1
|
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).
Collapse
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
| |
Collapse
|
2
|
Wang XM, Wang J, Fokina V, Patrikeeva S, Rytting E, Ahmed MS, La JH, Nanovskaya T. Effect of deuteration on the single dose pharmacokinetic properties and postoperative analgesic activity of methadone. Drug Metab Pharmacokinet 2022; 47:100477. [PMID: 36368298 PMCID: PMC9886271 DOI: 10.1016/j.dmpk.2022.100477] [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: 06/29/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 02/01/2023]
Abstract
Although methadone is effective in the management of acute pain, the complexity of its absorption-distribution-metabolism-excretion profile limits its use as an opioid of choice for perioperative analgesia. Because deuteration is known to improve the pharmacokinetic, pharmacodynamic and toxicological properties of some drugs, here we characterized the single dose pharmacokinetic properties and post-operative analgesic efficacy of d9-methadone. The pharmacokinetic profiles of d9-methadone and methadone administered intravenously to CD-1 male mice revealed that deuteration leads to a 5.7- and 4.4-fold increase in the area under the time-concentration curve and maximum concentration in plasma, respectively, as well as reduction in clearance (0.9 ± 0.3 L/h/kg vs 4.7 ± 0.8 L/h/kg). The lower brain-to-plasma ratio of d9-methadone compared to that of methadone (0.35 ± 0.12 vs 2.05 ± 0.62) suggested that deuteration decreases the transfer of the drug across the blood-brain barrier. The estimated LD50 value for a single intravenous dose of d9-methadone was 2.1-fold higher than that for methadone. Moreover, d9-methadone outperformed methadone in the efficacy against postoperative pain by primarily activating peripheral opioid receptors. Collectively, these data suggest that the replacement of three hydrogen atoms in three methyl groups of methadone altered its pharmacokinetic properties, improved safety, and enhanced its analgesic efficacy.
Collapse
Affiliation(s)
- Xiao-Ming Wang
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Jigong Wang
- Department of Neuroscience, Cell Biology and Anatomy, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Valentina Fokina
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Svetlana Patrikeeva
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Erik Rytting
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Mahmoud S Ahmed
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Jun-Ho La
- Department of Neuroscience, Cell Biology and Anatomy, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Tatiana Nanovskaya
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA.
| |
Collapse
|
3
|
Wang PF, Sharma A, Montana M, Neiner A, Juriga L, Reddy KN, Tallchief D, Blood J, Kharasch ED. Methadone pharmacogenetics in vitro and in vivo: Metabolism by CYP2B6 polymorphic variants and genetic variability in paediatric disposition. Br J Clin Pharmacol 2022; 88:4881-4893. [PMID: 35538637 PMCID: PMC10908252 DOI: 10.1111/bcp.15393] [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: 01/06/2022] [Revised: 04/06/2022] [Accepted: 04/22/2022] [Indexed: 11/02/2022] Open
Abstract
AIMS Methadone metabolism and clearance are determined principally by polymorphic cytochrome P4502B6 (CYP2B6). Some CYP2B6 allelic variants affect methadone metabolism in vitro and disposition in vivo. We assessed methadone metabolism by CYP2B6 minor variants in vitro. We also assessed the influence of CYP2B6 variants, and P450 oxidoreductase (POR) and CYP2C19 variants, on methadone clearance in surgical patients in vivo. METHODS CYP2B6 and P450 oxidoreductase variants were coexpressed with cytochrome b5 . The metabolism of methadone racemate and enantiomers was measured at therapeutic concentrations and intrinsic clearances were determined. Adolescents receiving methadone for surgery were genotyped for CYP2B6, CYP2C19 and POR, and methadone clearance and metabolite formation clearance were determined. RESULTS In vitro, CYP2B6.4 was more active than wild-type CYP2B6.1. CYPs 2B6.5, 2B6.6, 2B6.7, 2B6.9, 2B6.17, 2B6.19 and 2B6.26 were less active. CYPs 2B6.16 and 2B6.18 were inactive. CYP2B6.1 expressed with POR variants POR.28, POR.5 and P228L had lower rates of methadone metabolism than wild-type reductase. In vivo, methadone clinical clearance decreased linearly with the number of CYP2B6 slow metabolizer alleles, but was not different in CYP2C19 slow or rapid metabolizer phenotypes, or in carriers of the POR*28 allele. CONCLUSIONS Several CYP2B6 and POR variants were slow metabolizers of methadone in vitro. Polymorphisms in CYP2B6, but not CYP2C19 or P450 reductase, affected methadone clearance in vivo. CYP2B6 polymorphisms 516G>T and 983T>C code for canonical loss of function variants and should be assessed when considering genetic influences on clinical methadone disposition. These complementary translational in vitro and in vivo results inform on pharmacogenetic variability affecting methadone disposition in patients.
Collapse
Affiliation(s)
- Pan-Fen Wang
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Anshuman Sharma
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Michael Montana
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Alicia Neiner
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Kavya Narayana Reddy
- Department of Pediatric Anesthesiology, Arkansas Children's Hospital, Little Rock, AK, USA
| | - Dani Tallchief
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jane Blood
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University, Durham, NC, USA
| |
Collapse
|
4
|
Barry JM, Birnbaum AK, Jasin LR, Sherwin CM. Maternal Exposure and Neonatal Effects of Drugs of Abuse. J Clin Pharmacol 2021; 61 Suppl 2:S142-S155. [PMID: 34396555 DOI: 10.1002/jcph.1928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/17/2021] [Indexed: 11/08/2022]
Abstract
The public health crisis of pregnant women being exposed to drugs of abuse and of its impact on their unborn children continues to grow at an alarming rate globally. The state of pregnancy is unique, with physiological changes that can lead to changes in the way drugs are handled by the body in both pharmacokinetics and response. These changes place the pregnant woman, fetus, and newborn infant at risk, as many of these drugs can cross the placenta and into breast milk. The substances most commonly linked to harmful effects include alcohol, tobacco, cannabis, stimulants, and opioids. The pharmacological and toxicological changes caused by in utero exposure or breastfeeding exposure are difficult to study, and the full extent of the mechanisms involved are not fully understood. However, these changes can significantly affect the risks of substance abuse and influence optimal treatment of pregnant women with a substance use disorder. In addition, newborns who were exposed to drugs of abuse in utero can experience withdrawal syndromes. Pharmacological management in infants is used to guide and treat withdrawal symptoms, with the goal being to improve the infant's sleep, eating, and comfort. Several barriers may prevent pregnant women from seeking help for substance use, including stigma and interactions with the legal system. Understanding changes in pharmacology, including pharmacokinetic changes that happen during pregnancy, is essential for anticipating the extent of maternal exposure and neonatal adverse effects.
Collapse
Affiliation(s)
- Jessica M Barry
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minnesota, Minneapolis, USA
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minnesota, Minneapolis, USA
| | - Lisa R Jasin
- Neonatal Intensive Care Unit, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherine M Sherwin
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minnesota, Minneapolis, USA.,Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| |
Collapse
|
5
|
Langmia IM, Just KS, Yamoune S, Brockmöller J, Masimirembwa C, Stingl JC. CYP2B6 Functional Variability in Drug Metabolism and Exposure Across Populations-Implication for Drug Safety, Dosing, and Individualized Therapy. Front Genet 2021; 12:692234. [PMID: 34322158 PMCID: PMC8313315 DOI: 10.3389/fgene.2021.692234] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022] Open
Abstract
Adverse drug reactions (ADRs) are one of the major causes of morbidity and mortality worldwide. It is well-known that individual genetic make-up is one of the causative factors of ADRs. Approximately 14 million single nucleotide polymorphisms (SNPs) are distributed throughout the entire human genome and every patient has a distinct genetic make-up which influences their response to drug therapy. Cytochrome P450 2B6 (CYP2B6) is involved in the metabolism of antiretroviral, antimalarial, anticancer, and antidepressant drugs. These drug classes are commonly in use worldwide and face specific population variability in side effects and dosing. Parts of this variability may be caused by single nucleotide polymorphisms (SNPs) in the CYP2B6 gene that are associated with altered protein expression and catalytic function. Population variability in the CYP2B6 gene leads to changes in drug metabolism which may result in adverse drug reactions or therapeutic failure. So far more than 30 non-synonymous variants in CYP2B6 gene have been reported. The occurrence of these variants show intra and interpopulation variability, thus affecting drug efficacy at individual and population level. Differences in disease conditions and affordability of drug therapy further explain why some individuals or populations are more exposed to CYP2B6 pharmacogenomics associated ADRs than others. Variabilities in drug efficacy associated with the pharmacogenomics of CYP2B6 have been reported in various populations. The aim of this review is to highlight reports from various ethnicities that emphasize on the relationship between CYP2B6 pharmacogenomics variability and the occurrence of adverse drug reactions. In vitro and in vivo studies evaluating the catalytic activity of CYP2B6 variants using various substrates will also be discussed. While implementation of pharmacogenomic testing for personalized drug therapy has made big progress, less data on pharmacogenetics of drug safety has been gained in terms of CYP2B6 substrates. Therefore, reviewing the existing evidence on population variability in CYP2B6 and ADR risk profiles suggests that, in addition to other factors, the knowledge on pharmacogenomics of CYP2B6 in patient treatment may be useful for the development of personalized medicine with regards to genotype-based prescription.
Collapse
Affiliation(s)
- Immaculate M. Langmia
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Katja S. Just
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Sabrina Yamoune
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Collen Masimirembwa
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| |
Collapse
|
6
|
Tang F, Ng CM, Bada HS, Leggas M. Clinical pharmacology and dosing regimen optimization of neonatal opioid withdrawal syndrome treatments. Clin Transl Sci 2021; 14:1231-1249. [PMID: 33650314 PMCID: PMC8301571 DOI: 10.1111/cts.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022] Open
Abstract
In this paper, we review the management of neonatal opioid withdrawal syndrome (NOWS) and clinical pharmacology of primary treatment agents in NOWS, including morphine, methadone, buprenorphine, clonidine, and phenobarbital. Pharmacologic treatment strategies in NOWS have been mostly empirical, and heterogeneity in dosing regimens adds to the difficulty of extrapolating study results to broader patient populations. As population pharmacokinetics (PKs) of pharmacologic agents in NOWS become more well‐defined and knowledge of patient‐specific factors affecting treatment outcomes continue to accumulate, PK/pharmacodynamic modeling and simulation will be powerful tools to aid the design of optimal dosing regimens at the patient level. Although there is an increasing number of clinical trials on the comparative efficacy of treatment agents in NOWS, here, we also draw attention to the importance of optimizing the dosing regimen, which can be arguably equally important at identifying the optimal treatment agent.
Collapse
Affiliation(s)
- Fei Tang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Chee M Ng
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA.,NewGround Pharmaceutical Consulting LLC, Foster City, California, USA
| | - Henrietta S Bada
- Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Markos Leggas
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| |
Collapse
|
7
|
Abstract
Methadone is increasingly being used for its analgesic properties. Despite the increasing popularity, many healthcare providers are not familiar with methadone's complex pharmacology and best practices surrounding its use. The purpose of this narrative review article is to discuss the pharmacology of methadone, the evidence surrounding methadone's use in acute pain management and both chronic cancer and non-cancer pain settings, as well as highlight pertinent safety, monitoring, and opioid rotation considerations. Methadone has a unique mechanism of action when compared with all other opioids and for this reason methadone has come to hold a niche role in the management of opioid-induced hyperalgesia and central sensitization. Understanding of the mechanisms of variability in methadone disposition and drug interactions has evolved over the years, with the latest evidence revealing that CYP 2B6 is the major determinant of methadone elimination and plays a key role in methadone-related drug interactions. From an acute pain perspective, most studies evaluating the use of intraoperative intravenous methadone have reported lower pain scores and post-operative opioid requirements. Oral methadone is predominantly used as a second-line opioid treatment for select chronic pain conditions. As a result, several oral morphine to oral methadone conversion ratios have been proposed, as have methods in which to rotate to methadone. From an efficacy standpoint, limited literature exists regarding the effectiveness of methadone in the chronic pain setting with most of the available efficacy data pertaining to methadone's use in the treatment of cancer pain. Many of the prospective studies that exist feature low participant numbers. Few clinical trials investigating the role of methadone as an analgesic treatment are currently underway. The complicated pharmacokinetic properties of methadone and risks of harm associated with this drug highlight how critically important it is that healthcare providers understand these features before prescribing/dispensing methadone. Particular caution is required when converting patients from other opioids to methadone and for this reason only experienced healthcare providers should undertake such a task. Further randomized trials with larger sample sizes are needed to better define the effective and safe use of methadone for pain management.
Collapse
Affiliation(s)
- Denise Kreutzwiser
- Pain Management Program, St. Joseph's Hospital, St. Joseph's Health Care London, London, ON, Canada.
| | - Qutaiba A Tawfic
- Department of Anesthesia and Perioperative Medicine, Western University, London Health Sciences Centre, and St. Joseph's Health Care London, London, ON, Canada
| |
Collapse
|
8
|
Talal AH, Ding Y, Venuto CS, Chakan LM, McLeod A, Dharia A, Morse GD, Brown LS, Markatou M, Kharasch ED. Toward precision prescribing for methadone: Determinants of methadone deposition. PLoS One 2020; 15:e0231467. [PMID: 32302325 PMCID: PMC7164646 DOI: 10.1371/journal.pone.0231467] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/24/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite the World Health Organization listing methadone as an essential medication, effective dose selection is challenging, especially in racial and ethnic minority populations. Subtherapeutic doses can result in withdrawal symptoms while supratherapeutic doses can result in overdose and death. Although CYP3A4 was conventionally considered the principal methadone metabolizing enzyme, more recent data have identified CYP2B6 as the principal enzyme. CYP2B6 has ethnically-associated polymorphisms that affect the metabolic rate. Our objective was to investigate the effects of genetic and nongenetic factors on methadone metabolism. METHODS We measured trough plasma methadone levels in 100 participants with opioid use disorder. We assessed methadone metabolism by calculating the metabolite ratio (major metabolite: 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine [EDDP] divided by methadone concentration). We assessed hepatic fibrosis and steatosis by transient elastography and CYP2B6 alleles, principally responsible for methadone metabolism. Mixed effects models modeled the data in 97 participants. RESULTS Participants were largely male (58%), minority (61% African American) and non-Hispanic (68%). Forty percent were HCV mono-infected, 40% were uninfected, and 20% were HCV/HIV co-infected. Female sex had significant effects on (R)- and (S)-methadone metabolism (p = 0.016 and p = 0.044, respectively). CYP2B6 loss of function (LOF) alleles significantly affected (S)-methadone metabolism (p = 0.012). Body mass index (BMI) significantly affected (R)-methadone metabolism (p = 0.034). Methadone metabolism appeared to be lower in males, in individuals with LOF alleles, and elevated BMI. CONCLUSIONS Genetic analysis, especially in minority populations, is essential to delivering individualized treatments. Although the principal methadone metabolizing enzyme remains controversial, our results suggest that sex, CYP2B6 genotype, and BMI should be incorporated into multivariate models to create methadone dosing algorithms. Methadone dosing algorithms should facilitate medication delivery, improve patient satisfaction, and diminish overdose potential.
Collapse
Affiliation(s)
- Andrew H. Talal
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Yuxin Ding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Charles S. Venuto
- Department of Neurology, University of Rochester, Rochester, NY, United States of America
| | - Lindsay M. Chakan
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Anthony McLeod
- START Treatment & Recovery Centers, Brooklyn, NY, United States of America
| | - Arpan Dharia
- Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Gene D. Morse
- NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Lawrence S. Brown
- START Treatment & Recovery Centers, Brooklyn, NY, United States of America
| | - Marianthi Markatou
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Evan D. Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States of America
| |
Collapse
|
9
|
Wolfe RC. Intraoperative Methadone: New Use for an Old Drug. J Perianesth Nurs 2020; 35:219-221. [PMID: 32247434 DOI: 10.1016/j.jopan.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Rachel C Wolfe
- Pharmacy Department, Barnes-Jewish Hospital, St. Louis, MO.
| |
Collapse
|
10
|
Ing Lorenzini K, Girardin F. Direct-acting antiviral interactions with opioids, alcohol or illicit drugs of abuse in HCV-infected patients. Liver Int 2020; 40:32-44. [PMID: 31654604 DOI: 10.1111/liv.14283] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/17/2019] [Accepted: 10/15/2019] [Indexed: 02/13/2023]
Abstract
The hepatitis C virus (HCV) prevalence is extremely high in patients who consume and inject illicit drugs. Concerns about poor adherence and fear of interaction with drugs of abuse could constitute further disincentive for treatment initiation in these patients. We discussed the pharmacokinetics (PKs) and pharmacodynamics (PD) of currently prescribed direct antiviral agents (NSA5 inhibitors: daclatasvir, elbasvir, ledipasvir, pibrentasvir, velpatasvir; NS5B inhibitor: sofosbuvir; NS3/4A protease inhibitors: glecaprevir, grazoprevir, voxilaprevir) and most common substances of abuse (opioids: buprenorphine, fentanyl, heroin, methadone, morphine, oxycodone; stimulants: amphetamines, cathinones, cocaine; cannabinoids; ethanol). Overall, most direct-acting antivirals (DAAs) are substrates and inhibitors of the transmembrane transporter P-glycoprotein (P-gp), and several of them are metabolized by cytochrome P450 enzymes. Clinically relevant interactions are associated with P-gp and CYP3A modulators. Most substances of abuse are eliminated by Phase I and Phase II metabolizing enzymes, but none of them are either major inhibitors or inducers. PK studies did not show any relevant interactions between DAA and methadone or buprenorphine. Based on pharmacological considerations, neither efficacy loss nor adverse drug event associated with detrimental interaction are expected with opioids, stimulants, cannabinoids and ethanol. In summary, our literature review shows that the interaction potential of DAA with most opioids and illicit drugs is limited and should not be a hurdle to the initiate DAA.
Collapse
Affiliation(s)
- Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - François Girardin
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| |
Collapse
|
11
|
McPhail BT, Emoto C, Fukuda T, Butler D, Wiles JR, Akinbi H, Vinks AA. Utilizing Pediatric Physiologically Based Pharmacokinetic Models to Examine Factors That Contribute to Methadone Pharmacokinetic Variability in Neonatal Abstinence Syndrome Patients. J Clin Pharmacol 2019; 60:453-465. [PMID: 31820437 DOI: 10.1002/jcph.1538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/09/2019] [Indexed: 12/30/2022]
Abstract
Chronic intrauterine exposure to psychoactive drugs often results in neonatal abstinence syndrome (NAS). NAS is the symptomatic drug withdrawal in newborns that generally occurs after in utero chronic opioid exposure. Methadone is an opioid analgesic commonly prescribed for pharmacologic management of NAS. It exhibits high pharmacokinetic (PK) variability. The current study used physiologically based PK modeling to predict the PK profile of methadone in 20 newborns treated for NAS. The physiologically based PK simulations adequately predicted the PK profile of the clinical data for 45% of the patients. Sensitivity analyses were conducted to explore contributing factors to methadone PK variability. The data suggest that P450 enzymatic activity impacts the clearance of methadone in virtual adults and neonates, while the contribution of cardiac output may be negligible. Understanding maturational and/or pharmacogenetic changes in cytochrome P450 enzymatic activity may further explain the large PK variability of methadone in newborns with NAS and will help individualized treatment.
Collapse
Affiliation(s)
- Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Henry Akinbi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Perinatal Institute, Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|