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Acton EK, Hennessy S, Gelfand MA, Leonard CE, Bilker WB, Shu D, Willis AW, Kasner SE. Thinking Three-Dimensionally: A Self- and Externally-Controlled Approach to Screening for Drug-Drug-Drug Interactions Among High-Risk Populations. Clin Pharmacol Ther 2024; 116:448-459. [PMID: 38860403 PMCID: PMC11262479 DOI: 10.1002/cpt.3310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
The global rise in polypharmacy has increased both the necessity and complexity of drug-drug interaction (DDI) assessments, given the growing potential for interactions involving more than two drugs. Leveraging large-scale healthcare claims data, we piloted a semi-automated, high-throughput case-crossover-based approach for drug-drug-drug interaction (3DI) screening. Cases were direct-acting oral anticoagulant (DOAC) users with either a major bleeding event during ongoing dispensings for potentially interacting, enzyme-inhibiting antihypertensive drugs (AHDs) (Study 1), or a thromboembolic event during ongoing dispensings for potentially interacting, enzyme-inducing antiseizure medications (ASMs) (Study 2). 3DI detection was based on screening for additional drug exposures that served as acute outcome triggers. To mitigate direct effects and confounding by concomitant drugs, self-controlled estimates were adjusted using negative cases (external "control" DOAC users with the same outcomes but co-dispensings for non-interacting AHDs or ASMs). Signal thresholds were set based on P-values and false discovery rate q-values to address multiple comparisons. Study 1: 285 drugs were examined among 3,306 episodes. Self-controlled assessments with q-value thresholds yielded 9 3DI signals (cases) and 40 DDI signals (negative cases). External adjustment generated 10 3DI signals from the P-value threshold and no signals from the q-value threshold. Study 2: 126 drugs were examined among 604 episodes. Assessments with P-value thresholds yielded 3 3DI and 26 DDI signals following self-control, as well as 4 3DI signals following adjustment. No 3DI signals met the q-value threshold. The presented self- and externally-controlled approach aimed to advance paradigms for real-world higher order drug interaction screening among high-susceptibility populations with pre-existent DDI risk.
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Affiliation(s)
- Emily K. Acton
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Michael A. Gelfand
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, US
| | - Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
| | - Warren B. Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Di Shu
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Allison W. Willis
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, US
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, US
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Robinson KM, Eum S, Desta Z, Tyndale RF, Gaedigk A, Crist RC, Haidar CE, Myers AL, Samer CF, Somogyi AA, Zubiaur P, Iwuchukwu OF, Whirl-Carrillo M, Klein TE, Caudle KE, Donnelly RS, Kharasch ED. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2B6 Genotype and Methadone Therapy. Clin Pharmacol Ther 2024. [PMID: 38863207 DOI: 10.1002/cpt.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/22/2024] [Indexed: 06/13/2024]
Abstract
Methadone is a mu (μ) opioid receptor agonist used clinically in adults and children to manage opioid use disorder, neonatal abstinence syndrome, and acute and chronic pain. It is typically marketed as a racemic mixture of R- and S-enantiomers. R-methadone has 30-to 50-fold higher analgesic potency than S-methadone, and S-methadone has a greater adverse effect (prolongation) on the cardiac QTc interval. Methadone undergoes stereoselective metabolism. CYP2B6 is the primary enzyme responsible for catalyzing the metabolism of both enantiomers to the inactive metabolites, S- and R-2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (S- and R-EDDP). Genetic variation in the CYP2B6 gene has been investigated in the context of implications for methadone pharmacokinetics, dose, and clinical outcomes. Most CYP2B6 variants result in diminished or loss of CYP2B6 enzyme activity, which can lead to higher plasma methadone concentrations (affecting S- more than R-methadone). However, the data do not consistently indicate that CYP2B6-based metabolic variability has a clinically significant effect on methadone dose, efficacy, or QTc prolongation. Expert analysis of the published literature does not support a change from standard methadone prescribing based on CYP2B6 genotype (updates at www.cpicpgx.org).
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Affiliation(s)
- Katherine M Robinson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Seenae Eum
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel F Tyndale
- Department of Pharmacology & Toxicology, and Psychiatry, The Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Richard C Crist
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Alan L Myers
- Department of Diagnostic & Biomedical Sciences, The University of Texas Health Science Center, Houston, Texas, USA
| | - Caroline F Samer
- Department of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Pablo Zubiaur
- Department of Clinical Pharmacology, Hospital Universitario de la Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Otito F Iwuchukwu
- Department of Pharmaceutical Sciences, School of Pharmacy and Health Sciences, Farleigh Dickinson University, Florham Park, New Jersey, USA
| | | | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Kelly E Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Roseann S Donnelly
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine | Bermaride LLC, Durham, North Carolina, USA
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3
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Wang PF, Yang Y, Patel V, Neiner A, Kharasch ED. Natural Products Inhibition of Cytochrome P450 2B6 Activity and Methadone Metabolism. Drug Metab Dispos 2024; 52:252-265. [PMID: 38135504 PMCID: PMC10877711 DOI: 10.1124/dmd.123.001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023] Open
Abstract
Methadone is cleared predominately by hepatic cytochrome P450 (CYP) 2B6-catalyzed metabolism to inactive metabolites. CYP2B6 also catalyzes the metabolism of several other drugs. Methadone and CYP2B6 are susceptible to pharmacokinetic drug-drug interactions. Use of natural products such as herbals and other botanicals is substantial and growing, and concomitant use of prescription medicines and non-prescription herbals is common and may result in interactions, often precipitated by CYP inhibition. Little is known about herbal product effects on CYP2B6 activity, and CYP2B6-catalyzed methadone metabolism. We screened a family of natural product compounds used in traditional medicines, herbal teas, and synthetic analogs of compounds found in plants, including kavalactones, flavokavains, chalcones and gambogic acid, for inhibition of expressed CYP2B6 activity and specifically inhibition of CYP2B6-mediated methadone metabolism. An initial screen evaluated inhibition of CYP2B6-catalyzed 7-ethoxy-4-(trifluoromethyl) coumarin O-deethylation. Hits were further evaluated for inhibition of racemic methadone metabolism, including mechanism of inhibition and kinetic constants. In order of decreasing potency, the most effective inhibitors of methadone metabolism were dihydromethysticin (competitive, K i 0.074 µM), gambogic acid (noncompetitive, K i 6 µM), and 2,2'-dihydroxychalcone (noncompetitive, K i 16 µM). Molecular modeling of CYP2B6-methadone and inhibitor binding showed substrate and inhibitor binding position and orientation and their interactions with CYP2B6 residues. These results show that CYP2B6 and CYP2B6-catalyzed methadone metabolism are inhibited by certain natural products, at concentrations which may be clinically relevant. SIGNIFICANCE STATEMENT: This investigation identified several natural product constituents which inhibit in vitro human recombinant CYP2B6 and CYP2B6-catalyzed N-demethylation of the opioid methadone. The most potent inhibitors (K i) were dihydromethysticin (0.074 µM), gambogic acid (6 µM) and 2,2'-dihydroxychalcone (16 µM). Molecular modeling of ligand interactions with CYP2B6 found that dihydromethysticin and 2,2'-dihydroxychalcone bound at the active site, while gambogic acid interacted with an allosteric site on the CYP2B6 surface. Natural product constituents may inhibit CYP2B6 and methadone metabolism at clinically relevant concentrations.
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Affiliation(s)
- Pan-Fen Wang
- Department of Anesthesiology, Duke University, Durham, North Carolina (P.-F.W., E.D.K.) and Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri (Y.Y., V.P., A.N.)
| | - Yanming Yang
- Department of Anesthesiology, Duke University, Durham, North Carolina (P.-F.W., E.D.K.) and Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri (Y.Y., V.P., A.N.)
| | - Vishal Patel
- Department of Anesthesiology, Duke University, Durham, North Carolina (P.-F.W., E.D.K.) and Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri (Y.Y., V.P., A.N.)
| | - Alicia Neiner
- Department of Anesthesiology, Duke University, Durham, North Carolina (P.-F.W., E.D.K.) and Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri (Y.Y., V.P., A.N.)
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University, Durham, North Carolina (P.-F.W., E.D.K.) and Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri (Y.Y., V.P., A.N.)
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Erstad BL, Glenn MJ. Management of Critically Ill Patients Receiving Medications for Opioid Use Disorder. Chest 2024; 165:356-367. [PMID: 37898187 DOI: 10.1016/j.chest.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 10/30/2023] Open
Abstract
TOPIC IMPORTANCE Critical care clinicians are likely to see an increasing number of patients admitted to the ICU who are receiving US Food and Drug Administration-approved medications for opioid use disorder (MOUDs) given the well-documented benefits of these agents. Oral methadone, multiple formulations of buprenorphine, and extended-release naltrexone are the three types of MOUD most likely to be encountered by ICU clinicians; however, these drugs vary with respect to formulations, pharmacokinetics, and adverse effects. REVIEW FINDINGS No published clinical practice guidelines or consensus statements are available to guide decision-making in patients admitted to the ICU setting who are receiving MOUDs before admission. Additionally, no randomized trials and limited observational studies have evaluated issues related to MOUD use in the ICU. Therefore, ICU clinicians caring for patients admitted who are taking MOUDs must base their decision-making on data extrapolation from pharmacokinetic, pharmacologic, and clinical studies performed in non-ICU settings. SUMMARY Despite the challenges in administering MOUDs in critically ill patients, extrapolation of data from other hospital settings suggests that the benefits of continuing MOUD therapy outweigh the risks in patients able to continue therapy. This article provides guidance for critical care clinicians caring for patients admitted to the ICU already receiving methadone, buprenorphine, or extended-release naltrexone. The guidance includes algorithms to aid clinicians in the clinical decision-making process, recognizing the inherent limitations of the existing evidence on which the algorithms are based and the need to account for patient-specific considerations.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ.
| | - Melody J Glenn
- Departments of Emergency Medicine and Psychiatry, University of Arizona College of Medicine/Banner University Medical Center, Tucson, AZ
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Lance Tippit T, O'Connell MA, Costantino RC, Scott-Richardson M, Peters S, Pakieser J, Tilley LC, Highland KB. Racialized and beneficiary inequities in medication to treat opioid use disorder receipt within the US Military Health System. Drug Alcohol Depend 2023; 253:111025. [PMID: 38006670 DOI: 10.1016/j.drugalcdep.2023.111025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) can be critical to managing opioid use disorder (OUD). It is unknown the extent to which US Military Health System (MHS) patients diagnosed with OUD receive MOUD. METHODS Healthcare records of MHS-enrolled active duty and retired service members (N = 13,334) with a new (index) OUD diagnosis were included between 2018 and 2021, without 90-day pre-index MOUD receipt were included. Elastic net logistic and Cox regressions evaluated care- and system-level factors associated with 1-year MOUD receipt (primary outcome) and time-to-receipt. RESULTS Only 9% of patients received MOUD 1-year post-index; only 4% received MOUD within 14 days. Black patients (OR for receipt 0.38, 95% CI 0.30-0.49), Latinx patients (OR for receipt 0.44, 95% CI 0.33-0.59), and patients whose race and ethnicity was Other (OR for receipt 0.52, 95%CI 0.35, 0.77) experienced lower MOUD access (all p < 0.001). Retirees were more likely to receive MOUD relative to active duty service members (OR for receipt 1.81, 95%CI 1.52, 2.16, p <0.001). CONCLUSIONS Institutional racism in MOUD prescribing, combined with the overall low rates of MOUD receipt after OUD diagnosis, highlight the need for evidence-based, multifaceted, and multilevel approaches to OUD care in the Military Health System. Without clear Defense Health Agency policy, including the designation of responsible entities, transparent and ongoing evaluation and responsiveness using standardized methodology, and resourced programming and public health campaigns, MOUD rates will likely remain poor and inequitable.
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Affiliation(s)
- T Lance Tippit
- School of Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Department of Psychiatry, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Megan A O'Connell
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Enterprise Intelligence & Data Solutions Program Management Office Data Innovation Branch, Defense Health Management Systems, USA; Henry M. Jackson Foundation, Inc., 11300 Rockville Pike Suite 709, Rockville, MD 20852, USA
| | - Ryan C Costantino
- Enterprise Intelligence & Data Solutions Program Management Office Data Innovation Branch, Defense Health Management Systems, USA; Department of Military & Emergency Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | | | - Sidney Peters
- Department of Emergency Medicine, Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA
| | - Jennifer Pakieser
- Department of Emergency Medicine, University of California, Davis School of Medicine, 4150 V Street, PSSB Suite 2100, Sacramento, CA 95817, USA
| | - Laura C Tilley
- Department of Military & Emergency Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Domzaridou E, Carr MJ, Millar T, Webb RT, Ashcroft DM. Non-fatal overdose risk associated with prescribing opioid agonists concurrently with other medication: Cohort study conducted using linked primary care, secondary care and mortality records. Addiction 2023; 118:2374-2383. [PMID: 37536685 DOI: 10.1111/add.16306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/25/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND AIMS An apparently protective effect of opioid agonist treatment (OAT) on all-cause and cause-specific mortality risk has been widely reported. Non-fatal overdose (NFO) often precedes subsequent drug-poisoning deaths. We hypothesized that benzodiazepines, gabapentinoids, antipsychotics, antidepressants, Z-drugs or opioids increase the NFO risk when co-prescribed with OAT. DESIGN We conducted a cohort study using the Clinical Practice Research Datalink GOLD and Aurum databases. The cohort was linked to Hospital Episode Statistics admitted patient care data (HES-APC), neighbourhood- and practice-level Index of Multiple Deprivation quintiles and mortality records from the Office for National Statistics. SETTING Primary care in England. PARTICIPANTS We studied patients with opioid use disorder, aged 18-64 years, who were prescribed OAT (15155 methadone and 5743 buprenorphine recipients) between Jan 1, 1998, and Dec 31, 2017. MEASUREMENTS The main outcome examined was NFO risk during co-prescription of OAT with benzodiazepines, antipsychotics, gabapentinoids, antidepressants, Z-drugs or opioids. Overdose was defined according to International Classification of Diseases codes from the HES-APC data set. Negative binomial regression models were used to estimate weighted rate ratios (wRR) for NFO during co-prescription of OAT and benzodiazepines, antipsychotics, gabapentinoids, antidepressants, Z-drugs or opioids with periods of exclusive OAT usage. FINDINGS Among 20 898 patients observed over 83 856 person-years, we found an elevated overdose risk that resulted in hospital admission during co-prescription of OAT with benzodiazepines [wRR: 1.45; 95% confidence interval (CI) = 1.26-1.67], gabapentinoids (wRR = 2.22; 95% CI = 1.77-2.79), Z-drugs (wRR = 1.60; 95% CI = 1.31-1.96), antipsychotics (wRR = 1.85; 95% CI = 1.53-2.25) and opioids (wRR = 1.28; 95% CI = 1.02-1.60). The risk ratio for antidepressant co-prescriptions was below unity (wRR = 0.90; 95% CI = 0.79-1.02) but this result was not statistically significant. CONCLUSION Elevated risk of non-fatal overdose among opioid agonist treatment recipients is associated with concurrent use of medication prescribed for other reasons.
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Affiliation(s)
- Eleni Domzaridou
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Matthew J Carr
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tim Millar
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Roger T Webb
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Daglish MRC, Reilly SR, Mostafa S, Edwards C, O'Gorman TM, Hayllar JS. Cytochrome P450-2D6 activity in people with codeine use disorder. THE PHARMACOGENOMICS JOURNAL 2023; 23:195-200. [PMID: 37940651 PMCID: PMC10661737 DOI: 10.1038/s41397-023-00319-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 10/22/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
Compound-analgesics containing codeine (CACC) have been a common source of codeine for people seeking opioid replacement therapy (ORT) for codeine use disorder (CUD). Our previous work demonstrated no relationship between pre-treatment CACC and ORT buprenorphine doses; we hypothesised that CYP2D6 activity would partially account for this disconnection. One hundred six participants with CUD were compared to a published population sample of 5408 Australian patients. Mean age of participants with CUD at treatment entry was 35 years, with mean 6.1 years duration of CUD. Mean codeine dose was 660 mg/day (range 40-2700 mg). Mean calculated CYP2D6 activity scores were significantly higher in the codeine group (CUD 1.65 + 0.63 vs. Gen pop 1.39 + 0.65, Wilcoxon W = 347,001, p < 0.001). Pre-treatment CACC dose weakly predicted sublingual buprenorphine doses overall; there was a stronger relationship within ultrarapid metabolisers. While normal and ultrarapid metabolisers of codeine were more likely to have a diagnosis of CUD, poor or intermediate CYP2D6 metaboliser status may protect against CUD.
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Affiliation(s)
- Mark R C Daglish
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, QLD, Australia.
- Hospital Alcohol & Drug Service, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, QLD, Australia.
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Sarah R Reilly
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, QLD, Australia
| | - Sam Mostafa
- myDNA Life, Australia Ltd, South Yarra, VIC, Australia
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Cameron Edwards
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, QLD, Australia
| | - Thomas M O'Gorman
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, QLD, Australia
| | - Jeremy S Hayllar
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, QLD, Australia
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