
  • British Columbia
    • North Vancouver, British Columbia, Canada, V7M 2K2
      • Dr. Helene Bertrand Inc.

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 19 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria

1. - Suffering from post-herpetic neuralgia on the trunk or the extremities for at least three months.
2. - Maximum daily pain score greater than or equal to 5/10.
3. - Having failed to improve with at least one neuropathic pain medication.

4- Able and willing to fill a fluid survey NRS pain scale and a medication intake questionnaire daily, preferably online but on paper, if unable, for the first 24 days of the study, then once a month for three months..

5 - Preferably have access to someone who can apply cream to their back if they have pain in the back and cannot reach the area.

6 - If that is not possible, ability to apply the cream to their own back, using an applicator which will be supplied.

Exclusion Criteria:

1. Allergies to any of the ingredients of the cream
2. Open lesions or abrasions on the skin where the cream will be applied
3. Using corticosteroids
4. Unwilling to stop using other topical products (creams or patches) for the treatment of post-herpetic neuralgia
5. Pregnant, breast-feeding or not using birth control

6. Suffering from severe chronic pain from a cause other than post-herpetic neuralgia

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Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: mannitol in vehicle cream /vehicle cream; one week on the mannitol cream (mannitol 30% in vehicle cream), a 3 day washout period, and one week on the placebo cream (vehicle cream alone). To be applied over the painful area as needed for pain. Usual frequency is 2 to 3 times daily.	Drug: Mannitol cream; Apply to area of postherpetic neuralgia pain as needed for pain control. Usual frequency is 2 to 3 times per day.For crossover study, will be applied for 7 days. For observational study, will be applied up to 3 months; Other Names: QR cream; Mannitol in vehicle cream; Drug: Placebo; Apply to area of postherpetic neuralgia pain as needed for pain control.Usual frequency is unknown. For crossover study, will be applied for 7 days. Will not be used after crossover study; Other Names: Vehicle cream
Active Comparator: vehicle cream /mannitol in vehicle cream; one week on the placebo cream (vehicle cream alone), a 3 day washout period, and one week on the mannitol cream (mannitol 30% in vehicle cream).To be applied over the painful area as needed for pain. Usual frequency is unknown.	Drug: Mannitol cream; Apply to area of postherpetic neuralgia pain as needed for pain control. Usual frequency is 2 to 3 times per day.For crossover study, will be applied for 7 days. For observational study, will be applied up to 3 months; Other Names: QR cream; Mannitol in vehicle cream; Drug: Placebo; Apply to area of postherpetic neuralgia pain as needed for pain control.Usual frequency is unknown. For crossover study, will be applied for 7 days. Will not be used after crossover study; Other Names: Vehicle cream

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in worst NRS (Numerical Rating Scale) pain score	In the last 24 hours, how bad was your pain at its worst? No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain imaginable	Before each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3 months
Change in average NRS (Numerical Rating Scale) pain score	In the last 24 hours, how bad was your pain on average? No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain imaginable	Before each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Pain medication intake	Number of pills taken for pain in one day. Will decrease as the pain intensity decreases. Write the number of tablets that you took: 1. Tylenol/acetaminophen______, 2. Anti-inflammatory medication like Advil/ibuprofen, naproxen, diclofenac, Voltaren, Aleve______, 3. Tylenol or ASA (acetylsalicylic acid) plus narcotic like Tylenol 3, or 292 or Tramacet (acetaminophen/tramadol) ______, 4. Narcotic like morphine, hydromorphone/dilaudid, fentanyl, Demerol, tramadol______, 5. Cannabis, marijuana, or pot______, The total in each category will be added to calculate the total number of tablets taken in 24 hours.	Before each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3,months
Change in Alcohol intake	Number of alcoholic drinks in one day. May decrease as the pain intensity decreases. Write down the total number of alcoholic drinks you had in the last 24 hours:how many glasses of wine ______ glasses of hard liquor______ bottles of beer______. The total number of glasses will be recorded.	Before each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3 months
Change in questions from the brief pain inventory score	The total from the following questions will be recorded to measure how much their pain is interfering with their lives: Circle one number. In the last 24 hours, how much has your pain interfered with your: General activity:, Mood: Walking ability: Normal work: (includes both work outside the home and housework) Relations with other people: Sleep: Enjoyment of life: Each of these will be scored as follows: does not interfere 0 1 2 3 4 5 6 7 8 9 10 completely interferes. The scores added up. This sum should decrease as the pain decreases.	Before each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3 months
Change in PHQ-9 (Personal health questionnaire, 9 questions) Score	Patients will fill the PHQ - 9 score. http://phqscreeners.com/pdfs/02_PHQ-9/English.pdf The sum of the answers from this questionnaire, which is used to measure the degree of depression, may decrease as the pain intensity decreases.	Before each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3 months
Change in Method of cream application	Patients will describe whether they use cling wrap (4), gentle applicator (3) or rubbing in gently (2) or vigourous rubbing (1)	when each cream is first applied, 7 days later, and for mannitol cream 1,2 and 3 months
Change in effect and side effects of the cream	How many times did you apply the cream today?_______ Circle one number. How bad was your pain?.. Before you applied the cream? NRS 0-10 1hour after you applied the cream? NRS 0-10 Did the cream relieve your pain? No □ if Yes □ in how many minutes?____ For how many hours was your pain relieved?____ Did you experience a side effect from the cream? No □ if Yes □ What was it?_________________ Any comments?_______________________	Daily for the 14 days, of the crossover study, then at 1,2 and 3 months
Satisfaction from cream use	How satisfied were you with the use of this cream? Not at all satisfied 0 1 2 3 4 5 6 7 8 9 10 extremely satisfied	Three months after use of mannitol cream was started.
Change in pain score from mannitol cream use to mannitol and menthol cream use	Maximum pain score after 3 months of mannitol cream use compared to maximum pain score after one month of mannitol and menthol cream use	1st measurement Three months after use of mannitol cream was started 2nd measurement one month after mannitol and menthol cream started

Collaborators and Investigators

• Sponsor: University of British Columbia
• Investigators: Principal Investigator: Helene Bertrand, MD, CM, CCFP, University of British Columbia, Department of family practice

Publications and helpful links

General Publications

• Bertrand H, Kyriazis M, Reeves KD, Lyftogt J, Rabago D. Topical Mannitol Reduces Capsaicin-Induced Pain: Results of a Pilot-Level, Double-Blind, Randomized Controlled Trial. PM R. 2015 Nov;7(11):1111-1117. doi: 10.1016/j.pmrj.2015.05.002. Epub 2015 May 12.
• Gilron I, Baron R, Jensen T. Neuropathic pain: principles of diagnosis and treatment. Mayo Clin Proc. 2015 Apr;90(4):532-45. doi: 10.1016/j.mayocp.2015.01.018.
• Shannon HJ, Anderson J, Damle JS. Evidence for interventional procedures as an adjunct therapy in the treatment of shingles pain. Adv Skin Wound Care. 2012 Jun;25(6):276-84; quiz 285-6. doi: 10.1097/01.ASW.0000415345.22307.f3.
• Szolcsanyi J, Sandor Z. Multisteric TRPV1 nocisensor: a target for analgesics. Trends Pharmacol Sci. 2012 Dec;33(12):646-55. doi: 10.1016/j.tips.2012.09.002. Epub 2012 Oct 12.

Study record dates

Study Major Dates

• Study Start: September 30, 2015
• Primary Completion (Actual): April 29, 2016
• Study Completion (Actual): April 30, 2017

Study Registration Dates

• First Submitted: June 13, 2015
• First Submitted That Met QC Criteria: June 24, 2015
• First Posted (Estimate): June 29, 2015

Study Record Updates

• Last Update Posted (Actual): October 23, 2018
• Last Update Submitted That Met QC Criteria: October 21, 2018
• Last Verified: October 1, 2018

More Information

Terms related to this study

• Keywords: neuropathic pain; Mannitol; cream
• Additional Relevant MeSH Terms: Nervous System Diseases; Pain; Neurologic Manifestations; Neuromuscular Diseases; Peripheral Nervous System Diseases; Neuralgia; Neuralgia, Postherpetic; Physiological Effects of Drugs; Natriuretic Agents; Diuretics, Osmotic; Diuretics; Mannitol
• Other Study ID Numbers: H15-01260