ERK1/2 Phosphorylation Was Observed After Remifentanil Infusion
Most p-ERK1/2–immunoreactive cells showed neuronal nuclei immunoreactivity (Fig. 3) and were located in laminae I and II of the spinal dorsal horn (Fig. 4). These cells expressed no immunoreactivity for OX-42 or glial fibrillary acidic protein (data not shown). Significantly more p-ERK1/ 2–immunoreactive cells were observed in the remifentanil 120-minute groups than the other groups (Fig. 5).
Intrathecal MEK Inhibitor Could Not Suppress Hyperalgesia
None of the 14 rats used in this study showed any motor deficits or health problems. Two rats were excluded after ineffective placement of the catheter was confirmed by the lidocaine test, resulting in 6 rats per treatment group. Behavioral tests showed that remifentanil induced hyperalgesia even after administration of the MAPK inhibitor U0126, despite the fact that Western blotting showed that U0126 inhibited ERK1/2 phosphorylation in the spinal cord (data not shown).
We report 2 significant findings. First, remifentanil-induced hyperalgesia was dependent on infusion duration, with minimal, if any, dose effect. Second, remifentanil administration leads to rapid ERK1/2 phosphorylation in spinal dorsal horn neurons.
OIH is a well-known phenomenon, especially in basic research.20 Various pathways may be involved in OIH, including those related to N-methyl-D-aspartate receptors,21,22 MAPK,6 the nitric oxide system,12,23 μ-opioid receptors,21 and neurokinin-1 receptors.24 Although morphine is one of the most prototypical opioids that induces OIH, several reports showed that other μ-opioids such as fentanyl, frequently used in clinical practice, also induce OIH.23 Remifentanil is widely used as an analgesic during surgery. However, some studies have indicated that remifentanil decreases pain thresholds and worsens postoperative pain,1 – 5 suggesting that remifentanil induces hyperalgesia. Conversely, some studies have reported that remifentanil does not induce hyperalgesia.25 Based on its definition, OIH is a phenomenon that occurs during opioid administration; thus, the remifentanil “withdrawal” hyperalgesia we observed may be a discrete phenomenon. Cèlérier et al.26 suggested that opioid withdrawal hyperalgesia results from disequilibrium between pronociceptive and antinociceptive systems. Opioid administration sensitizes pronociceptive systems, leading to hyperalgesia, and opioid-dependent antinociceptive systems counteradapt after discontinuation of opioids to offset the hyperalgesia. Remifentanil may have resulted in more-pronounced pronociceptive system sensitization because of its rapid offset (which may be masked in other opioids).
Some in vivo research of remifentanil-induced hyperalgesia has been published.6,23 In those studies, remifentanil was administered intraperitoneally or subcutaneously using incisional pain models. Remifentanil is frequently administered through IV infusion in clinical anesthesia. Therefore, we established an IV infusion model, which may lead to clinically relevant outcomes. We chose intact rats as subjects for our study, because we first wanted to determine whether remifentanil itself affects pain behaviors in intact animals. We selected remifentanil infusion doses based on the dose response to continuous infusion of remifentanil measured preliminarily, which ranged up to the tail-flick cutoff value. Our results show that IV remifentanil induced rapid withdrawal hyperalgesia dependent on infusion duration. Additionally, the hyperalgesia was transient and observed in the absence of any painful pretreatment, such as incision or inflammation. Previous studies have suggested that occurrence of remifentanil-induced hyperalgesia correlates with remifentanil dose.3,27 However, the nature and time course of the hyperalgesia we observed completely differ from those previously reported. We therefore hypothesize that a sufficient duration of exposure is necessary to trigger the molecular cascades that lead to hyperalgesia. We observed a discrepancy between the tail-flick and von Frey tests only in the remi0.1-120 group. One possible reason for this finding is the different modality of nociception between these tests.
Hyperalgesia can be produced by peripheral or central sensitization. Many molecules may be involved in central sensitization. We hypothesized that the modality of sensitization in remifentanil-induced hyperalgesia is similar to that involved in the early phase of other pain models and that the sensitization is induced by the MAPK phosphorylation cascade, considered to be the quickest change in the central nervous system induced by nociception or nerve injury.9,11 ERK1/2, well known as the classic MAPK family, is quickly activated by various extracellular stimuli and is involved in short-term pain hypersensitivity, has been shown to be phosphorylated in various pain models, and has been proved to be a sensitive marker of central sensitization.9
We found significantly more p-ERK1/2–immunoreactive neurons in remi10-120 and remi0.1-120 groups with behavioral hyperalgesia than groups without hyperalgesia. This result indicates some excitatory effect of remifentanil on neurons. Because ERK1/2 phosphorylation was localized in laminae I and II, where primary afferent fibers terminate, and was not observed in short-term or control groups, we considered that this change was related to the hyperalgesia. Although administration of opioids such as morphine induces ERK1/2 phosphorylation via μ-opioid receptors in the central nervous system,28 the significance of this phenomenon remains controversial.13,28,29 Campillo et al.6 recently reported a possible relationship between ERK1/2 and remifentanil-induced hyperalgesia. They concluded that ERK1/2 phosphorylation modulates dynorphin or c-Fos and then induces hyperalgesia, but that other signaling pathways may also be implicated. However, their hypothesis cannot explain the early-phase hyperalgesia we observed. In fact, Campillo et al. suggested that dynorphin could be involved in the persistence of hyperalgesia, but not its initiation. We speculate that the mechanism of acute hyperalgesia during remifentanil withdrawal and that of persistent hyperalgesia after remifentanil administration, which has been reported in many previous studies,27 are inherently different. The combination of remifentanil and incisional stimulation induces persistent hyperalgesia that may last for several days,6,23 whereas remifentanil administration alone induced rapid, short-duration hyperalgesia in our study. We found that ERK1/2 phosphorylation was consistent with behavioral hyperalgesia. However, U0126 could not suppress this hyperalgesia. Thus, we cannot conclude that ERK1/2 phosphorylation is the essential factor that induces hyperalgesia. We suggest the following mechanisms. Generally, ERK1/2 phosphorylation induces rapid central sensitization by posttranslational regulation, such as by increasing the activity of AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) or N-methyl-D-aspartate receptors and suppressing the activity of potassium channels (Kv4.2).9 These mechanisms are likely related to the initiation of remifentanil-induced hyperalgesia, although signaling pathways other than ERK1/2, such as protein kinase C or phospholipase C, may concurrently be involved in this early-phase sensitization. Simultaneous inhibition of all pathways may be necessary to prevent remifentanil-induced hyperalgesia. We suspect that ERK and other signaling pathways together sensitize neurons and trigger subsequent transcriptional changes when combined with surgical incision, thus leading to transition from withdrawal hyperalgesia to persistent hyperalgesia.
It is important to recognize that remifentanil administration may result in hyperalgesia. We may avoid this hyperalgesia by controlling the duration of remifentanil administration, although the results of this study do not indicate specific limitations to infusion duration in human clinical practice.
In conclusion, remifentanil induced hyperalgesia after long-term (120 minutes), but not short-term (30 minutes), IV infusion, suggesting that the duration of exposure to remifentanil is the primary factor influencing hyperalgesia induction. Contrary to our hypothesis, ERK1/2 alone was not the essential factor involved in hyperalgesia induction. Further investigation is needed to clarify the mechanisms of remifentanil-induced hyperalgesia to prevent it, and thus overall improve the quality of anesthesia.
Name: Ryosuke Ishida, MD.
Contribution: This author helped design the study, analyze the data, write the manuscript, and collect data.
Attestation: Ryosuke Ishida has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Tetsuro Nikai, MD.
Contribution: This author helped design the study, conduct the study, analyze the data, write the manuscript, and collect data.
Attestation: Tetsuro Nikai has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Tatsuya Hashimoto, MD, PhD.
Contribution: This author helped design the study and analyze the data.
Attestation: Tatsuya Hashimoto has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Toshiko Tsumori, PhD.
Contribution: This author helped analyze the data and collect data.
Attestation: Toshiko Tsumori has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Yoji Saito, MD, PhD.
Contribution: This author helped design the study, conduct the study, and write the manuscript.
Attestation: Yoji Saito has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
This manuscript was handled by: Tony L. Yaksh, PhD.
The authors are very grateful to Mai Takahashi, MSc, and Yukiko Katsube for their excellent technical assistance in Western blotting and behavioral experiments.
1. Guignard B, Bossard AE, Coste C, Sessler DI, Lebrault C, Alfonsi P, Fletcher D, Chauvin M. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology 2000;93:409–17
2. Joly V, Richebe P, Guignard B, Fletcher D, Maurette P, Sessler DI, Chauvin M. Remifentanil-induced postoperative hyperalgesia and its prevention with small-dose ketamine. Anesthesiology 2005;103:147–55
3. Schmidt S, Bethge C, Forster MH, Schafer M. Enhanced postoperative sensitivity to painful pressure stimulation after intraoperative high dose remifentanil in patients without significant surgical site pain. Clin J Pain 2007;23:605–11
4. Angst MS, Koppert W, Pahl I, Clark DJ, Schmelz M. Short-term infusion of the mu-opioid agonist remifentanil in humans causes hyperalgesia during withdrawal. Pain 2003;106:49–57
5. Hood DD, Curry R, Eisenach JC. Intravenous remifentanil produces withdrawal hyperalgesia in volunteers with capsaicin-induced hyperalgesia. Anesth Analg 2003;97:810–5
6. Campillo A, Gonzalez-Cuello A, Cabanero D, Garcia-Nogales P, Romero A, Milanes MV, Laorden ML, Puig MM. Increased spinal dynorphin levels and phospho-extracellular signal-regulated kinases 1 and 2 and c-Fos immunoreactivity after surgery under remifentanil anesthesia in mice. Mol Pharmacol 2010;77:185–94
7. Cui W, Li Y, Li S, Yang W, Jiang J, Han S, Li J. Systemic lidocaine inhibits remifentanil-induced hyperalgesia via the inhibition of cPKCgamma membrane translocation in spinal dorsal horn of rats. J Neurosurg Anesthesiol 2009;21:318–25
8. Cui XY, Dai Y, Wang SL, Yamanaka H, Kobayashi K, Obata K, Chen J, Noguchi K. Differential activation of p38 and extracellular signal-regulated kinase in spinal cord in a model of bee venom-induced inflammation and hyperalgesia. Mol Pain 2008;4:17
9. Gao YJ, Ji RR. c-Fos and pERK, which is a better marker for neuronal activation and central sensitization after noxious stimulation and tissue injury? Open Pain J 2009;2:11–7
10. Gutstein HB, Rubie EA, Mansour A, Akil H, Woodgett JR. Opioid effects on mitogen-activated protein kinase signaling cascades. Anesthesiology 1997;87:1118–26
11. Ji RR, Gereau RW IV, Malcangio M, Strichartz GR. MAP kinase and pain. Brain Res Rev 2009;60:135–48
12. Komatsu T, Sakurada C, Sasaki M, Sanai K, Tsuzuki M, Bagetta G, Sakurada S, Sakurada T. Extracellular signal-regulated kinase (ERK) and nitric oxide synthase mediate intrathecal morphine-induced nociceptive behavior. Neuropharmacology 2007;52:1237–43
13. Narita M, Ioka M, Suzuki M, Suzuki T. Effect of repeated administration of morphine on the activity of extracellular signal regulated kinase in the mouse brain. Neurosci Lett 2002;324:97–100
14. Wang Z, Ma W, Chabot JG, Quirion R. Cell-type specific activation of p38 and ERK mediates calcitonin gene-related peptide involvement in tolerance to morphine-induced analgesia. FASEB J 2009;23:2576–86
15. Chaplan SR, Bach FW, Pogrel JW, Chung JM, Yaksh TL. Quantitative assessment of tactile allodynia in the rat paw. J Neurosci Methods 1994;53:55–63
16. Kirihara Y, Saito Y, Sakura S, Hashimoto K, Kishimoto T, Yasui Y. Comparative neurotoxicity of intrathecal and epidural lidocaine in rats. Anesthesiology 2003;99:961–8
17. Tsuda M, Ueno H, Kataoka A, Tozaki-Saitoh H, Inoue K. Activation of dorsal horn microglia contributes to diabetes-induced tactile allodynia via extracellular signal-regulated protein kinase signaling. Glia 2008;56:378–86
18. Steel RGD. A rank sum test for comparing all pairs of treatments. Technometrics 1960;2:197–207
19. Dwass M. Some k-sample rank-order tests. In: Olkin I ed. Contributions to Probability and Statistics. Palo Alto, CA: Stanford University Press, 1960:198–202
20. Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology 2006;104:570–87
21. Zhao M, Joo DT. Enhancement of spinal N-methyl-D-aspartate receptor function by remifentanil action at delta-opioid receptors as a mechanism for acute opioid-induced hyperalgesia or tolerance. Anesthesiology 2008;109:308–17
22. Gu X, Wu X, Liu Y, Cui S, Ma Z. Tyrosine phosphorylation of the N-methyl-D-aspartate receptor 2B subunit in spinal cord contributes to remifentanil-induced postoperative hyperalgesia: the preventive effect of ketamine. Mol Pain 2009;5:76
23. Celerier E, Gonzalez JR, Maldonado R, Cabanero D, Puig MM. Opioid-induced hyperalgesia in a murine model of postoperative pain: role of nitric oxide generated from the inducible nitric oxide synthase. Anesthesiology 2006;104:546–55
24. King T, Gardell LR, Wang R, Vardanyan A, Ossipov MH, Malan TP Jr, Vanderah TW, Hunt SP, Hruby VJ, Lai J, Porreca F. Role of NK-1 neurotransmission in opioid-induced hyperalgesia. Pain 2005;116:276–88
25. Lahtinen P, Kokki H, Hynynen M. Remifentanil infusion does not induce opioid tolerance after cardiac surgery. J Cardiothorac Vasc Anesth 2008;22:225–9
26. Célèrier E, Laulin JP, Corcuff JB, Le Moal M, Simonnet G. Progressive enhancement of delayed hyperalgesia induced by repeated heroin administration: a sensitization process. J Neurosci 2001;21:4074–80
27. Cabanero D, Campillo A, Celerier E, Romero A, Puig MM. Pronociceptive effects of remifentanil in a mouse model of postsurgical pain: effect of a second surgery. Anesthesiology 2009;111:1334–45
28. Macey TA, Bobeck EN, Hegarty DM, Aicher SA, Ingram SL, Morgan MM. Extracellular signal-regulated kinase 1/2 activation counteracts morphine tolerance in the periaqueductal gray of the rat. J Pharmacol Exp Ther 2009;331:412–8
© 2012 International Anesthesia Research Society
29. Mouledous L, Diaz MF, Gutstein HB. Extracellular signal-regulated kinase (ERK) inhibition does not prevent the development or expression of tolerance to and dependence on morphine in the mouse. Pharmacol Biochem Behav 2007;88:39–46