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Physiologically-Based Pharmacokinetic (PBPK) Modeling of Buprenorphine in Adults, Children and Preterm Neonates. Pharmaceutics 2020; 12:pharmaceutics12060578. [PMID: 32585880 PMCID: PMC7355427 DOI: 10.3390/pharmaceutics12060578] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/15/2022] Open
Abstract
Buprenorphine plays a crucial role in the therapeutic management of pain in adults, adolescents and pediatric subpopulations. However, only few pharmacokinetic studies of buprenorphine in children, particularly neonates, are available as conducting clinical trials in this population is especially challenging. Physiologically-based pharmacokinetic (PBPK) modeling allows the prediction of drug exposure in pediatrics based on age-related physiological differences. The aim of this study was to predict the pharmacokinetics of buprenorphine in pediatrics with PBPK modeling. Moreover, the drug-drug interaction (DDI) potential of buprenorphine with CYP3A4 and P-glycoprotein perpetrator drugs should be elucidated. A PBPK model of buprenorphine and norbuprenorphine in adults has been developed and scaled to children and preterm neonates, accounting for age-related changes. One-hundred-percent of the predicted AUClast values in adults (geometric mean fold error (GMFE): 1.22), 90% of individual AUClast predictions in children (GMFE: 1.54) and 75% in preterm neonates (GMFE: 1.57) met the 2-fold acceptance criterion. Moreover, the adult model was used to simulate DDI scenarios with clarithromycin, itraconazole and rifampicin. We demonstrate the applicability of scaling adult PBPK models to pediatrics for the prediction of individual plasma profiles. The novel PBPK models could be helpful to further investigate buprenorphine pharmacokinetics in various populations, particularly pediatric subgroups.
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Fihlman M, Hemmilä T, Hagelberg NM, Backman JT, Laitila J, Laine K, Neuvonen PJ, Olkkola KT, Saari TI. Voriconazole greatly increases the exposure to oral buprenorphine. Eur J Clin Pharmacol 2018; 74:1615-1622. [PMID: 30167757 DOI: 10.1007/s00228-018-2548-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/22/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Buprenorphine has low oral bioavailability. Regardless of sublingual administration, a notable part of buprenorphine is exposed to extensive first-pass metabolism by the cytochrome P450 (CYP) 3A4. As drug interaction studies with buprenorphine are limited, we wanted to investigate the effect of voriconazole, a strong CYP3A4 inhibitor, on the pharmacokinetics and pharmacodynamics of oral buprenorphine. METHODS Twelve healthy volunteers were given either placebo or voriconazole (orally, 400 mg twice on day 1 and 200 mg twice on days 2-5) for 5 days in a randomized, cross-over study. On day 5, they ingested 0.2 mg (3.6 mg during placebo phase) oral buprenorphine. We measured plasma and urine concentrations of buprenorphine and norbuprenorphine and monitored their pharmacological effects. Pharmacokinetic parameters were normalized for a buprenorphine dose of 1.0 mg. RESULTS Voriconazole greatly increased the mean area under the plasma concentration-time curve (AUC0-18) of buprenorphine (4.3-fold, P < 0.001), its peak concentration (Cmax) (3.9-fold), half-life (P < 0.05), and excretion into urine (Ae; P < 0.001). Voriconazole also markedly enhanced the Cmax (P < 0.001), AUC0-18 (P < 0.001), and Ae (P < 0.05) of unconjugated norbuprenorphine but decreased its renal clearance (P < 0.001). Mild dizziness and nausea occurred during both study phases. CONCLUSIONS Voriconazole greatly increases exposure to oral buprenorphine, mainly by inhibiting intestinal and liver CYP3A4. Effect on some transporters may explain elevated norbuprenorphine concentrations. Although oral buprenorphine is not commonly used, this interaction may become relevant in patients receiving sublingual buprenorphine together with voriconazole or other CYP3A4 or transporter inhibitors.
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Affiliation(s)
- Mari Fihlman
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland.,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Tuija Hemmilä
- Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Nora M Hagelberg
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland.,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Laitila
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kari Laine
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.,Medbase Ltd., Turku, Finland
| | - Pertti J Neuvonen
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland. .,Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland.
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Davis MP, Pasternak G, Behm B. Treating Chronic Pain: An Overview of Clinical Studies Centered on the Buprenorphine Option. Drugs 2018; 78:1211-1228. [PMID: 30051169 PMCID: PMC6822392 DOI: 10.1007/s40265-018-0953-z] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The buprenorphine receptor binding profile is unique in that it binds to all three major opioid receptors (mu, kappa, delta), and also binds to the orphan-like receptor, the receptor for orphanin FQ/nociceptin, with lower affinity. Within the mu receptor group, buprenorphine analgesia in rodents is dependent on the recently discovered arylepoxamide receptor target in brain, which involves a truncated 6-transmembrane mu receptor gene protein, distinguishing itself from morphine and most other mu opioids. Although originally designed as an analgesic, buprenorphine has mainly been used for opioid maintenance therapy and only now is increasingly recognized as an effective analgesic with an improved therapeutic index relative to certain potent opioids. Albeit a second-, third-, or fourth-line analgesic, buprenorphine is a reasonable choice in certain clinical situations. Transdermal patches and buccal film formulations are now commercially available as analgesics. This review discusses buprenorphine pharmacodynamics and pharmacokinetics, use in certain populations, and provides a synopsis of systematic reviews and randomized analgesic trials. We briefly discuss postoperative management in patients receiving buprenorphine maintenance therapy, opioid equivalence to buprenorphine, rotations to buprenorphine from other opioids, and clinical relevance of buprenorphine-related QTc interval changes.
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Affiliation(s)
- Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, PA, USA.
| | - Gavril Pasternak
- Anne Burnett Tandy Chair in Neurology, Laboratory Head, Molecular Pharmacology and Chemistry Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bertrand Behm
- Department of Palliative Care, Geisinger Medical Center, Danville, PA, USA
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Feng XQ, Zhu LL, Zhou Q. Opioid analgesics-related pharmacokinetic drug interactions: from the perspectives of evidence based on randomized controlled trials and clinical risk management. J Pain Res 2017; 10:1225-1239. [PMID: 28579821 PMCID: PMC5449157 DOI: 10.2147/jpr.s138698] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Multimorbidity results in complex polypharmacy which may bear a risk of drug interactions. A better understanding of opioid analgesics combination therapy used for pain management could help warrant medication safety, efficacy, and economic relevance. Until now there has been no review summarizing the opioid analgesics-related pharmacokinetic drug interactions from the perspective of evidence based on randomized controlled trials (RCTs). METHOD A literature search was performed using PubMed, MEDLINE, and the Cochrane Library, using a PRISMA flowchart. RESULTS Fifty-two RCTs were included for data interpretation. Forty-two RCTs (80.8%) were conducted in healthy volunteers, whereas 10 RCTs (19.2%) enrolled true patients. None of the opioid-drug/herb pairs was listed as contraindications of opioids involved in this review. Circumstances in which opioid is comedicated as a precipitant drug include morphine-P2Y12 inhibitors, morphine-gabapentin, and methadone-zidovudine. Circumstances in which opioid is comedicated as an object drug include rifampin-opioids (morphine, tramadol, oxycodone, methadone), quinidine-opioids (morphine, fentanyl, oxycodone, codeine, dihydrocodeine, methadone), antimycotics-opioids (buprenorphine, fentanyl, morphine, oxycodone, methadone, tilidine, tramadol), protease inhibitors-opioids (ritonavir, ritonavir/lopinavir-oxycodone, ritonavir-fentanyl, ritonavir-tilidine), grapefruit juice-opioids (oxycodone, fentanyl, methadone), antidepressants-opioids (paroxetine-tramadol, paroxetine-hydrocodone, paroxetine-oxycodone, escitalopram-tramadol), metoclopramide-morphine, amantadine-morphine, sumatriptan-butorphanol nasal sprays, ticlopidine-tramadol, St John's wort-oxycodone, macrolides/ketolides-oxycodone, and levomepromazine-codeine. RCTs investigating the same combination, almost unanimously, drew consistent conclusions, except two RCTs on amantadine-intravenous morphine combination where a different amantadine dose was used and two RCTs on morphine-ticagrelor combination where healthy volunteers and true patients were enrolled, respectively. RCTs investigating in true patients may reflect a realistic clinical scenario and overcome the limitation of RCTs performed in healthy volunteers under standardized conditions. Further research opportunities are also presented in this review. CONCLUSION Effective and safe combination therapy of opioids can be achieved by promoting the awareness of potential changes in therapeutic efficacy and toxicities, prescribing alternatives or changing administration strategy, tailoring dose, reviewing the appropriateness of orders, and paying attention to medication monitoring.
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Affiliation(s)
- Xiu-Qin Feng
- Nursing Administration Office, Division of Nursing
| | | | - Quan Zhou
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Hagelberg NM, Fihlman M, Hemmilä T, Backman JT, Laitila J, Neuvonen PJ, Laine K, Olkkola KT, Saari TI. Rifampicin decreases exposure to sublingual buprenorphine in healthy subjects. Pharmacol Res Perspect 2016; 4:e00271. [PMID: 28097004 PMCID: PMC5226287 DOI: 10.1002/prp2.271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/30/2016] [Indexed: 01/03/2023] Open
Abstract
Buprenorphine is mainly metabolized by the cytochrome P450 (CYP) 3A4 enzyme. The aim of this study was to evaluate the role of first‐pass metabolism in the interaction of rifampicin and analgesic doses of buprenorphine. A four‐session paired cross‐over study design was used. Twelve subjects ingested either 600 mg oral rifampicin or placebo once daily in a randomized order for 7 days. In the first part of the study, subjects were given 0.6‐mg (placebo phase) or 0.8‐mg (rifampicin phase) buprenorphine sublingually on day 7. In the second part of the study, subjects received 0.4‐mg buprenorphine intravenously. Plasma concentrations of buprenorphine and urine concentrations of buprenorphine and its primary metabolite norbuprenorphine were measured over 18 h. Adverse effects were recorded. Rifampicin decreased the mean area under the dose‐corrected plasma concentration–time curve (AUC0–18) of sublingual buprenorphine by 25% (geometric mean ratio (GMR): 0.75; 90% confidence interval (CI) of GMR: 0.60, 0.93) and tended to decrease the bioavailability of sublingual buprenorphine, from 22% to 16% (P = 0.31). Plasma concentrations of intravenously administered buprenorphine were not influenced by rifampicin. The amount of norbuprenorphine excreted in the urine was decreased by 65% (P < 0.001) and 52% (P < 0.001) after sublingual and intravenous administration, respectively, by rifampicin. Adverse effects were frequent. Rifampicin decreases the exposure to sublingual but not intravenous buprenorphine. This can be mainly explained by an enhancement of CYP3A‐mediated first‐pass metabolism, which sublingual buprenorphine only partially bypasses. Concomitant use of rifampicin and low‐dose sublingual buprenorphine may compromise the analgesic effect of buprenorphine.
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Affiliation(s)
- Nora M Hagelberg
- Department of Anaesthesiology, Intensive Care and Pain Medicine University of Turku and Turku University Hospital Turku Finland
| | - Mari Fihlman
- Department of Anaesthesiology, Intensive Care and Pain Medicine University of Turku and Turku University Hospital Turku Finland
| | - Tuija Hemmilä
- Department of Anaesthesiology, Intensive Care and Pain Medicine University of Turku and Turku University Hospital Turku Finland
| | - Janne T Backman
- Department of Clinical Pharmacology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Jouko Laitila
- Department of Clinical Pharmacology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Pertti J Neuvonen
- Department of Clinical Pharmacology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kari Laine
- Department of Pharmacology Drug Development and Therapeutics University of Turku Turku Finland; Medbase Ltd Turku Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Teijo I Saari
- Department of Anaesthesiology, Intensive Care and Pain Medicine University of Turku and Turku University Hospital Turku Finland
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Rolke R, Rolke S, Hiddemann S, Mücke M, Cuhls H, Radbruch L, Elsner F, Peuckmann-Post V. [Update palliative pain therapy]. Internist (Berl) 2016; 57:959-970. [PMID: 27631529 DOI: 10.1007/s00108-016-0126-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cancer pain and pain associated with non-neoplastic diseases can be associated with pain mechanisms, such as a peripheral or central sensitization or deafferentation. The clarification allows indirect conclusions about the underlying mechanisms based on clinical signs, such as allodynia or hyperalgesia. Non-opioid analgesics are the basis of cancer pain therapy according to the World Health Organization (WHO) pain ladder. In the case of severe cancer pain, treatment can be escalated directly from level 1 to level 3. Opioids are highly effective for the treatment of cancer pain even with a neuropathic component, which can occur in up to 40 % of cases as amixed pain syndrome. Coanalgesics represent a valuable therapeutic adjunct for better pain control and can address treatment of comorbidities, such as anxiety, depression and sleep disorders. When liver and/or renal function is reduced, the dosage of many drugs has to be adapted. Treatment of multimorbid or critically ill patients with opioids and antidepressants/anticonvulsants requires consideration of numerous possible pharmacodynamic and pharmacokinetic interactions.
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Affiliation(s)
- R Rolke
- Klinik für Palliativmedizin, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - S Rolke
- Klinik für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum RWTH Aachen, Aachen, Deutschland
| | - S Hiddemann
- Klinik für Palliativmedizin, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - M Mücke
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Deutschland.,Institut für Hausarztmedizin, Medizinische Fakultät, Universität Bonn, Bonn, Deutschland.,Zentrum für Seltene Erkrankungen Bonn (ZSEB), Universitätsklinikum Bonn, Bonn, Deutschland
| | - H Cuhls
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
| | - L Radbruch
- Klinik für Palliativmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
| | - F Elsner
- Klinik für Palliativmedizin, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - V Peuckmann-Post
- Klinik für Palliativmedizin, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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Fihlman M, Hemmilä T, Hagelberg NM, Kuusniemi K, Backman JT, Laitila J, Laine K, Neuvonen PJ, Olkkola KT, Saari TI. Voriconazole more likely than posaconazole increases plasma exposure to sublingual buprenorphine causing a risk of a clinically important interaction. Eur J Clin Pharmacol 2016; 72:1363-1371. [PMID: 27510521 DOI: 10.1007/s00228-016-2109-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/26/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE This study aimed to determine possible effects of voriconazole and posaconazole on the pharmacokinetics and pharmacological effects of sublingual buprenorphine. METHODS We used a randomized, placebo-controlled crossover study design with 12 healthy male volunteers. Subjects were given a dose of 0.4 mg (0.6 mg during placebo phase) sublingual buprenorphine after a 5-day oral pretreatment with either (i) placebo, (ii) voriconazole 400 mg twice daily on the first day and 200 mg twice daily thereafter or (iii) posaconazole 400 mg twice daily. Plasma and urine concentrations of buprenorphine and its primary active metabolite norbuprenorphine were monitored over 18 h and pharmacological effects were measured. RESULTS Compared to placebo, voriconazole increased the mean area under the plasma concentration-time curve (AUC0-∞) of buprenorphine 1.80-fold (90 % confidence interval 1.45-2.24; P < 0.001), its peak concentration (Cmax) 1.37-fold (P < 0.013) and half-life (t ½ ) 1.37-fold (P < 0.001). Posaconazole increased the AUC00-∞ of buprenorphine 1.25-fold (P < 0.001). Most of the plasma norbuprenorphine concentrations were below the limit of quantification (0.05 ng/ml). Voriconazole, unlike posaconazole, increased the urinary excretion of norbuprenorphine 1.58-fold (90 % confidence interval 1.18-2.12; P < 0.001) but there was no quantifiable parent buprenorphine in urine. Plasma buprenorphine concentrations correlated with the pharmacological effects, but the effects did not differ significantly between the phases. CONCLUSIONS Voriconazole, and to a minor extent posaconazole, increase plasma exposure to sublingual buprenorphine, probably via inhibition of cytochrome P450 3 A and/or P-glycoprotein. Care should be exercised in the combined use of buprenorphine with triazole antimycotics, particularly with voriconazole, because their interaction can be of clinical importance.
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Affiliation(s)
- Mari Fihlman
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20521, Turku, Finland.,Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, 20521, Turku, Finland
| | - Tuija Hemmilä
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, 20521, Turku, Finland
| | - Nora M Hagelberg
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20521, Turku, Finland.,Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, 20521, Turku, Finland
| | - Kristiina Kuusniemi
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20521, Turku, Finland.,Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, 20521, Turku, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki and HUSLAB, Helsinki University Central Hospital, 00014, Helsinki, Finland
| | - Jouko Laitila
- Department of Clinical Pharmacology, University of Helsinki and HUSLAB, Helsinki University Central Hospital, 00014, Helsinki, Finland
| | - Kari Laine
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, 20100, Turku, Finland.,Medbase Ltd, FI-20100, Turku, Finland
| | - Pertti J Neuvonen
- Department of Clinical Pharmacology, University of Helsinki and HUSLAB, Helsinki University Central Hospital, 00014, Helsinki, Finland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, 00014, Helsinki, Finland
| | - Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20521, Turku, Finland. .,Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, 20521, Turku, Finland.
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Kotlinska-Lemieszek A, Klepstad P, Haugen DF. Clinically significant drug-drug interactions involving opioid analgesics used for pain treatment in patients with cancer: a systematic review. Drug Des Devel Ther 2015; 9:5255-67. [PMID: 26396499 PMCID: PMC4577251 DOI: 10.2147/dddt.s86983] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Opioids are the most frequently used drugs to treat pain in cancer patients. In some patients, however, opioids can cause adverse effects and drug-drug interactions. No advice concerning the combination of opioids and other drugs is given in the current European guidelines. OBJECTIVE To identify studies that report clinically significant drug-drug interactions involving opioids used for pain treatment in adult cancer patients. DESIGN AND DATA SOURCES Systematic review with searches in Embase, MEDLINE, and Cochrane Central Register of Controlled Trials from the start of the databases (Embase from 1980) through January 2014. In addition, reference lists of relevant full-text papers were hand-searched. RESULTS Of 901 retrieved papers, 112 were considered as potentially eligible. After full-text reading, 17 were included in the final analysis, together with 15 papers identified through hand-searching of reference lists. All of the 32 included publications were case reports or case series. Clinical manifestations of drug-drug interactions involving opioids were grouped as follows: 1) sedation and respiratory depression, 2) other central nervous system symptoms, 3) impairment of pain control and/or opioid withdrawal, and 4) other symptoms. The most common mechanisms eliciting drug-drug interactions were alteration of opioid metabolism by inhibiting the activity of cytochrome P450 3A4 and pharmacodynamic interactions due to the combined effect on opioid, dopaminergic, cholinergic, and serotonergic activity in the central nervous system. CONCLUSION Evidence for drug-drug interactions associated with opioids used for pain treatment in cancer patients is very limited. Still, the cases identified in this systematic review give some important suggestions for clinical practice. Physicians prescribing opioids should recognize the risk of drug-drug interactions and if possible avoid polypharmacy.
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Affiliation(s)
- Aleksandra Kotlinska-Lemieszek
- Palliative Medicine Chair and Department, University Hospital of the Lord’s Transfiguration, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
| | - Pål Klepstad
- European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anaesthesiology and Intensive Care Medicine, St Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Regional Centre of Excellence for Palliative Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
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Regina KJ, Kharasch ED. High-sensitivity analysis of buprenorphine, norbuprenorphine, buprenorphine glucuronide, and norbuprenorphine glucuronide in plasma and urine by liquid chromatography-mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 939:23-31. [PMID: 24095872 DOI: 10.1016/j.jchromb.2013.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/30/2013] [Accepted: 09/01/2013] [Indexed: 10/26/2022]
Abstract
A new method using ultra-fast liquid chromatography and tandem mass spectrometry (UFLC-MS/MS) was developed for the simultaneous determination of buprenorphine and the metabolites norbuprenorphine, buprenorphine-3β-glucuronide, and norbuprenorphine-3β-glucuronide in plasma and urine. Sample handling, sample preparation and solid-phase extraction procedures were optimized for maximum analyte recovery. All four analytes of interest were quantified by positive ion electrospray ionization tandem mass spectrometry after solid-phase microextraction. The lower limits of quantification in plasma were 1pg/mL for buprenorphine and buprenorphine glucuronide, and 10pg/mL for norbuprenorphine and norbuprenorphine glucuronide. The lower limits of quantitation in urine were 10pg/mL for buprenorphine, norbuprenorphine and their glucuronides. Overall extraction recoveries ranged from 68-100% in both matrices. Interassay precision and accuracy was within 10% for all four analytes in plasma and within 15% in urine. The method was applicable to pharmacokinetic studies of low-dose buprenorphine.
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Affiliation(s)
- Karen J Regina
- Department of Anesthesiology, Division of Clinical and Translational Research, Washington University in St. Louis, St. Louis, MO, United States
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