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Zahari Z, Ismail R. Influence of Cytochrome P450, Family 2, Subfamily D, Polypeptide 6 (CYP2D6) Polymorphisms on Pain Sensitivity and Clinical Response to Weak Opioid Analgesics. Drug Metab Pharmacokinet 2014; 29:29-43. [DOI: 10.2133/dmpk.dmpk-13-rv-032] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sastre JA, Varela G, López M, Muriel C, González-Sarmiento R. Influence of uridine diphosphate-glucuronyltransferase 2B7 (UGT2B7) variants on postoperative buprenorphine analgesia. Pain Pract 2013; 15:22-30. [PMID: 24256307 DOI: 10.1111/papr.12152] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 10/07/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Genetic factors are known to influence individual differences in pain and sensitivity to analgesics. Different genetic polymorphisms in opioid-metabolizing enzymes that can affect the analgesic response to opioids have been proposed. This study investigates a possible difference in the response to postoperative buprenorphine analgesia related to the presence of different isoforms (cytosine or thymine substitution at nucleotide 802) of UGT2B7 gene. METHODS Transdermal buprenorphine was administered to 91 patients who underwent muscle-sparing thoracotomy. UGT2B7 polymorphism at locus C802T (His268Tyr) was detected using a PCR Taqman-based procedure. The severity of postoperative pain at rest and during coughing or deep inspiration was assessed by visual analog scale score after surgery. Hospital stay and perioperative opioid consumption were collected. RESULTS Genotype frequencies were 18.4% for UGT2B7*1/*1, 52.9% for UGT2B7*1/*2, and 28.7% for UGT2B7*2/*2. VAS pain scores at rest were statistically similar among the groups except at 24, 60, and 120 hours (UGT2B7*2/*2 genotype showing higher pain scores). Patients with the UGT2B7*2/*2 genotype showed higher VAS scores triggered by coughing after the 48 hours (P < 0.05). In addition, patients with this genotype reported a higher prevalence of severe pain after 48 postoperative hours (P < 0.05). Thirty-eight percent of patients carrying genotype UGT2B7*2/*2 experienced severe pain in a final survey vs. 17% in the group with UGT2B7*1/*1 (P = 0.36). CONCLUSIONS The presence of the SNP 802C>T UGT2B7 (UGT2B7*2/*2) is associated with a worse analgesic response to transdermal buprenorphine in the postoperative period of thoracic surgery.
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Affiliation(s)
- José A Sastre
- Department of Anesthesiology and Pain Clinic, Cardiothoracic division, University Hospital and IBSAL, Salamanca, Spain
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Cargnin S, Magnani F, Viana M, Tassorelli C, Mittino D, Cantello R, Sances G, Nappi G, Canonico PL, Genazzani AA, Raffaeli W, Terrazzino S. An Opposite-Direction Modulation of the COMT Val158Met Polymorphism on the Clinical Response to Intrathecal Morphine and Triptans. THE JOURNAL OF PAIN 2013; 14:1097-106. [DOI: 10.1016/j.jpain.2013.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/05/2013] [Accepted: 04/13/2013] [Indexed: 12/19/2022]
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Yee MM, Josephson C, Hill CE, Harrington R, Castillejo MI, Ramjit R, Osunkwo I. Cytochrome P450 2D6 polymorphisms and predicted opioid metabolism in African American children with sickle cell disease. J Pediatr Hematol Oncol 2013; 35:e301-5. [PMID: 23619115 PMCID: PMC3762954 DOI: 10.1097/mph.0b013e31828e52d2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The opioid medications codeine and hydrocodone, commonly prescribed in sickle cell disease (SCD), require metabolic conversion by cytochrome P450 2D6 (CYP2D6) to morphine and hydromorphone, respectively, to exert their analgesic effects. The CYP2D6 gene is highly polymorphic, with variant alleles that result in decreased, absent, or ultrarapid enzyme activity. Seventy-five children with SCD were tested for CYP2D6 polymorphisms, and metabolic phenotypes were inferred from the genotypes. The most common variant alleles were CYP2D6*2 (normal activity, 28.7%), CYP2D6*17 (reduced activity, 17.3%), CYP2D6*5 (gene deletion, 8.7%), and CYP2D6*4 (absent function, 8.0%). Normal/extensive metabolizer genotypes were found in 28/75 (37.5%), intermediate metabolism in 33/75 (44.0%), poor metabolism in 4/75 (5.3%), ultrarapid metabolism in 3/75 (4.0%), indeterminate in 6/75 (8.0%). Allele frequencies did not vary significantly among different hemoglobin genotypes. Identification of variant CYP2D6 genotypes may identify individuals with altered metabolism and therefore altered analgesic response to codeine and hydrocodone, thus providing a personalized medicine approach to treatment of pain in SCD. Further pharmacokinetic and pharmacodynamic studies are needed to define the relationship of CYP2D6 and other gene polymorphisms to individual opioid effect in SCD.
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Affiliation(s)
- Marianne McPherson Yee
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta
- Department of Pediatrics, Hematology/Oncology, Emory University, Atlanta, GA
| | - Cassandra Josephson
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta
- Department of Pediatrics, Hematology/Oncology, Emory University, Atlanta, GA
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Charles E. Hill
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | | | | | - Ruan Ramjit
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Ifeyinwa Osunkwo
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta
- Department of Pediatrics, Hematology/Oncology, Emory University, Atlanta, GA
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Xu Y, Johnson A. Opioid therapy pharmacogenomics for noncancer pain: efficacy, adverse events, and costs. PAIN RESEARCH AND TREATMENT 2013; 2013:943014. [PMID: 24167729 PMCID: PMC3791560 DOI: 10.1155/2013/943014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 08/18/2013] [Accepted: 08/18/2013] [Indexed: 01/16/2023]
Abstract
Chronic non-cancer pain is a debilitating condition associated with high individual and societal costs. While opioid treatment for pain has been available for centuries, it is associated with high variability in outcome, and a considerable proportion of patients is unable to attain relief from symptoms while suffering adverse events and developing medication dependence. We performed a review of the efficacy of pharmacogenomic markers and their abilities to predict adverse events, dependence, and associated economic costs, focusing on two genes: OPRM1 and CYP2D6. Data sources were articles indexed by PubMed on or before August 6, 2013. Articles were first selected after review of their titles and abstracts, and full papers were read to confirm eligibility. Initially, fifty-two articles were identified. Of these, 17 were relevant to biological actions of pharmacogenomic markers and their effect on therapeutic efficacy, 16 to adverse events, 15 to opioid dependence, and eight to economic costs. In conclusion, increasing costs of opioid therapy have made the advances in pharmacogenomics an attractive solution to personalize care with unclear repercussions related to the impact on costs, morbidity, and outcomes. This intersection of pharmacoeconomics and pharmacogenomics presents a unique platform to further examine current advances in clinical medicine and their utility in cost-effective treatment of chronic pain.
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Affiliation(s)
- Yan Xu
- Queen's University, Kingston, ON, Canada K7L 3N6
| | - Ana Johnson
- Department of Population Health Sciences, Queen's University, Kingston, ON, Canada K7L 3N6
- Institute for Clinical Evaluative Services, Queen's University, Kingston, ON, Canada K7L 3N6
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Su W, Pasternak GW. The role of multidrug resistance-associated protein in the blood-brain barrier and opioid analgesia. Synapse 2013; 67:609-19. [PMID: 23508590 DOI: 10.1002/syn.21667] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 03/13/2013] [Indexed: 01/11/2023]
Abstract
The blood-brain barrier protects the brain from circulating compounds and drugs. The ATP-binding cassette (ABC) transporter P-glycoprotein (Pgp) is involved with the barrier, both preventing the influx of agent from the blood into the brain and facilitating the efflux of compounds from the brain into the blood, raising the possibility of a similar role for other transporters. Multidrug resistance-associated protein (MRP), a 190 kDa protein, similar to Pgp is also ABC transporter that has been implicated in the blood-brain barrier. The current study explores its role in opioid action. Immunohistochemically, it is localized in the choroid plexus in rats and can be selectively downregulated by antisense treatment at both the level of mRNA, as shown by RT-PCR, and protein, as demonstrated immunohistochemically. Behaviorally, downregulation of MRP significantly enhances the analgesic potency of systemic morphine in MRP knockout mice and in antisense-treated rats by lowering the blood-brain barrier. Following intracerebroventricular administration, a number of compounds, including some opioids, are rapidly secreted from the brain into the blood where they contribute to the overall analgesic effects by activating peripheral systems. MRP plays a role in this efflux. Downregulating MRP expression leads to a corresponding decrease in the transport and a diminished analgesic response from opioids administered intracerebroventricularly. Thus, the transporter protein MRP plays a role in maintaining the blood-brain barrier and modulates the activity of opioids.
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Affiliation(s)
- Wendy Su
- Laboratory of Molecular Neuropharmacology, Molecular Pharmacology and Chemistry Program and Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Wachman EM, Hayes MJ, Brown MS, Paul J, Harvey-Wilkes K, Terrin N, Huggins GS, Aranda JV, Davis JM. Association of OPRM1 and COMT single-nucleotide polymorphisms with hospital length of stay and treatment of neonatal abstinence syndrome. JAMA 2013; 309:1821-7. [PMID: 23632726 PMCID: PMC4432911 DOI: 10.1001/jama.2013.3411] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Neonatal abstinence syndrome (NAS) caused by in utero opioid exposure is a growing problem; genetic factors influencing the incidence and severity have not been previously examined. Single-nucleotide polymorphisms (SNPs) in the μ-opioid receptor (OPRM1), multidrug resistance (ABCB1), and catechol-o-methyltransferase (COMT) genes are associated with risk for opioid addiction in adults. OBJECTIVE To determine whether SNPs in the OPRM1, ABCB1, and COMT genes are associated with length of hospital stay and the need for treatment of NAS. DESIGN, SETTING, AND PARTICIPANTS Prospective multicenter cohort study conducted at 5 tertiary care centers and community hospitals in Massachusetts and Maine between July 2011 and July 2012. DNA samples were genotyped for SNPs, and then NAS outcomes were correlated with genotype. Eighty-six of 140 eligible mother-infant dyads were enrolled. Infants were eligible if they were 36 weeks' gestational age or older and exposed to methadone or buprenorphine in utero . MAIN OUTCOMES AND MEASURES Primary outcome measure was length of hospital stay, with between-group differences expressed as β and calculated with linear regression models. Secondary outcome measures included need for any medical treatment for NAS and treatment with 2 or more medications. RESULTS Infants with the OPRM1 118A>G AG/GG genotype had shortened length of stay (β = -8.5 days; 95% CI, -14.9 to -2.1 days; P = .009) and were less likely to receive any treatment than AA infants (48% vs 72%; adjusted odds ratio, 0.76; 95% CI, 0.63-0.96; P = .006). The COMT 158A>G AG/GG genotype was associated with shortened length of stay (β = -10.8 days; 95% CI, -18.2 to -3.4 days; P = .005) and less treatment with 2 or more medications (18% vs 56%; adjusted odds ratio, 0.68; 95% CI, 0.55-0.86; P = .001) than the AA genotype. Associations with the ABCB1 SNPs were not significant. CONCLUSIONS AND RELEVANCE Among infants with NAS, variants in the OPRM1 and COMT genes were associated with a shorter length of hospital stay and less need for treatment. These preliminary findings may provide insight into the mechanisms underlying NAS.
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Affiliation(s)
- Elisha M Wachman
- Department of Pediatrics, The Floating Hospital for Children, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
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Tramadol-induced apnea. Am J Emerg Med 2013; 31:26-31. [DOI: 10.1016/j.ajem.2012.05.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 11/19/2022] Open
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Gudin J. Opioid therapies and cytochrome p450 interactions. J Pain Symptom Manage 2012; 44:S4-14. [PMID: 23218233 DOI: 10.1016/j.jpainsymman.2012.08.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 08/24/2012] [Accepted: 09/04/2012] [Indexed: 01/16/2023]
Abstract
Adverse drug reactions are common and associated with substantial economic and human costs. Particularly among older adult populations, preventable adverse drug reactions are often caused by drug-drug interactions. All analgesics have side effect profiles and many have known drug-drug interactions. Opioids are recognized as a necessary option for managing moderate-to-severe pain, yet many opioid side effects can be enhanced by metabolic interactions within the liver, involving other drugs, diseases, or genetics.
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Affiliation(s)
- Jeffrey Gudin
- The Pain Management and Wellness Center, Englewood Hospital and Medical Center, Englewood, New Jersey 07631, USA.
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de Leon-Casasola OA. Opioid therapy in 2012: a call for a high degree of attention to detail. Introduction. J Pain Symptom Manage 2012; 44:S1-3. [PMID: 23218231 DOI: 10.1016/j.jpainsymman.2012.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 08/24/2012] [Accepted: 08/29/2012] [Indexed: 11/22/2022]
Affiliation(s)
- Oscar A de Leon-Casasola
- Department of Anesthesiology, School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, New York, USA.
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61
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Brennan MJ. The clinical implications of cytochrome p450 interactions with opioids and strategies for pain management. J Pain Symptom Manage 2012; 44:S15-22. [PMID: 23218232 DOI: 10.1016/j.jpainsymman.2012.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 08/07/2012] [Accepted: 09/04/2012] [Indexed: 11/29/2022]
Abstract
Pharmacokinetic differences among opioids influence a patient's response to opioid treatment. An important element affecting a drug's pharmacokinetics, its metabolism, may be altered under various circumstances, thereby enhancing or mitigating a patient's response to opioids. The genetic background of the metabolic enzymes involved in opioid metabolism, comorbid medical conditions, older age, and the presence of other drugs that influence metabolism are such factors that can cause the response to opioid therapy to vary greatly from the expected response to a standard dose. As a result of the variability in individual responses to opioids, clinical management of pain with opioids must be empirical.
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Abstract
INTRODUCTION Although chronic opioid therapy is usually initiated using short-acting opioids, many patients with chronic pain are subsequently converted to long-acting and extended-release preparations. In clinical practice, optimal management requires careful individualization of dosage in order to achieve an appropriate balance of efficacy and adverse effects. After successful initiation and stabilization of opioid treatment, subsequent changes in regimen may still be required to maintain efficacy with an acceptable adverse effect profile. METHODS This is a qualitative review of the available literature from June 2012 or earlier on opioid rotation for the management of chronic pain in the clinical setting. The PubMed database was searched using various search terms, and additional articles were identified through manual search of the bibliographies of articles identified through the PubMed search. Papers were selected based on relevance to the topic. RESULTS When considering opioid rotation, clinicians must take into account not only the significant differences in potency among opioid drugs but also the considerable interpatient variability in response to opioids. The estimate of relative potency used in calculating an appropriate starting dose when switching from one opioid to another has been codified on equianalgesic dose tables. To reduce the risk of unintentional overdose, a two-step calculation has been proposed, which incorporates an initial reduction (typically 25-50%) in the equianalgesic dose followed by a second evaluation based on the severity of pain at the time of rotation along with other medical or psychosocial factors that might alter the effectiveness and tolerability of the new drug. Given the uncertainty of accurately predicting a patient's response to treatment, each initial exposure to a new opioid should be considered a discrete clinical trial to assess the degree of response. Systematic reviews of opioid rotation have documented the re-establishment of adequate pain control or reduced adverse effects in 50-80% of patients. CONCLUSIONS Although continued research is needed to refine equianalgesic doses further, opioid rotation is an important and necessary practice in patients with chronic cancer or noncancer pain that is refractory to the initially used opioid.
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63
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Eissing T, Lippert J, Willmann S. Pharmacogenomics of Codeine, Morphine, and Morphine-6-Glucuronide. Mol Diagn Ther 2012. [DOI: 10.1007/bf03256429] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Henker RA, Lewis A, Dai F, Lariviere WR, Meng L, Gruen GS, Sereika SM, Pape H, Tarkin IS, Gowda I, Conley YP. The associations between OPRM 1 and COMT genotypes and postoperative pain, opioid use, and opioid-induced sedation. Biol Res Nurs 2012; 15:309-17. [PMID: 22718527 DOI: 10.1177/1099800411436171] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous studies have associated mu-opioid receptor (OPRM1) genotype with pain and analgesia responses in postoperative and patient populations. This study investigates the role of catechol-O-methyltransferase (COMT) and OPRM1 genotypes in acute postoperative pain scores, opioid use, and opioid-induced sedation after surgical procedures for orthopedic trauma in an otherwise healthy patient population. Verbal pain/sedation scores, opioid use, and physiologic responses in the immediate postoperative period were examined for association with genetic variants in Caucasians genotyped for OPRM1 single nucleotide polymorphisms (SNPs) A118G and C17T and COMT SNPs. The OPRM1 A118G genotype was associated with patients' postoperative Numerical Pain scale (NPS) ratings at 15 min in the postanesthesia care unit (PACU) (p = .01) and patients' sedation scores at 15 min in the PACU (p = .02). COMT genotype (rs4818) was associated with opioid consumption in the first 45 min in the PACU (p = .04). NPS ratings at 45 min were also higher in the group of patients with A/A genotype of rs4680 than in patients with the other two genotypes at this SNP (p = .03). Our haplotype trend analysis identified a COMT haplotype "GCGG" significantly associated with NPS at 15 min (p = .0013), amount of opioids consumed in the first 45 min (p = .0024), and heart rate at 45 min in the PACU (p = .017). The results indicate that genetic variations in COMT contribute to the acute postoperative pain and analgesia responses and physiologic responses in this group of otherwise healthy postoperative orthopedic trauma patients.
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Affiliation(s)
- Richard A Henker
- Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA 15261, USA.
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Abstract
The purpose of this review is to discuss the clinical application of pharmacogenomics for select drug therapies (eg, proton pump inhibitors [PPIs], codeine, and carbamazepine) and to highlight limitations and challenges that preclude implementation of pharmacogenomics into clinical practice. Genetic polymorphisms of cytochrome P450 (CYP) enzymes and the presence of the human leukocyte antigen ( HLA) -B*1502 allele influence drug disposition and/or response. A portion of PPI pharmacokinetic and pharmacodynamic variability can be explained by CYP2C19 genotype. However, conflicting evidence exists related to Helicobacter pylori cure rates based on CYP2C19 genotype. For codeine, adverse drug reactions in neonates through breast-feeding from CYP2D6 ultra-rapid metabolizers have been reported. However, there is lack of conclusive evidence regarding the overall influence of CYP2D6 polymorphisms on codeine efficacy and toxicity. Although CYP2C19 and CYP2D6 genotyping tests are available, clinical utility remains low. The presence of the HLA-B*1502 allele is associated with carbamazepine-induced Stevens-Johnson syndrome (SJS) and/or toxic epidermal necrolysis (TEN). Pharmacogenomic testing is required prior to initiating carbamazepine in high-risk patients. Lack of sufficient resources, provider knowledge, and ethical, legal, and social issues are several limitations and challenges to implementing pharmacogenomic testing in clinical practice.
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Affiliation(s)
- Joseph D. Ma
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Kelly C. Lee
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Grace M. Kuo
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
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Eissing T, Lippert J, Willmann S. Pharmacogenomics of codeine, morphine, and morphine-6-glucuronide: model-based analysis of the influence of CYP2D6 activity, UGT2B7 activity, renal impairment, and CYP3A4 inhibition. Mol Diagn Ther 2012; 16:43-53. [PMID: 22352453 DOI: 10.2165/11597930-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE The analgesic effect of codeine depends on the formation of the opioid metabolites morphine and morphine-6-glucuronide. Different factors have been shown or suspected to affect the safety and efficacy of codeine treatment. The objective of the current study is to assess and quantify the impact of important pharmacokinetic factors, using a mechanistic modeling approach. METHODS By means of a generic modeling approach integrating prior physiologic knowledge, we systematically investigated the complex dependence of opioid exposure on cytochrome P450 2D6 and 3A4 (CYP2D6 and CYP3A4), and uridine diphosphate glucuronosyltransferase 2B7 (UGT2B7) activity, as well as renal function, by means of a virtual clinical trial. RESULTS First, the known dominant role of CYP2D6 activity for morphine exposure was reproduced. Second, the model demonstrated that mild and moderate renal impairment and co-administration of CYP3A4 inhibitors have only minor influences on opioid exposure. Third, the model showed - in contrast to current opinion - that increased UGT2B7 activity is associated with a decrease in active opioid exposure. CONCLUSION Overall, the model-based analysis predicts a wide range of morphine levels after codeine administration and supports recent doubts about safe and efficacious use of codeine for analgesia in non-genotyped individuals.
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Affiliation(s)
- Thomas Eissing
- Competence Center Systems Biology and Computational Solutions, Bayer Technology Services GmbH, Leverkusen, Germany
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67
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Abstract
The pharmacokinetic (PK) parameters that are important for dosing (e.g., clearance and volume) are well known. They are used in universal mathematical formulae that describe the time course of drug concentration. Additional formulae can be used to describe major covariate effects in children, such as size and maturation. PK parameters describing the time-concentration profile of a drug after administration are those for a typical individual in a population. These parameters are associated with variability. Further, any one individual may not be typical of the population studied. While size and maturation are two important considerations in children and assist with dosing estimation, there are also a number of additional PK covariates (e.g., organ function, disease, drug interactions, pharmacogenetics), and identifying these sources of variability allows us to individualize drug dose. Pharmacology is not simply an application of PK, and determinants of drug dose also require an understanding of the variability associated with pharmacodynamic response and a balancing of beneficial effects against unwanted effects. Each child is unique in this respect.
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Affiliation(s)
- Brian J Anderson
- Paediatric Intensive Care Unit, Auckland Children's Hospital, Auckland, New Zealand.
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68
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Abstract
Many clinicians hoped that the completion of the Human Genome Project would result in "individualized drug therapy," i.e., determining the right medication at the right dose 100% of the time based upon the individual's genetics. The pharmacogenomic prediction of drug efficacy and safety has not become a reality due to continuing realization of the complexity dictating the human-drug interaction. New methods of metabolomics, proteomics, and transcriptomics that account for this complexity hold promise for translational researchers hoping to increase drug efficacy and decrease drug toxicity.
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69
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Domeque Valiente N, Prieto Andrés P, Lozano Ortiz R, Andrés Arribas I. Interacción farmacocinética entre metadona y metamizol: a propósito de 53 casos. Med Clin (Barc) 2012; 138:498-9. [DOI: 10.1016/j.medcli.2011.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 06/22/2011] [Accepted: 06/28/2011] [Indexed: 10/17/2022]
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70
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Abstract
BACKGROUND The metabolism of opioids is critical to consider for multiple reasons. The most commonly prescribed opioid agents often have metabolites that are active and are the source of both analgesic activity and an increased incidence of adverse events. Many opioids are metabolized by cytochrome P450 enzymes. Polymorphisms in cytochrome P450 genes and inhibition or induction of cytochrome P450 enzymes by coadministered drugs may significantly impact the systemic concentration of opioids and their metabolites and the associated efficacy or adverse events. METHODS This is a narrative review of the metabolism of various opioids that will highlight the impact of their active metabolites, and the potential impact of cytochrome P450 activity on analgesic activity. RESULTS An understanding of "opioid metabolic machinery," cytochrome P450 activity, and drug-drug interactions in the context of opioid selection may benefit clinicians and patients alike. CONCLUSIONS A greater appreciation of the metabolism of commonly prescribed opioid analgesics and the impact of their active metabolites on efficacy and safety may aid prescribers in tailoring care for optimal outcomes.
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Baron EP, Moskowitz SI, Tepper SJ, Gupta R, Novak E, Hussain MS, Stillman MJ. Headache following intracranial neuroendovascular procedures. Headache 2011; 52:739-48. [PMID: 22211779 DOI: 10.1111/j.1526-4610.2011.02059.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS Predicting who will develop post-procedure headache (PPH) following intracranial endovascular procedures (IEPs) would be clinically useful and potentially could assist in reducing the excessive diagnostic testing so often obtained in these patients. Although limited safety data exist, the use of triptans or dihydroergotamine (DHE) often raise concern when used with pre/post-coiled aneurysms. We sought to determine risk factors for PPH following IEP, to evaluate the utility of diagnostic testing in patients with post-coil acute headache (HA), and to record whether triptans and DHE have been used safely in this clinical setting. METHODS We conducted a retrospective chart review of adult patients undergoing IEPs. Bivariate analyses were conducted to compare patients who did and did not develop PPH. RESULTS We reviewed records pertaining to 372 patients, of whom 263 underwent intracranial coil embolizations, 21 acrylic glue embolizations, and 88 stent placements. PPH occurred in 72% of coil patients, 33% of glue patients, and 14% of stent patients. Significant risk factors for post-coil HA were female gender, any pre-coil HA history, smoking, and anxiety/depression. A pre-stent history of HA exceeding 1 year's duration, and smoking were risk factors for post-stent HA. A pre-glue history of HA exceeding 1 year was the only risk factor for post-glue HA. In the small subgroup available for study, treatment with triptans or DHE was not associated with adverse events in pre/post-coiled aneurysms. Diagnostic testing was low yield. CONCLUSIONS Occurrence of PPH was common after IEPs and especially so with coiling and in women, smokers, and those with anxiety/depression, and was often of longer duration than allowed by current International Classification of Headache Disorders-II criteria. The yield of diagnostic testing was low, and in a small subgroup treatment with triptans or DHE did not cause adverse events in pre/post-coiled aneurysms. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Eric P Baron
- Cleveland Clinic Neurological Institute-Neurology, Center for Headache and Pain, Center for Regional Neurology, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Devlin JW, Roberts RJ. Pharmacology of commonly used analgesics and sedatives in the ICU: benzodiazepines, propofol, and opioids. Anesthesiol Clin 2011; 29:567-585. [PMID: 22078910 DOI: 10.1016/j.anclin.2011.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The ideal sedative or analgesic agent should have a rapid onset of activity, a rapid recovery after drug discontinuation, a predictable dose response, a lack of drug accumulation,and no toxicity. Unfortunately, none of the earlier analgesics, the benzodiazepines,or propofol share all of these characteristics. Patients who are critically ill experience numerous physiologic derangements and commonly require high doses and long durations of analgesic and sedative therapy. There is a paucity of well designed clinical trials evaluating the safety and efficacy of earlier sedative and analgesic agents in the ICU. In addition, the ever-changing dynamics of patients who are critically ill makes the use of sedation a continual challenge during the course of each patient’s admission. To optimize care, clinicians should be familiar with the many pharmacokinetic, pharmacodynamic, and pharmacogenetic variables that can affect the safety and efficacy of sedatives and analgesics.
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Affiliation(s)
- John W Devlin
- Northeastern University School of Pharmacy, MU206, 360 Huntington Avenue, Boston, MA 02115, USA.
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73
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Abstract
OBJECTIVES In the clinical setting, there is marked intersubject variability in the intensity of pain reported by patients with apparently similar pain states, as well as widely differing analgesic dosing requirements between individuals to produce satisfactory pain relief with tolerable side-effects. Genetic and environmental factors as well as their interaction are implicated, and these are discussed in this review. KEY FINDINGS Pioneering work undertaken in mice more than a decade ago, showed a strong genetic contribution to levels of nociception/hypersensitivity as well as levels of antinociception produced by commonly available analgesic agents. To date more than 300 candidate 'pain' genes have been identified as potentially contributing to heritable differences in pain sensitivity and analgesic responsiveness in animals and humans, with this information available in a publicly accessible database http://www.jbldesign.com/jmogil/enter.html. Since then, many genetic association studies have been conducted in humans to investigate the possibility that single nucleotide polymorphisms (SNPs) in an individual gene may explain drug inefficacy or excessive toxicity experienced by a small subset of the whole population who have the rare allele for a particular SNP. SUMMARY Despite the fact that SNPs in more than 20 genes that affect pain sensitivity or contribute to interindividual variability in responses to analgesic medications have been identified in the human genome, much of the data is conflicting. Apart from deficiencies in the design and conduct of human genetic association studies, recent research from other fields has implicated epigenetic mechanisms that facilitate dynamic gene-environment communication, as a possible explanation.
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Affiliation(s)
- Arjun Muralidharan
- The University of Queensland, Centre for Integrated Preclinical Drug Development and School of Pharmacy, Steele Building, St Lucia Campus, Brisbane, Queensland, Australia
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Jannetto PJ, Bratanow NC. Pain management in the 21st century: utilization of pharmacogenomics and therapeutic drug monitoring. Expert Opin Drug Metab Toxicol 2011; 7:745-52. [DOI: 10.1517/17425255.2011.565051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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75
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Genetic variability of pain perception and treatment—clinical pharmacological implications. Eur J Clin Pharmacol 2011; 67:541-51. [DOI: 10.1007/s00228-011-1012-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
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Meyer MR, Maurer HH. Absorption, distribution, metabolism and excretion pharmacogenomics of drugs of abuse. Pharmacogenomics 2011; 12:215-33. [DOI: 10.2217/pgs.10.171] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pharmacologic and toxic effects of xenobiotics, such as drugs of abuse, depend on the genotype and phenotype of an individual, and conversely on the isoenzymes involved in their metabolism and transport. The current knowledge of such isoenzymes of frequently abused therapeutics such as opioids (oxycodone, hydrocodone, methadone, fentanyl, buprenorphine, tramadol, heroin, morphine and codeine), anesthetics (γ-hydroxybutyric acid, propofol, ketamine and phencyclidine) and cognitive enhancers (methylphenidate and modafinil), and some important plant-derived hallucinogens (lysergide, salvinorin A, psilocybin and psilocin), as well as of nicotine in humans are summarized in this article. The isoenzymes (e.g., cytochrome P450, glucuronyltransferases, esterases and reductases) involved in the metabolism of drugs and some pharmacokinetic data are discussed. The relevance of such data is discussed for predicting possible interactions with other xenobiotics, understanding pharmacokinetic behavior and pharmacogenomic variations, assessing toxic risks, developing suitable toxicological analysis procedures, and finally for interpretating drug testing results.
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Affiliation(s)
- Markus R Meyer
- Department of Experimental & Clinical Toxicology, Institute of Experimental & Clinical Pharmacology & Toxicology, Saarland University, D 66421 Homburg (Saar), Germany
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77
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Influence of anticancer therapy on oxidation phenotype and acetylation phenotype in patients with acute myeloblastic leukemia. Pharmacol Rep 2011; 63:149-56. [DOI: 10.1016/s1734-1140(11)70409-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 09/21/2010] [Indexed: 11/22/2022]
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Kolesnikov Y, Gabovits B, Levin A, Voiko E, Veske A. Combined catechol-O-methyltransferase and mu-opioid receptor gene polymorphisms affect morphine postoperative analgesia and central side effects. Anesth Analg 2010; 112:448-53. [PMID: 21127283 DOI: 10.1213/ane.0b013e318202cc8d] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Previous studies have generated controversial results regarding the influence of the genetic variations of μ-opioid receptors on morphine analgesia and opioid-related side effects in the postoperative period. Few studies have been conducted attempting to assess the combined effects of variation within ≥2 genes in relation to morphine response. In this study, we investigated whether combined catechol-O-methyltransferase and μ-opioid receptor polymorphisms contribute to the morphine response in postoperative analgesia. METHODS One hundred two surgical patients were enrolled in this prospective, observational study. All patients received general anesthesia and were screened for μ-opioid receptor polymorphism A118G (Asn40Asp) and catechol-O-methyltransferase G1947A (Val158Met) polymorphism using a blood sample of DNA. Patient-controlled analgesia was provided postoperatively and morphine consumption was observed. Any pain at rest or side effects were measured with rating scales. RESULTS The heterozygous patients with μ-opioid receptor A118G and catechol-O-methyltransferase G1947A mutation consumed significantly less morphine in the postanesthetic recovery room and 48 hours after surgery compared with homozygous patients of the A118 variant. Nausea and sedation scores were also significantly lower during all observed postoperative periods for heterozygous patients and only 2 patients (18%) from this group received antinausea treatment. CONCLUSION This study has demonstrated the importance of the gene-gene approach in understanding the morphine response in patients after lower abdominal surgery. More studies are needed to characterize the combined effects of multiple genes and demographic as well as clinical variables in predicting the correct morphine dosage and corresponding opioid-related side effects.
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Affiliation(s)
- Yuri Kolesnikov
- East Tallinn Central Hospital, Parnu mnt., 104, Tallinn, 11312, Estonia.
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79
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Nossaman VE, Ramadhyani U, Kadowitz PJ, Nossaman BD. Advances in perioperative pain management: use of medications with dual analgesic mechanisms, tramadol & tapentadol. Anesthesiol Clin 2010; 28:647-666. [PMID: 21074743 DOI: 10.1016/j.anclin.2010.08.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Recovery from ambulatory surgical procedures can be limited by postoperative pain. Inadequate analgesia may delay or prevent patient discharge and can result in readmission. More frequently, postoperative pain produces discomfort and interrupts sleep, contributing to postoperative fatigue. The development of effective analgesic regimens for the management of postoperative pain is a priority especially in patients with impaired cardiorespiratory, hepatic, or renal function. Tramadol and tapentadol hydrochloride are novel in that their analgesic actions occur at multiple sites. Both agents are reported to be mu-opioid receptor agonists and monoamine-reuptake inhibitors. In contrast to pure opioid agonists, both drugs are believed to have lower risks of respiratory depression, tolerance, and dependence. The Food and Drug Administration has approved both drugs for the treatment of moderate-to-severe acute pain in adults. This article provides an evidence-based account of the role of tramadol and tapentadol in modern clinical practice.
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Affiliation(s)
- Vaughn E Nossaman
- Department of Pharmacology, Tulane University Medical Center, 1430 Tulane Avenue, New Orleans, LA 70129, USA.
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80
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Abstract
Large inter-individual variability in drug response and toxicity, as well as in drug concentrations after application of the same dosage, can be of genetic, physiological, pathophysiological, or environmental origin. Absorption, distribution and metabolism of a drug and interactions with its target often are determined by genetic differences. Pharmacokinetic and pharmacodynamic variations can appear at the level of drug metabolizing enzymes (e.g., the cytochrome P450 system), drug transporters, drug targets or other biomarker genes. Pharmacogenetics or toxicogenetics can therefore be relevant in forensic toxicology. This review presents relevant aspects together with some examples from daily routines.
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Hammoud HA, Aymard G, Lechat P, Boccheciampe N, Riou B, Aubrun F. Relationships between plasma concentrations of morphine, morphine-3-glucuronide, morphine-6-glucuronide, and intravenous morphine titration outcomes in the postoperative period. Fundam Clin Pharmacol 2010; 25:518-27. [DOI: 10.1111/j.1472-8206.2010.00867.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Peniston JH, Xiang Q, Gould EM. Factors affecting acceptability of titrated oxymorphone extended release in chronic low back pain - an individual patient analysis. Curr Med Res Opin 2010; 26:1861-71. [PMID: 20521870 DOI: 10.1185/03007995.2010.490457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the influence of age, sex, and previous opioid experience on the likelihood of successfully titrating opioid-naive and experienced patients with chronic low back pain (CLBP) to an effective and well-tolerated dose of oxymorphone extended release (ER). METHODS Post hoc analysis of open-label titration phases of two enriched-enrollment randomized-withdrawal phase III trials in 575 adults with moderate-to-severe CLBP. Opioid-naive patients (n = 325) initiated oxymorphone ER at 10 mg/day (5 mg q12 h). Opioid-experienced patients (n = 250) initiated at a dose equianalgesic to their previous opioid and were allowed doses of 5 mg oxymorphone immediate-release rescue medication every 4-6 h, as needed. Oxymorphone ER was gradually titrated to a dose that reduced pain to <or=40 mm on a 100 mm visual analog scale. CLINICAL TRIAL REGISTRATION NCT00225797, NCT00226421. MAIN OUTCOME MEASURES Number of patients reaching stabilized oxymorphone ER dose, reasons for treatment discontinuation in patients not reaching stabilized dose. RESULTS Open-label titration was successful in 61% (348/575) of patients, and similar proportions of men (63%) and women (59%) and opioid-naive (63%) and experienced (57%) patients. Patients aged >or=65 years were less likely than patients aged <65 years to complete titration (45 vs. 63%; p = 0.002; 95% CI, -0.30 to -0.06) and more likely to discontinue owing to adverse events (40 vs. 15%; p < 0.001; 95% CI, 0.14-0.36). Oxycodone-experienced patients were less likely than hydrocodone-experienced patients to complete titration (46 vs. 62%, p = 0.03; 95% CI,-0.30 to -0.02). Among successfully titrated patients, pain decreased regardless of prior opioid therapy, sex, or age. CONCLUSIONS Most patients with CLBP were titrated to an effective, generally well-tolerated oxymorphone ER dose. Older patients and those converted from oxycodone may require more gradual titration. A study limitation is that patients initiated oxymorphone ER to comply with protocol, whereas treatment failure typically motivates opioid initiation or switching in clinical practice.
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Affiliation(s)
- John H Peniston
- Feasterville Family Health Care Center, Feasterville, PA 19053, USA.
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83
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Dabo F, Grönbladh A, Nyberg F, Sundström-Poromaa I, Akerud H. Different SNP combinations in the GCH1 gene and use of labor analgesia. Mol Pain 2010; 6:41. [PMID: 20633294 PMCID: PMC2912270 DOI: 10.1186/1744-8069-6-41] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 07/15/2010] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to investigate if there is an association between different SNP combinations in the guanosine triphosphate cyclohydrolase (GCH1) gene and a number of pain behavior related outcomes during labor. A population-based sample of pregnant women (n = 814) was recruited at gestational week 18. A plasma sample was collected from each subject. Genotyping was performed and three single nucleotide polymorphisms (SNP) previously defined as a pain-protective SNP combination of GCH1 were used. Results Homozygous carriers of the pain-protective SNP combination of GCH1 arrived to the delivery ward with a more advanced stage of cervical dilation compared to heterozygous carriers and non-carriers. However, homozygous carriers more often used second line labor analgesia compared to the others. Conclusion The pain-protective SNP combination of GCH1 may be of importance in the limited number of homozygous carriers during the initial dilation of cervix but upon arrival at the delivery unit these women are more inclined to use second line labor analgesia.
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Affiliation(s)
- Fatimah Dabo
- Department of Women's and Children's health, Uppsala University, Uppsala, Sweden
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84
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Mague SD, Blendy JA. OPRM1 SNP (A118G): involvement in disease development, treatment response, and animal models. Drug Alcohol Depend 2010; 108:172-82. [PMID: 20074870 PMCID: PMC2887703 DOI: 10.1016/j.drugalcdep.2009.12.016] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 12/17/2009] [Accepted: 12/17/2009] [Indexed: 12/21/2022]
Abstract
Endogenous opioids acting at mu-opioid receptors mediate many biological functions. Pharmacological intervention at these receptors has greatly aided in the treatment of acute and chronic pain, in addition to other uses. However, the development of tolerance and dependence has made it difficult to adequately prescribe these therapeutics. A common single nucleotide polymorphism (SNP), A118G, in the mu-opioid receptor gene can affect opioid function and, consequently, has been suggested to contribute to individual variability in pain management and drug addiction. Investigation into the role of A118G in human disease and treatment response has generated a large number of association studies across various disease states as well as physiological responses. However, characterizing the functional consequences of this SNP and establishing if it causes or contributes to disease phenotypes have been significant challenges. In this manuscript, we will review a number of association studies as well as investigations of the functional impact of this gene variant. In addition, we will describe a novel mouse model that was generated to recapitulate this SNP in mice. Evaluation of models that incorporate known human genetic variants into a tractable system, like the mouse, will facilitate the understanding of discrete contributions of SNPs to human disease.
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Affiliation(s)
| | - Julie A. Blendy
- Address correspondence to: Julie A. Blendy, Ph.D., Department of Pharmacology, University of Pennsylvania, TRL, 125 South 31st Street, Tel: (215) 898-0730, Fax: (215) 573-2041,
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&NA;. Genetic variations in cytochrome P450 (CYP) 2D6 activity may have important clinical consequences for some drugs. DRUGS & THERAPY PERSPECTIVES 2010. [DOI: 10.2165/11205190-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Anand KJS, Willson DF, Berger J, Harrison R, Meert KL, Zimmerman J, Carcillo J, Newth CJL, Prodhan P, Dean JM, Nicholson C. Tolerance and withdrawal from prolonged opioid use in critically ill children. Pediatrics 2010; 125:e1208-25. [PMID: 20403936 PMCID: PMC3275643 DOI: 10.1542/peds.2009-0489] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE After prolonged opioid exposure, children develop opioid-induced hyperalgesia, tolerance, and withdrawal. Strategies for prevention and management should be based on the mechanisms of opioid tolerance and withdrawal. PATIENTS AND METHODS Relevant manuscripts published in the English language were searched in Medline by using search terms "opioid," "opiate," "sedation," "analgesia," "child," "infant-newborn," "tolerance," "dependency," "withdrawal," "analgesic," "receptor," and "individual opioid drugs." Clinical and preclinical studies were reviewed for data synthesis. RESULTS Mechanisms of opioid-induced hyperalgesia and tolerance suggest important drug- and patient-related risk factors that lead to tolerance and withdrawal. Opioid tolerance occurs earlier in the younger age groups, develops commonly during critical illness, and results more frequently from prolonged intravenous infusions of short-acting opioids. Treatment options include slowly tapering opioid doses, switching to longer-acting opioids, or specifically treating the symptoms of opioid withdrawal. Novel therapies may also include blocking the mechanisms of opioid tolerance, which would enhance the safety and effectiveness of opioid analgesia. CONCLUSIONS Opioid tolerance and withdrawal occur frequently in critically ill children. Novel insights into opioid receptor physiology and cellular biochemical changes will inform scientific approaches for the use of opioid analgesia and the prevention of opioid tolerance and withdrawal.
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Affiliation(s)
- Kanwaljeet J. S. Anand
- Department of Pediatrics, Le Bonheur Children’s Hospital and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas F. Willson
- Department of Pediatrics & Anesthesiology, University of Virginia Children’s Hospital, Charlottesville, Virginia
| | - John Berger
- Department of Pediatrics, Children’s National Medical Center, Washington, DC
| | - Rick Harrison
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, California
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, Michigan
| | - Jerry Zimmerman
- Department of Pediatrics, Children’s Hospital and Medical Center, Seattle, Washington
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Parthak Prodhan
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - J. Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Carol Nicholson
- Pediatric Critical Care and Rehabilitation Program, National Center for Medical Rehabilitation Research (NCMRR), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Abstract
Target-controlled infusion (TCI) pumps currently do not satisfactorily cater for the pediatric population, particularly for those under 5 years. Growth and development are two major aspects of children not readily apparent in adults, and these two aspects influence clearance (CL) and volume of distribution (V). In simple terms, V determines initial dose, and CL determines infusion rate at steady state. Three major covariates (size, age, and organ function) contribute to parameter variability in children. Size can be standardized for clearance in a 70-kg person using the allometric (3/4) power model. Remifentanil, a drug cleared by hydrolysis, can be modeled in all age groups by simple application of this model using a standardized clearance of 2790 ml x min(-1) for a 70-kg person. Allometry alone is insufficient to predict clearance in neonates and infants from adult parameters for most drugs used in anesthesia. The addition of a model describing maturation is required. The sigmoid Emax or Hill model has been found useful for describing this maturation process. Propofol maturation has been described with a mature clearance of 1.83 l x min(-1) x 70 kg(-1), a maturation half-time (TM(50)) of 44 weeks and a Hill coefficient of 4.9. Organ function also affects clearance, and propofol clearance is reduced in neonates and infants after cardiac surgery. Although pharmacokinetics (PK) in children is receiving increasing attention and is eminently programmable into a TCI device, pharmacodynamic (PD) measures in children remain poorly defined, partly because the depth of anesthesia monitoring are inadequate. Both PK and PD are necessary for safe use of TCI pumps.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
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Afilalo M, Stegmann JU, Upmalis D. Tapentadol immediate release: a new treatment option for acute pain management. J Pain Res 2010; 3:1-9. [PMID: 21197304 PMCID: PMC3004637 DOI: 10.2147/jpr.s4989] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Indexed: 11/23/2022] Open
Abstract
The undertreatment of acute pain is common in many health care settings. Insufficient management of acute pain may lead to poor patient outcomes and potentially life-threatening complications. Opioids provide relief of moderate to severe acute pain; however, therapy with pure μ-opioid agonists is often limited by the prevalence of side effects, particularly opioid-induced nausea and vomiting. Tapentadol is a novel, centrally acting analgesic with 2 mechanisms of action, μ-opioid receptor agonism and norepinephrine reuptake inhibition. The analgesic effects of tapentadol are independent of metabolic activation and tapentadol has no active metabolites; therefore, in theory, tapentadol may be associated with a low potential for interindividual efficacy variations and drug-drug interactions. Previous phase 3 trials in patients with various types of moderate to severe acute pain have shown that tapentadol immediate release (IR; 50 to 100 mg every 4 to 6 hours) provides analgesia comparable to that provided by the pure μ-opioid agonist comparator, oxycodone HCl IR (10 or 15 mg every 4 to 6 hours), with a lower incidence of nausea, vomiting, and constipation. Findings suggest tapentadol may represent an improved treatment option for acute pain.
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Affiliation(s)
- Marc Afilalo
- Sir Mortimer B. Davis Jewish General Hospital, Montréal, Canada
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Lasheen W, Walsh D, Mahmoud F, Sarhill N, Rivera N, Davis M, Lagman R, Legrand S. The intravenous to oral relative milligram potency ratio of morphine during chronic dosing in cancer pain. Palliat Med 2010; 24:9-16. [PMID: 19910396 DOI: 10.1177/0269216309346595] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Morphine (M) is the opioid analgesic of choice for severe cancer pain. The IV to PO M equipotent switch ratio (CR) is controversial. We designed this prospective observational cohort to confirm the efficacy and safety of M IV to PO CR of 1:3. Consecutive cancer patients admitted to an inpatient palliative medicine unit were screened for inclusion. Pain was managed by palliative medicine specialists. They were blinded to the patient data collected, and the calculated CR. The switch was considered successful if the following criteria were met: (1) Pain adequately controlled: pain rated as none or mild (2) Number of RD less than 4 (for non incident pain) per 24 hours (3) No limiting side effects. We used Day 3 ATC M dose for CR calculations. The major outcome measures were the IV : PO CR ratio, morphine doses (mg/day), pain severity, number of PRN doses, and day 1 and day 3side effects. Descriptive statistics were used to report mean, median, standard deviation and range of different variables. Two hundred and fifty six consecutive admissions were screened, and 106 were eligible for the study. Sixty two underwent a successful M route switch and were included in this analysis. A ratio of 1:3 was safely implemented over a wide M dose range. About 80% were successfully switched with a calculated CR of 1:3. 20% required an oral M dose adjustment after route switch either to better pain control or reduce side effects with a resultant higher (e.g. 1:4) or lower (e.g. 1:2) calculated potency ratios respectively. A potency ratio of 1:3 was safe as evaluated by common M side-effects, the dose also easy to calculate. The 1: 3 M IV to PO relative milligram potency ratio appears correct and practical for most patients over a wide M dose range.
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Affiliation(s)
- Wael Lasheen
- The Harry R Horvitz Center for Palliative Medicine, Cleveland, OH 44195, USA
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91
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Affiliation(s)
- Shu-Feng Zhou
- Discipline of Chinese Medicine, School of Health Sciences, RMIT University, Victoria, Australia.
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92
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Zhou SF, Liu JP, Chowbay B. Polymorphism of human cytochrome P450 enzymes and its clinical impact. Drug Metab Rev 2009; 41:89-295. [PMID: 19514967 DOI: 10.1080/03602530902843483] [Citation(s) in RCA: 502] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pharmacogenetics is the study of how interindividual variations in the DNA sequence of specific genes affect drug response. This article highlights current pharmacogenetic knowledge on important human drug-metabolizing cytochrome P450s (CYPs) to understand the large interindividual variability in drug clearance and responses in clinical practice. The human CYP superfamily contains 57 functional genes and 58 pseudogenes, with members of the 1, 2, and 3 families playing an important role in the metabolism of therapeutic drugs, other xenobiotics, and some endogenous compounds. Polymorphisms in the CYP family may have had the most impact on the fate of therapeutic drugs. CYP2D6, 2C19, and 2C9 polymorphisms account for the most frequent variations in phase I metabolism of drugs, since almost 80% of drugs in use today are metabolized by these enzymes. Approximately 5-14% of Caucasians, 0-5% Africans, and 0-1% of Asians lack CYP2D6 activity, and these individuals are known as poor metabolizers. CYP2C9 is another clinically significant enzyme that demonstrates multiple genetic variants with a potentially functional impact on the efficacy and adverse effects of drugs that are mainly eliminated by this enzyme. Studies into the CYP2C9 polymorphism have highlighted the importance of the CYP2C9*2 and *3 alleles. Extensive polymorphism also occurs in other CYP genes, such as CYP1A1, 2A6, 2A13, 2C8, 3A4, and 3A5. Since several of these CYPs (e.g., CYP1A1 and 1A2) play a role in the bioactivation of many procarcinogens, polymorphisms of these enzymes may contribute to the variable susceptibility to carcinogenesis. The distribution of the common variant alleles of CYP genes varies among different ethnic populations. Pharmacogenetics has the potential to achieve optimal quality use of medicines, and to improve the efficacy and safety of both prospective and currently available drugs. Further studies are warranted to explore the gene-dose, gene-concentration, and gene-response relationships for these important drug-metabolizing CYPs.
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Affiliation(s)
- Shu-Feng Zhou
- School of Health Sciences, RMIT University, Bundoora, Victoria, Australia.
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93
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Abstract
BACKGROUND Opioid therapy is the standard treatment for moderate-to-severe cancer pain and is becoming a more frequent treatment for moderate-to-severe chronic noncancer pain. Response to opioids varies significantly between patients and even within the individual patient at different stages of treatment. Finding an opioid at a dose that provides adequate long-term analgesia with minimal adverse effects can be difficult. Opioid switching and opioid rotation, at different stages of therapy, represent two clinical strategies used to optimize opioid response for patients with moderate-to-severe pain. OBJECTIVES Review the theoretical and clinical evidence supporting the concepts of opioid switching and rotation, outline the conditions under which these practices should be considered, and briefly suggest practical steps for their implementation. SCOPE Clinical literature, clinical practice and guideline databases, and professional society websites were searched for articles or reports describing opioid switching or opioid rotation in chronic pain therapy; variability in patient response to opioid therapy; physiologic, pharmacologic, and genetic factors that affect clinical response to opioids; and practical approaches to maximizing analgesia and minimizing adverse effects in opioid therapy. It is outside the scope of this review to evaluate the pharmacoeconomic aspects that affect changes in opioid therapy. FINDINGS The variability in de novo clinical response to opioids likely represents the interaction of the varying properties of the individual opioids with the variability in individual patient biology. This interaction forms the rationale for opioid switching and explains its clinical utility. As with opioid switching, success with opioid rotation is related to the myriad of factors determining an individual patient's response to a specific opioid. However, the benefits of opioid rotation also derive from a partial reversal of tolerance at the mu-opioid receptor and the response of different micro-opioid receptor subtypes to the different opioids.
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Affiliation(s)
- Neal E Slatkin
- California Cancer Specialists Medical Group, Pasadena, CA 91105, USA.
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Friday JH, Kanegaye JT, McCaslin I, Zheng A, Harley JR. Ibuprofen provides analgesia equivalent to acetaminophen-codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial. Acad Emerg Med 2009; 16:711-6. [PMID: 19624576 DOI: 10.1111/j.1553-2712.2009.00471.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study compared the analgesic effectiveness of acetaminophen-codeine with that of ibuprofen for children with acute traumatic extremity pain, with the hypothesis that the two medications would demonstrate equivalent reduction in pain scores in an emergency department (ED) setting. METHODS This was a randomized, double-blinded equivalence trial. Pediatric ED patients 5 to 17 years of age with acute traumatic extremity pain received acetaminophen-codeine (1 mg/kg as codeine, maximum 60 mg) or ibuprofen (10 mg/kg, maximum 400 mg). The patients provided Color Analog Scale (CAS) pain scores at baseline and at 20, 40, and 60 minutes after medication administration. The primary outcome measured was the difference in changes in pain score at 40 minutes, compared to a previously described minimal clinically significant change in pain score of 2 cm. The difference was defined as (change in ibuprofen CAS score from baseline) - (change in acetaminophen-codeine CAS score from baseline); negative values thus favor the ibuprofen group. Additional outcomes included need for rescue medication and adverse effects. RESULTS The 32 acetaminophen-codeine and the 34 ibuprofen recipients in our convenience sample had indistinguishable pain scores at baseline. The intergroup differences in pain score change at 20 minutes (-0.6, 95% confidence interval [CI] = -1.5 to 0.3), 40 minutes (-0.4, 95% CI = -1.4 to 0.6), and 60 minutes (0.2, 95% CI = -0.8 to 1.2) were all less than 2 cm. Adverse effects were minimal: vomiting (one patient after acetaminophen-codeine), nausea (one patient after ibuprofen), and pruritus (one after acetaminophen-codeine). The three patients in each group who received rescue medications all had radiographically demonstrated fractures or dislocations. CONCLUSIONS This study found similar performance of acetaminophen-codeine and ibuprofen in analgesic effectiveness among ED patients aged 5-17 years with acute traumatic extremity pain. Both drugs provided measurable analgesia. Patients tolerated them well, with few treatment failures and minimal adverse effects.
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Affiliation(s)
- Janet H Friday
- Department of Pediatrics, University of California-San Diego, La Jolla, CA, USA.
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95
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Affiliation(s)
- Caroline F Thorn
- Department of Genetics, Stanford University, Stanford, California, USA
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96
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Pharmacology of Commonly Used Analgesics and Sedatives in the ICU: Benzodiazepines, Propofol, and Opioids. Crit Care Clin 2009; 25:431-49, vii. [PMID: 19576523 DOI: 10.1016/j.ccc.2009.03.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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97
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Affiliation(s)
- Howard S Smith
- Department of Anesthesiology, Albany Medical College, Albany, NY 12208, USA.
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98
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Abstract
Clinicians understand that individual patients differ in their response to specific opioid analgesics and that patients may require trials of several opioids before finding an agent that provides effective analgesia with acceptable tolerability. Reasons for this variability include factors that are not clearly understood, such as allelic variants that dictate the complement of opioid receptors and subtle differences in the receptor-binding profiles of opioids. However, altered opioid metabolism may also influence response in terms of efficacy and tolerability, and several factors contributing to this metabolic variability have been identified. For example, the risk of drug interactions with an opioid is determined largely by which enzyme systems metabolize the opioid. The rate and pathways of opioid metabolism may also be influenced by genetic factors, race, and medical conditions (most notably liver or kidney disease). This review describes the basics of opioid metabolism as well as the factors influencing it and provides recommendations for addressing metabolic issues that may compromise effective pain management. Articles cited in this review were identified via a search of MEDLINE, EMBASE, and PubMed. Articles selected for inclusion discussed general physiologic aspects of opioid metabolism, metabolic characteristics of specific opioids, patient-specific factors influencing drug metabolism, drug interactions, and adverse events.
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Affiliation(s)
- Howard S Smith
- Department of Anesthesiology, Albany Medical College, Albany, NY 12208, USA.
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99
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Kanaan M, Daali Y, Dayer P, Desmeules J. Uptake/efflux transport of tramadol enantiomers and O-desmethyl-tramadol: focus on P-glycoprotein. Basic Clin Pharmacol Toxicol 2009; 105:199-206. [PMID: 19496778 PMCID: PMC2774482 DOI: 10.1111/j.1742-7843.2009.00428.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract: The analgesic effect of tramadol (TMD) results from the monoaminergic effect of its two enantiomers, (+)-TMD and (−)-TMD as well as its opioid metabolite (+)-O-desmethyl-tramadol (M1). P-glycoprotein (P-gp) might be of importance in the analgesic and tolerability profile variability of TMD. Our study investigated the involvement of P-gp in the transepithelial transport of (+)-TMD, (−)-TMD and M1, using a Caco-2 cell monolayer model. The bidirectional transport of racemic TMD and M1 (1–100 µM) across the monolayers was investigated at two pH conditions (pH 6.8/7.4 and 7.4/7.4) in the presence and absence of P-gp inhibitor cyclosporine A (10 µM) and assessed with the more potent and specific P-gp inhibitor GF120918 (4 µM). Analytical quantification was performed by liquid chromatography coupled to the fluorescence detector. A net secretion of (+)-TMD, (−)-TMD and M1 was observed when a pH gradient was applied (TR: Papp(B − A)/Papp(A − B): 1.8–2.7; P < 0.05). However, the bidirectional transport of all compounds was equal in the non-gradient system. In the presence of P-gp inhibitors, a slight but significant increase of secretory flux was observed (up to 26%; P < 0.05) at both pH conditions. In conclusion, (+)-TMD, (−)-TMD and M1 are not P-gp substrates. However, proton-based efflux pumps may be involved in limiting the gastrointestinal absorption of TMD enantiomers as well as enhancing TMD enantiomers and M1 renal excretion. A possible involvement of uptake carriers in the transepithelial transport of TMD enantiomers and M1 is suggested.
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Affiliation(s)
- Mouna Kanaan
- Department of Anaesthesiology, Clinical Pharmacology and Toxicology and Multidisciplinary Pain Center, Pharmacology and Intensive care, Geneva University Hospitals, Faculty of Medicine, University of Geneva, CH-1211 Geneva 14, Switzerland
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Abstract
Interindividual variability in pain sensitivity and the response to analgesic manipulations remains a considerable clinical challenge as well as an area of intense scientific investigation. Techniques in this field have matured rapidly so that much relevant data have emerged only in the past few years. Our increasing understanding of the genetic mediation of these biological phenomena have nonetheless revealed their surprising complexity. This review provides a comprehensive picture and critical analysis of the field and its prospects.
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Affiliation(s)
- Michael L Lacroix-Fralish
- Department of Psychology and Center for Research on Pain, McGill University, Montréal, Quebec, H3A1B1 Canada
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