How is ultra-low-dose naltrexone clinically important?

July 8, 2021

Ultra low-dose naltrexone or naloxone (ULDN) refers to a dosing spectrum when less than one μg quantity of the naltrexone is used. Its mechanism of action is linked to a bimodal cellular response to opioids. Additionally to their inhibitory GI-coupled response, concomitant and mild Gs-coupled stimulatory response are also induced by opioids. The stimulatory response is sharply exclusive if tiny quantities of opioid blockers are used; otherwise, it progresses steadily with continuous μ-opioid receptors stimulation. This response cascade of Gs-coupled opioid receptors has been linked to prolonging the action potential, tolerance, hyperalgesia, and dependence.

Clinical reports

One of the earliest clinical trials carried out on ULDN is when a patient undergoing the final stage of cancer and severe, intractable cholestasis pruritus improved functionally after the introduction of 0.2 mg ultra- LOW DOSE NALTREXONE (LDN) in a 24hour-continuous intravenous infusion, her pruritus score dropped from 9/10 to 2/10. The ULDN infusion did not decrease her concurrent buprenorphine-based analgesia and also improved her mental condition affected by high opioid doses. In comparison to an improvised use of ULDN, larger-scale clinical trials with a combination of opioids and ULDN were conducted as continuous stages of drug development and interpretation of preclinical investigation. A combination of oxycodone and 2-4 μg of naltrexone given every day has experimented against oxycodone and placebo in a randomized controlled trial comprising 719 patients afflicted by lower back pain. Following an initial titration period to gain tolerable and sufficient pain control by not surpassing 80 mg of oxycodone per day, there was a 12-week progressive study time with an extra four days post-study evaluating symptoms of opioid withdrawal. The ultimate analysis involved 360 patients. All treated groups had notable pain relief in comparison to the placebo, but the combination of oxycodone and 2 μg naltrexone given every day was declared to be the best modality of all the study treatments available. Patients getting that combination reported highly fewer opioid-related side effects like drowsiness, constipation, and pruritus. The same group contained the smallest percentage of patients influenced by opioid withdrawal consequences following active treatment discontinuance. The patient groups getting any combination treatment with naltrexone experienced a notable 12% reduced daily opioid consumption in contrast to the oxycodone group. Unfortunately, a huge dropout rate invites serious caution when evaluating the clinical significance of an intervention like that. The same study group ran a comparable clinical trial assessing the effect of opioids in combination with ultra- LOW DOSE NALTREXONE (LDN) for osteoarthritic pain. Despite supporting phase II conclusions, there were great dropout rates in the next phase, whereby no conclusive results could be achieved. Both kinds of pain used in the investigations might not have been fitting to test the medicine combination, as more advanced evidence would not recommend the selection of opioid treatment in such cases. There are some strong and convincing pieces of evidence appearing from the surgical setting, in which ULDN was added to therapy to support acute responses to opioids. A placebo-controlled randomized trial involving 80 subjects who had lumbar discectomy procedures investigated the effects of ULDN combined with patient-controlled postoperative analgesia. Naloxone was delivered continuously through the IV route at a rate of 0.25 μg/kg/h. It was revealed that the ULDN group, statistically, had significantly faster pain relief. In the beginning, fewer patients stated having nausea or pruritus, although both groups displayed very similar end-point scores. Median morphine administration for the same group was noted to be 26 mg, and on the other hand, it was 34 mg for the placebo group. Another double-blind placebo-controlled, randomized trial investigated the effects of Ultra low-dose naltrexone delivered from the start of anesthesia till 72h post-open-colorectal operation. 72 patients were given sevoflurane anesthesia in combination with lower dose remifentanil, high dose remifentanil, or high dose of remifentanil with ultra-low-dose naltrexone, respectively. The analysis revealed that the ULDN group of subjects exhibited notably more active bowel function restoration and a lower average hospital stay. Cumulative postoperative use of morphine was almost the same in ULDN and lower dosed remifentanil groups, but significantly varied from the high-dose remifentanil group, whose postoperative opioid consumption was nearly twice as high. The clinical qualities of ULDN were also examined for axillary brachial plexus inhibition, where it was combined with drugs given for regional anesthesia. In this randomized, double-blind research, 112 patients who just had elective forearm operation have introduced either placebo or 100ng of naltrexone with lidocaine and/or fentanyl. Groups that were being given ULDN (with or without fentanyl) revealed a significantly prolonged span of motor and sensory block periods, but the time of onset for these inhibitions was also increased 5–7 min. Consequently, postoperative pain arose quite later in ULDN groups.

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