Open-label Milnacipran for Persistent Knee Pain One Year After Total Knee Arthroplasty (TKA)

The current study proposes to collect pilot data on the utility of open-label milnacipran for the treatment of pain and other outcomes in this unfortunate group of patients with chronic persistent pain after TKA. Among marketed serotonin norepinephrine reuptake inhibitors (SNRIs), milnacipran has a unique property in that it blocks serotonin and norepinephrine reuptake equally. It is plausible that equipotent reuptake inhibition may confer greater analgesic benefit compared to other agents, and in preclinical animal models milnacipran has shown superior effects of ameliorating hyperalgesia and allodynia compared to some other antidepressant drugs. Additionally, milnacipran does not have inhibitory effects on cytochrome P (CYP) 450 enzymes, no binding affinity to neurotransmitter receptors liable to cause adverse events, and simple pharmacokinetics.

Inclusion criteria

• Subject is a male or female adult outpatient age 18 or older at the time of consent.
• Subject has chronic persistent pain 1 year after TKA without history of new injury, infection, or implant failure.
• Subject has VAS > or = 40 mm at screen and baseline visits.
• Subject has an understanding, ability and willingness to fully comply with study procedures and restrictions.
• Subject has the ability to provide written, personally signed and dated informed consent to participate in the study, in accordance with the International Conference on Harmonisation (ICH) Good Clinical Practice (GCP) Guideline E6 and applicable regulations, before completing any study-related procedures.

Exclusion criteria

• Subjects unable to complete assessments due to language or cognitive impairment
• Subjects with a history of bipolar disorder or psychosis as confirmed by the Mini International Neuropsychiatric Interview (MINI).
• Subject currently has (or had a history within the last 6 months of) a drug dependence or substance abuse disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) criteria (excluding nicotine).
• Subjects who are currently considered a suicide risk, any subject who has previously made a suicide attempt or who has a prior history of or are currently demonstrating active suicidal ideation.
• Subject has any clinically significant ECG or clinically significant laboratory abnormality (including a positive urine drug screen) at Screening.
• Subject has a concurrent chronic or acute illness, disability, or other condition that might confound the results of safety assessments administered in the study or that might increase risk to the subject. Similarly, the subject will be excluded if he or she has any additional condition(s) that in the Investigator's opinion would prohibit the subject from completing the study or would not be in the best interest of the subject. This would include any significant illness or unstable medical condition that could lead to difficulty complying with the protocol.
• Subjects who do not agree to use adequate and reliable contraception throughout the study.
• Subject previously completed, discontinued or was withdrawn from this study.
• Subject has taken an investigational drug or taken part in a clinical trial within 30 days prior to Screening.
• Subjects treated with antidepressant medication within 4 weeks of screening visit (6 weeks for fluoxetine).
• Subjects with known sensitivity to milnacipran.
• Subjects with liver disease or reduced liver function
• Subjects with obstructive uropathies
• Subjects who consume alcohol in amounts viewed by the Investigator to be contraindicated
• Subjects taking monoamine oxidase inhibitors
• Subjects with uncontrolled narrow angle glaucoma
• Subjects who are pregnant, may become pregnant, or who are nursing
• Subjects with seizure disorders
• Subjects with bleeding disorders or use of other medications that may cause bleeding.