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Klose M, Cristofoletti R, Silva CDM, Mangal N, Turgeon J, Michaud V, Lesko LJ, Schmidt S. Exploring the impact of CYP2D6 and UGT2B7 gene-drug interactions, and CYP-mediated DDI on oxycodone and oxymorphone pharmacokinetics using physiologically-based pharmacokinetic modeling and simulation. Eur J Pharm Sci 2024; 194:106689. [PMID: 38171419 DOI: 10.1016/j.ejps.2023.106689] [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: 09/01/2023] [Revised: 11/30/2023] [Accepted: 12/31/2023] [Indexed: 01/05/2024]
Abstract
Oxycodone is one of the most commonly used opioids to treat moderate to severe pain. It is metabolized mainly by CYP3A4 and CYP2D6, while only a small fraction of the dose is excreted unchanged into the urine. Oxymorphone, the metabolite primarily formed by CYP2D6, has a 40- to 60-fold higher mu-opioid receptor affinity than the parent compound. While CYP2D6-mediated gene-drug-interactions (GDIs) and drug-drug interactions (DDIs) are well-studied, they only account for a portion of the variability in oxycodone and oxymorphone exposure. The combined impact of CYP2D6-mediated GDIs and DDIs, CYP3A4-mediated DDIs, and UGT2B7 GDIs is not fully understood yet and hard to study in head-to-head clinical trials given the relatively large number of scenarios. Instead, we propose the use of a physiologically-based pharmacokinetic model that integrates available information on oxycodone's metabolism to characterize and predict the impact of DDIs and GDIs on the exposure of oxycodone and its major, pharmacologically-active metabolite oxymorphone. To this end, we first developed and verified a PBPK model for oxycodone and its metabolites using published clinical data. The verified model was then applied to determine the dose-exposure relationship of oxycodone and oxymorphone stratified by CYP2D6 and UGT2B7 phenotypes respectively, and administered perpetrators of CYP-based drug interactions. Our simulations demonstrate that the combination of CYP2D6 UM and a UGT2B7Y (268) mutation may lead to a 2.3-fold increase in oxymorphone exposure compared to individuals who are phenotyped as CYP2D6 NM / UGT2B7 NM. The extent of oxymorphone exposure increases up to 3.2-fold in individuals concurrently taking CYP3A4 inhibitors, such as ketoconazole. Inhibition of the CYP3A4 pathway results in a relative increase in the partial metabolic clearance of oxycodone to oxymorphone. Oxymorphone is impacted to a higher extent by GDIs and DDIs than oxycodone. We predict oxymorphone exposure to be highest in CYP2D6 UMs/UGT2B7 PMs in the presence of ketoconazole (strong CYP3A4 index inhibitor) and lowest in CYP2D6 PMs/UGT2B7 NMs in the presence of rifampicin (strong CYP3A4 index inducer) covering a 55-fold exposure range.
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Affiliation(s)
- Marian Klose
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Florida
| | - Rodrigo Cristofoletti
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Florida
| | - Carolina de Miranda Silva
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Florida
| | | | | | - Veronique Michaud
- GalenusRx Inc, Florida, USA; Faculty of Pharmacy, Université de Montréal, Canada
| | - Lawrence J Lesko
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Florida
| | - Stephan Schmidt
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida, Florida.
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Hoshi RA, Liu Y, Luttmann-Gibson H, Tiwari S, Giulianini F, Andres AM, Watrous JD, Cook NR, Costenbader KH, Okereke OI, Ridker PM, Manson JE, Lee IM, Vinayagamoorthy M, Cheng S, Copeland T, Jain M, Chasman DI, Demler OV, Mora S. Association of Physical Activity With Bioactive Lipids and Cardiovascular Events. Circ Res 2022; 131:e84-e99. [PMID: 35862024 PMCID: PMC9357171 DOI: 10.1161/circresaha.122.320952] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND To clarify the mechanisms underlying physical activity (PA)-related cardioprotection, we examined the association of PA with plasma bioactive lipids (BALs) and cardiovascular disease (CVD) events. We additionally performed genome-wide associations. METHODS PA-bioactive lipid associations were examined in VITAL (VITamin D and OmegA-3 TriaL)-clinical translational science center (REGISTRATION: URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01169259; N=1032) and validated in JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin)-NC (REGISTRATION: URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00239681; N=589), using linear models adjusted for age, sex, race, low-density lipoprotein-cholesterol, total-C, and smoking. Significant BALs were carried over to examine associations with incident CVD in 2 nested CVD case-control studies: VITAL-CVD (741 case-control pairs) and JUPITER-CVD (415 case-control pairs; validation). RESULTS We detected 145 PA-bioactive lipid validated associations (false discovery rate <0.1). Annotations were found for 6 of these BALs: 12,13-diHOME, 9,10-diHOME, lysoPC(15:0), oxymorphone-3b-D-glucuronide, cortisone, and oleoyl-glycerol. Genetic analysis within JUPITER-NC showed associations of 32 PA-related BALs with 22 single-nucleotide polymorphisms. From PA-related BALs, 12 are associated with CVD. CONCLUSIONS We identified a PA-related bioactive lipidome profile out of which 12 BALs also had opposite associations with incident CVD events.
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Affiliation(s)
- Rosangela A. Hoshi
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Yanyan Liu
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Heike Luttmann-Gibson
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Saumya Tiwari
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92037, USA
| | - Franco Giulianini
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Allen M. Andres
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92037, USA
| | - Jeramie D. Watrous
- Department of Pharmacology, University of California San Diego, La Jolla, CA 92037, USA
| | - Nancy R. Cook
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Karen H. Costenbader
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Olivia I. Okereke
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Paul M Ridker
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - JoAnn E. Manson
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - I-Min Lee
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | | | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Ctr, Los Angeles, CA 90048, USA
| | - Trisha Copeland
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Mohit Jain
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Daniel I. Chasman
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Olga V. Demler
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Computer Science, ETH Zurich, Zurich 8092, Switzerland
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Mandigma MJP, Žurauskas J, MacGregor CI, Edwards LJ, Shahin A, d'Heureuse L, Yip P, Birch DJS, Gruber T, Heilmann J, John MP, Barham JP. An organophotocatalytic late-stage N-CH 3 oxidation of trialkylamines to N-formamides with O 2 in continuous flow. Chem Sci 2022; 13:1912-1924. [PMID: 35308839 PMCID: PMC8849051 DOI: 10.1039/d1sc05840a] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/26/2021] [Indexed: 12/25/2022] Open
Abstract
We report an organophotocatalytic, N-CH3-selective oxidation of trialkylamines in continuous flow. Based on the 9,10-dicyanoanthracene (DCA) core, a new catalyst (DCAS) was designed with solubilizing groups for flow processing. This allowed O2 to be harnessed as a sustainable oxidant for late-stage photocatalytic N-CH3 oxidations of complex natural products and active pharmaceutical ingredients bearing functional groups not tolerated by previous methods. The organophotocatalytic gas-liquid flow process affords cleaner reactions than in batch mode, in short residence times of 13.5 min and productivities of up to 0.65 g per day. Spectroscopic and computational mechanistic studies showed that catalyst derivatization not only enhanced solubility of the new catalyst compared to poorly-soluble DCA, but profoundly diverted the photocatalytic mechanism from singlet electron transfer (SET) reductive quenching with amines toward energy transfer (EnT) with O2.
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Affiliation(s)
- Mark John P Mandigma
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
| | - Jonas Žurauskas
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
| | - Callum I MacGregor
- GlaxoSmithKline Medicines Research Centre Gunnels Wood Road Stevenage SG1 2NY UK
| | - Lee J Edwards
- GlaxoSmithKline Medicines Research Centre Gunnels Wood Road Stevenage SG1 2NY UK
| | - Ahmed Shahin
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
- Chemistry Department, Faculty of Science, Benha University 13518 Benha Egypt
| | - Ludwig d'Heureuse
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
| | - Philip Yip
- Department of Physics, SUPA, University of Strathclyde 107 Rottenrow East Glasgow G4 0NG UK
| | - David J S Birch
- Department of Physics, SUPA, University of Strathclyde 107 Rottenrow East Glasgow G4 0NG UK
| | - Thomas Gruber
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
| | - Jörg Heilmann
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
| | - Matthew P John
- GlaxoSmithKline Medicines Research Centre Gunnels Wood Road Stevenage SG1 2NY UK
| | - Joshua P Barham
- Fakultät für Chemie und Pharmazie, Universität Regensburg 93040 Regensburg Germany
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Opioids: Understanding How Acute Actions Impact Chronic Consequences. Dimens Crit Care Nurs 2021; 40:268-274. [PMID: 34398562 DOI: 10.1097/dcc.0000000000000487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In the last decade, critical-care nurses have seen a surge in acute opioid overdose admissions to intensive care units; there have also been significant increases in intensive care unit admissions due to opioid-related illness such as dependence, tolerance, and hyperalgesia. Despite these issues, opioids continue to be the criterion standard of pain management, and the search for opioid alternatives has not produced a clear replacement. A contributor to this problem has been the prevailing opinion that once bound to a receptor, all opioids engaged in the same types of intracellular signaling, which resulted in the same types of responses, only differing in the magnitude of those responses. Contemporary research with G-protein-coupled receptor models (eg, opioids) has demonstrated that this oversimplification is incorrect or incomplete. Understanding the complexity of opioid pharmacodynamics and pharmacokinetics helps us to grasp the intricacies of opioid-related adverse effects. Although there are many potential adverse effects related to opioids, this review focuses on the major adverse effects commonly seen in critical care, namely, respiratory depression, tolerance, hyperalgesia, and central sensitization. In addition, a case study has been incorporated to aid in understanding of strategies nurses can incorporate into their practices: that help mitigate the development of these effects.
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A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future. J Clin Med 2021; 10:jcm10122568. [PMID: 34200695 PMCID: PMC8229260 DOI: 10.3390/jcm10122568] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/05/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.
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Emery MA, Eitan S. Members of the same pharmacological family are not alike: Different opioids, different consequences, hope for the opioid crisis? Prog Neuropsychopharmacol Biol Psychiatry 2019; 92:428-449. [PMID: 30790677 DOI: 10.1016/j.pnpbp.2019.02.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 01/14/2023]
Abstract
Pain management is the specialized medical practice of modulating pain perception and thus easing the suffering and improving the life quality of individuals suffering from painful conditions. Since this requires the modulation of the activity of endogenous systems involved in pain perception, and given the large role that the opioidergic system plays in pain perception, opioids are currently the most effective pain treatment available and are likely to remain relevant for the foreseeable future. This contributes to the rise in opioid use, misuse, and overdose death, which is currently characterized by public health officials in the United States as an epidemic. Historically, the majority of preclinical rodent studies were focused on morphine. This has resulted in our understanding of opioids in general being highly biased by our knowledge of morphine specifically. However, recent in vitro studies suggest that direct extrapolation of research findings from morphine to other opioids is likely to be flawed. Notably, these studies suggest that different opioid analgesics (opioid agonists) engage different downstream signaling effects within the cell, despite binding to and activating the same receptors. This recognition implies that, in contrast to the historical status quo, different opioids cannot be made equivalent by merely dose adjustment. Notably, even at equianalgesic doses, different opioids could result in different beneficial and risk outcomes. In order to foster further translational research regarding drug-specific differences among opioids, here we review basic research elucidating differences among opioids in pharmacokinetics, pharmacodynamics, their capacity for second messenger pathway activation, and their interactions with the immune system and the dopamine D2 receptors.
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Affiliation(s)
- Michael A Emery
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX 77843, USA; Interdisciplinary Program in Neuroscience, Texas A&M Institute for Neuroscience (TAMIN), College Station, TX, USA
| | - Shoshana Eitan
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX 77843, USA; Interdisciplinary Program in Neuroscience, Texas A&M Institute for Neuroscience (TAMIN), College Station, TX, USA.
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7
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Bonnecaze AK, Wilson MW, Dharod A, Fletcher A, Miller PJ. Acute kidney injury is common with intravenous abuse of extended-release oral oxymorphone and delayed renal recovery rates are associated with increased KDIGO staging. Nephrology (Carlton) 2019; 23:921-926. [PMID: 28802086 DOI: 10.1111/nep.13153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/28/2022]
Abstract
AIM Prescription opioid abuse poses a serious problem in the United States, representing 615 per 100 000 deaths annually. Extended-release oxymorphone (Opana-ER) is an oral opioid pain medication that has recently been found to cause thrombotic microangiopathy when intravenously abused. In this retrospective study, we attempted to determine the prevalence and outcomes of acute kidney injury (AKI) among patients intravenously abusing extended-release oral oxymorphone. METHODS A query of electronic medical records for 'drug abuse' at an academic medical centre during January 2012 to December 2015 was performed and yielded 2350 patients. Patients were further identified by documented intravenous abuse of extended-release oxymorphone. Patients were stratified based on multiple renal indices and outcomes. Potential confounders were also identified. RESULTS One hundred and sixty-five patients were found to have a documented history of intravenous abuse of extended-release oral oxymorphone. Prevalence of AKI in this population was a 47.8%. KDIGO stage-I patients consisted of 17.8% of patients with AKI, 40.5% were classified as KDIGO stage-II AKI, and 41.8% were classified as KDIGO stage-III AKI. Among patients with AKI, average age was found to be 37.5 years, 59.4% experienced renal recovery, 56.9% required intensive care unit admission, 13.9% progressed to end-stage renal disease (ESRD), and 7.6% expired during admission. CONCLUSION Clinicians should be educated to help recognize intravenous abuse of extended-release oral oxymorphone and its associated effects. Our data suggests AKI is common in these patients; higher KDIGO staging appears to be associated with slower rates of renal recovery, increased comorbidities and progression to both CKD and ESRD.
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Affiliation(s)
- Alex K Bonnecaze
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Matthew W Wilson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Ajay Dharod
- Department of Internal Medicine, Section on General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Alison Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Peter John Miller
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.,Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunological Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.,Department of Anesthesia, Section on Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.,Department of Internal Medicine, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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8
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Severino AL, Shadfar A, Hakimian JK, Crane O, Singh G, Heinzerling K, Walwyn WM. Pain Therapy Guided by Purpose and Perspective in Light of the Opioid Epidemic. Front Psychiatry 2018; 9:119. [PMID: 29740351 PMCID: PMC5925443 DOI: 10.3389/fpsyt.2018.00119] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/21/2018] [Indexed: 12/12/2022] Open
Abstract
Prescription opioid misuse is an ongoing and escalating epidemic. Although these pharmacological agents are highly effective analgesics prescribed for different types of pain, opioids also induce euphoria, leading to increasing diversion and misuse. Opioid use and related mortalities have developed in spite of initial claims that OxyContin, one of the first opioids prescribed in the USA, was not addictive in the presence of pain. These claims allayed the fears of clinicians and contributed to an increase in the number of prescriptions, quantity of drugs manufactured, and the unforeseen diversion of these drugs for non-medical uses. Understanding the history of opioid drug development, the widespread marketing campaign for opioids, the immense financial incentive behind the treatment of pain, and vulnerable socioeconomic and physical demographics for opioid misuse give perspective on the current epidemic as an American-born problem that has expanded to global significance. In light of the current worldwide opioid epidemic, it is imperative that novel opioids are developed to treat pain without inducing the euphoria that fosters physical dependence and addiction. We describe insights from preclinical findings on the properties of opioid drugs that offer insights into improving abuse-deterrent formulations. One finding is that the ability of some agonists to activate one pathway over another, or agonist bias, can predict whether several novel opioid compounds bear promise in treating pain without causing reward among other off-target effects. In addition, we outline how the pharmacokinetic profile of each opioid contributes to their potential for misuse and discuss the emergence of mixed agonists as a promising pipeline of opioid-based analgesics. These insights from preclinical findings can be used to more effectively identify opioids that treat pain without causing physical dependence and subsequent opioid abuse.
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Affiliation(s)
- Amie L. Severino
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Arash Shadfar
- Department of Psychiatry, Western University of Health Sciences, Pomona, CA, United States
| | - Joshua K. Hakimian
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Oliver Crane
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Ganeev Singh
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Keith Heinzerling
- Department of Family Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Wendy M. Walwyn
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
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9
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Peterson SE, Selvaggi KJ, Scullion BF, Blinderman CD. Pain Management and Antiemetic Therapy in Hematologic Disorders. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00091-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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10
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Vadivelu N, Chang D, Helander EM, Bordelon GJ, Kai A, Kaye AD, Hsu D, Bang D, Julka I. Ketorolac, Oxymorphone, Tapentadol, and Tramadol: A Comprehensive Review. Anesthesiol Clin 2017; 35:e1-e20. [PMID: 28526155 DOI: 10.1016/j.anclin.2017.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pain remains a tremendous burden on patients and for the health care system, with uncontrolled pain being the leading cause of disability in this country. There are a variety of medications that can be used in the treatment of pain, including ketorolac, oxymorphone, tapentadol, and tramadol. Depending on the clinical situation, these drugs can be used as monotherapy or in conjunction with other types of medications in a multimodal approach. A strong appreciation of pharmacologic properties of these agents and potential side effects is warranted for clinicians.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA.
| | - Daniel Chang
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA
| | - Erik M Helander
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Gregory J Bordelon
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Alice Kai
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Dora Hsu
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
| | - Daniel Bang
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
| | - Inderjeet Julka
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 3325, Los Angeles, CA 90095-7403, USA
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11
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Barham JP, John MP, Murphy JA. Contra-thermodynamic Hydrogen Atom Abstraction in the Selective C–H Functionalization of Trialkylamine N-CH3 Groups. J Am Chem Soc 2016; 138:15482-15487. [DOI: 10.1021/jacs.6b09690] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Joshua P. Barham
- WestCHEM,
Department of Pure and Applied Chemistry, University of Strathclyde, 295 Cathedral Street, Glasgow G1 1XL, United Kingdom
- GlaxoSmithKline Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, United Kingdom
| | - Matthew P. John
- GlaxoSmithKline Medicines Research Centre, Gunnels Wood Road, Stevenage SG1 2NY, United Kingdom
| | - John A. Murphy
- WestCHEM,
Department of Pure and Applied Chemistry, University of Strathclyde, 295 Cathedral Street, Glasgow G1 1XL, United Kingdom
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12
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Abstract
Chronic pain is associated with increased risk of suicide, and opioids are commonly used to treat moderate to severe pain. However, the association between opioid dose and suicide mortality has not been examined closely. This retrospective data analysis described the risk of suicide associated with differing prescribed opioid doses. Data were from Veterans Affairs health care system treatment records and the National Death Index. Records analyzed were those of Veterans Affairs patients with chronic pain receiving opioids in fiscal years 2004 to 2005 (N = 123,946). Primary predictors were maximum prescribed morphine-equivalent daily opioid dose and opioid fill type. The main outcome measured was suicide death, by any mechanism, and intentional overdose death during 2004 to 2009. Controlling for demographic and clinical characteristics, higher prescribed opioid doses were associated with elevated suicide risk. Compared with those receiving ≤20 milligrams/day (mg/d), hazard ratios were 1.48 (95% confidence intervals [CI], 1.25-1.75) for 20 to <50 mg/d, 1.69 (95% CI, 1.33-2.14) for 50 to <100 mg/d, and 2.15 (95% CI, 1.64-2.81) for 100+ mg/d. The magnitude of association between opioid dose and suicide by intentional overdose was not substantially different from that observed for the overall measure of suicide mortality. Risk of suicide mortality was greater among individuals receiving higher doses of opioids, and treatment providers may want to view high opioid dose as a marker of elevated risk for suicide. Additional research is needed on opioid use, pain treatment, and suicide.
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Affiliation(s)
- Mark A. Ilgen
- VA Serious Mental Illness Treatment Resource and Evaluation Center and VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Amy S. B. Bohnert
- VA Serious Mental Illness Treatment Resource and Evaluation Center and VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Dara Ganoczy
- VA Serious Mental Illness Treatment Resource and Evaluation Center and VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
| | - Matthew J. Bair
- Department of Veterans Affairs, HSR&D Center of Excellence, Indianapolis, IN
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - John F. McCarthy
- VA Serious Mental Illness Treatment Resource and Evaluation Center and VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Frederic C. Blow
- VA Serious Mental Illness Treatment Resource and Evaluation Center and VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
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Affiliation(s)
- Eric E. Prommer
- Division of Hematology/Oncology, Veterans Integrated Palliative Care Program, Veterans Integrated Palliative Care, David Geffen School of Medicine, University of California, Los Angeles, California
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Park TW, Saitz R, Ganoczy D, Ilgen MA, Bohnert ASB. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ 2015; 350:h2698. [PMID: 26063215 PMCID: PMC4462713 DOI: 10.1136/bmj.h2698] [Citation(s) in RCA: 402] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics. DESIGN Case-cohort study. SETTING Veterans Health Administration (VHA), 2004-09. PARTICIPANTS US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420,386) who received VHA medical services and opioid analgesics. MAIN OUTCOME MEASURE Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index. RESULTS During the study period 27% (n=112,069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose. CONCLUSIONS Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.
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Affiliation(s)
- Tae Woo Park
- Departments of Medicine and Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 111 Plain Street, Providence, RI 02903, United States
| | - Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA 02118, USA
| | - Dara Ganoczy
- Department of Veterans Affairs, Health Services Research and Development (HSR&D), 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Mark A Ilgen
- Department of Veterans Affairs, Health Services Research and Development (HSR&D), 2215 Fuller Road, Ann Arbor, MI 48105, USA Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Amy S B Bohnert
- Department of Veterans Affairs, Health Services Research and Development (HSR&D), 2215 Fuller Road, Ann Arbor, MI 48105, USA Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Kestenbaum MG, Vilches AO, Messersmith S, Connor SR, Fine PG, Murphy B, Davis M, Muir JC. Alternative routes to oral opioid administration in palliative care: a review and clinical summary. PAIN MEDICINE 2014; 15:1129-53. [PMID: 24995406 DOI: 10.1111/pme.12464] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.
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Kurogi K, Chepak A, Hanrahan MT, Liu MY, Sakakibara Y, Suiko M, Liu MC. Sulfation of opioid drugs by human cytosolic sulfotransferases: metabolic labeling study and enzymatic analysis. Eur J Pharm Sci 2014; 62:40-8. [PMID: 24832963 DOI: 10.1016/j.ejps.2014.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 03/26/2014] [Accepted: 05/04/2014] [Indexed: 12/25/2022]
Abstract
The current study was designed to examine the sulfation of eight opioid drugs, morphine, hydromorphone, oxymorphone, butorphanol, nalbuphine, levorphanol, nalorphine, and naltrexone, in HepG2 human hepatoma cells and human organ samples (lung, liver, kidney, and small intestine) and to identify the human SULT(s) responsible for their sulfation. Analysis of the spent media of HepG2 cells, metabolically labeled with [35S]sulfate in the presence of each of the eight opioid drugs, showed the generation and release of corresponding [35S]sulfated derivatives. Five of the eight opioid drugs, hydromorphone, oxymorphone, butorphanol, nalorphine, and naltrexone, appeared to be more strongly sulfated in HepG2 cells than were the other three, morphine, nalbuphine, and levorphanol. Differential sulfating activities toward the opioid drugs were detected in cytosol or S9 fractions of human lung, liver, small intestine, and kidney, with the highest activities being found for the liver sample. A systematic analysis using eleven known human SULTs and kinetic experiment revealed SULT1A1 as the major responsible SULTs for the sulfation of oxymorphone, nalbuphine, nalorphine, and naltrexone, SULT1A3 for the sulfation of morphine and hydromorphone, and SULT2A1 for the sulfation of butorphanol and levorphanol. Collectively, the results obtained imply that sulfation may play a significant role in the metabolism of the tested opioid drugs in vivo.
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Affiliation(s)
- Katsuhisa Kurogi
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, The University of Toledo, Toledo, OH 43614, USA
| | - Andriy Chepak
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, The University of Toledo, Toledo, OH 43614, USA
| | - Michael T Hanrahan
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, The University of Toledo, Toledo, OH 43614, USA
| | - Ming-Yih Liu
- National Synchrotron Radiation Research Center, Hsinchu, Taiwan, ROC
| | - Yoichi Sakakibara
- Biochemistry and Applied Biosciences, University of Miyazaki, Miyazaki 889-2192, Japan
| | - Masahito Suiko
- Biochemistry and Applied Biosciences, University of Miyazaki, Miyazaki 889-2192, Japan
| | - Ming-Cheh Liu
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, The University of Toledo, Toledo, OH 43614, USA.
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Crum ED, Bailey KM, Richards-Waugh LL, Clay DJ, Gebhardt MA, Kraner JC. Validation of blood and liver oxymorphone analysis using LC-MS-MS: concentrations in 30 fatal overdoses. J Anal Toxicol 2013; 37:512-6. [PMID: 23980120 DOI: 10.1093/jat/bkt077] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A sensitive liquid chromatography-tandem mass spectrometry method was developed and validated for the quantitation of oxymorphone (OM) in human whole blood and liver. Sample preparation was done by solid-phase extraction, using deuterated OM as the internal standard. Separation was achieved using a Waters Aquity UPLC HSS T3 column. Analysis utilized positive electrospray ionization and multiple reaction monitoring. As part of the validation, studies were conducted to determine potential interference, selectivity, ion suppression/enhancement and carryover. Calibration model, limit of detection (LOD), lower limit of quantitation (LLOQ), precision and accuracy were also established. The linear range of the method was 2-500 ng/mL in blood and 5-500 ng/g in the liver. The LOD and LLOQ were 2 ng/mL for blood and 5 ng/g for the liver. Blood and/or liver specimens from 30 cases were analyzed. OM concentrations ranged from 23 to 554 ng/mL ( , n = 26) in blood and 48 to 1740 ng/g ( , n = 30) in the liver.
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Affiliation(s)
- Erin D Crum
- 1 Marshall University, 1401 Forensic Science Drive, Huntington, WV 25701, USA
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Smith LJ, Kukanich BK, Krugner-Higby LA, Schmidt BH, Heath TD. Pharmacokinetics of ammonium sulfate gradient loaded liposome-encapsulated oxymorphone and hydromorphone in healthy dogs. Vet Anaesth Analg 2013; 40:537-45. [PMID: 23601353 DOI: 10.1111/vaa.12042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 06/28/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the pharmacokinetics, in dogs, of liposome-encapsulated oxymorphone and hydromorphone made by the ammonium sulfate gradient loading technique (ASG). ANIMALS Four healthy purpose-bred Beagles aged 9.5 ± 3.2 months and weighing 13.4 ± 2.3 kg. STUDY DESIGN Randomized cross-over design. METHODS Each dog was given either 4.0 mg kg(-1) of ASG-oxymorphone or 8.0 mg kg(-1) of ASG-hydromorphone SC on separate occasions with a 3-month washout period. Blood was collected at baseline and at serial time points up to 1032 hours (43 days) after injection for determination of serum opioid concentrations. Serum opioid concentrations were measured with HPLC-MS and pharmacokinetic parameters were calculated using commercial software and non-compartmental methods. RESULTS Serum concentrations of oxymorphone remained above the limit of quantification for 21 days, while those for hydromorphone remained above the limit of quantification for 29 days. Cmax for ASG-oxymorphone was 7.5 ng mL(-1) ; Cmax for ASG-hydromorphone was 5.7 ng mL(-1) . CONCLUSIONS AND CLINICAL RELEVANCE Oxymorphone and hydromorphone, when encapsulated into liposomes using the ammonium sulfate gradient loading technique, result in measureable serum concentrations for between 3 to 4 weeks. This formulation may have promise in the convenient use of opioids for clinical treatment of chronically painful conditions in dogs.
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Affiliation(s)
- Lesley J Smith
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, 2015 Linden Drive, Madison WI 53706, USA.
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19
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Abstract
In the United States, the prevalence and burden of chronic pain is large and still growing. Older adults (aged ≥65 years) make up a large portion of the population with chronic pain, and their presentation, diagnosis, and treatment tends to be more complicated because of age-related physiological changes and comorbidities. Guidelines on treating patients with severe back pain recommend opioids as an option for those who do not find adequate pain relief from acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). For older adult patients at higher risk for NSAID-related adverse effects, such as those who have gastrointestinal or cardiovascular disease, diabetes mellitus, or who are taking low-dose aspirin, opioids are recommended instead. Opioids may also be an appropriate option for patients with neuropathic pain who have not achieved adequate analgesia from maximum doses of first- and second-line antineuropathic agents. Still, opioids are not appropriate for all patients; rather, a differential diagnosis, consideration of other comorbidities, and the potential for opioid-related adverse effects and substance abuse are required to confirm the value of opioid treatment for each individual. For nonresponders to opioid therapy, opioid rotation should be considered before discontinuation is pursued.
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Affiliation(s)
- Oscar A de Leon-Casasola
- Department of Anesthesiology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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20
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Xu XS, Etropolski M, Upmalis D, Okamoto A, Lin R, Nandy P. Pharmacokinetic and pharmacodynamic modeling of opioid-induced gastrointestinal side effects in patients receiving tapentadol IR and oxycodone IR. Pharm Res 2012; 29:2555-64. [PMID: 22618801 DOI: 10.1007/s11095-012-0786-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 05/14/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE To understand the relationship between the risk of opioid-related gastrointestinal adverse effects (AEs) and exposure to tapentadol and oxycodone as well as its active metabolite, oxymorphone, using pharmacokinetic/pharmacodynamic models. METHODS The analysis was based on a study in patients with moderate-to-severe pain following bunionectomy. Population PK modeling was conducted to estimate population PK parameters for tapentadol, oxycodone, and oxymorphone. Time to AEs was analyzed using Cox proportional-hazards models. RESULTS Risk of nausea, vomiting, and constipation significantly increased with exposure to tapentadol or oxycodone/oxymorphone. However, elevated risk per drug exposure of AEs for tapentadol was ~3-4 times lower than that of oxycodone, while elevated AE risk per drug exposure of oxycodone was ~60 times lower than that for oxymorphone, consistent with reported in vitro receptor binding affinities for these compounds. Simulations show that AE incidence following administration of tapentadol IR is lower than that following oxycodone IR intake within the investigated range of analgesic noninferiority dose ratios. CONCLUSIONS This PK/PD analysis supports the clinical findings of reduced nausea, vomiting and constipation reported by patients treated with tapentadol, compared to patients treated with oxycodone.
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Affiliation(s)
- Xu Steven Xu
- Clinical Pharmacology, Advanced PK-PD Modeling and Simulation, Janssen Research and Development, Raritan, New Jersey, USA.
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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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Abstract
The experience of pain in cancer is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in oncology care. Pain is associated with both the disease as well as treatment, and management is essential from the onset of early disease through long-term survivorship or end-of-life care. Effective relief of pain is contingent upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and as a foundation for multidisciplinary interventions. Fortunately, advances in pain treatment and in the field of palliative care have provided effective treatments encompassing pharmacological, cognitive-behavioral, and other approaches. The field of palliative care has emphasized that attention to symptoms such as pain is integral to quality cancer care.
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Affiliation(s)
- Judith A Paice
- Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Grönlund J, Saari TI, Hagelberg NM, Neuvonen PJ, Olkkola KT, Laine K. Exposure to oral oxycodone is increased by concomitant inhibition of CYP2D6 and 3A4 pathways, but not by inhibition of CYP2D6 alone. Br J Clin Pharmacol 2011; 70:78-87. [PMID: 20642550 DOI: 10.1111/j.1365-2125.2010.03653.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Oxycodone is an opioid analgesic that is metabolized mainly in the liver by cytochrome P450 (CYP) 2D6 and 3A4 enzymes. So far, the effects of CYP2D6 or CYP3A4 inhibitors on the pharmacokinetics of oxycodone in humans have not been systematically studied. WHAT THIS STUDY ADDS Drug interactions arising from CYP2D6 inhibition most likely have minor clinical importance for oral oxycodone. When both of CYP2D6 and CYP3A4 pathways are inhibited, the exposure to oral oxycodone is increased substantially. AIM The aim of this study was to find out whether the inhibition of cytochrome P450 2D6 (CYP2D6) with paroxetine or concomitant inhibition of CYP2D6 and CYP3A4 with paroxetine and itraconazole, altered the pharmacokinetics and pharmacological response of orally administered oxycodone. METHODS A randomized placebo-controlled cross-over study design with three phases was used. Eleven healthy subjects ingested 10 mg of oral immediate release oxycodone on the fourth day of pre-treatment with either placebo, paroxetine (20 mg once daily) or paroxetine (20 mg once daily) and itraconazole (200 mg once daily) for 5 days. The plasma concentrations of oxycodone and its oxidative metabolites were measured for 48 h, and pharmacological (analgesic and behavioural) effects were evaluated. RESULTS Paroxetine alone reduced the area under concentration-time curve (AUC(0,0-48 h)) of the CYP2D6 dependent metabolite oxymorphone by 44% (P < 0.05), but had no significant effects on the plasma concentrations of oxycodone or its pharmacological effects when compared with the placebo phase. When both oxidative pathways of the metabolism of oxycodone were inhibited with paroxetine and itraconazole, the mean AUC(0,infinity) of oxycodone increased by 2.9-fold (P < 0.001), and its C(max) by 1.8-fold (P < 0.001). Visual analogue scores for subjective drug effects, drowsiness and deterioration of performance were slightly increased (P < 0.05) after paroxetine + itraconazole pre-treatment when compared with placebo. CONCLUSIONS Drug interactions arising from CYP2D6 inhibition most likely have minor clinical importance for oral oxycodone if the function of the CYP3A4 pathway is normal. When both CYP2D6 and CYP3A4 pathways are inhibited, the exposure to oral oxycodone is increased substantially.
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Affiliation(s)
- Juha Grönlund
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku and Turku University Hospital, Turku, Finland.
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SIAO KT, PYPENDOP BH, STANLEY SD, ILKIW JE. Pharmacokinetics of oxymorphone in cats. J Vet Pharmacol Ther 2011; 34:594-8. [DOI: 10.1111/j.1365-2885.2011.01271.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mayyas F, Fayers P, Kaasa S, Dale O. A systematic review of oxymorphone in the management of chronic pain. J Pain Symptom Manage 2010; 39:296-308. [PMID: 20152592 DOI: 10.1016/j.jpainsymman.2009.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 07/06/2009] [Accepted: 07/15/2009] [Indexed: 01/30/2023]
Abstract
Opioids are recommended for control of moderate-to-severe, chronic, malignant, and nonmalignant pain. A controlled-release formulation of the opioid oxymorphone has recently been launched. The aim of this review was to assess the effectiveness of oxymorphone as an analgesic in chronic pain. A systematic search for published studies of oral oxymorphone in the management of chronic pain was conducted. The studies were evaluated for their internal validity according to standard criteria. They were also evaluated for their external validity and research ethic aspects. A meta-analysis was performed to examine the effect of oxymorphone compared with placebo. Nine studies were evaluated; three were excluded because of low quality. Six controlled studies (duration 2-12 weeks) included a total of 1489 subjects suffering from chronic low back pain, chronic pain from osteoarthritis, and chronic cancer pain. Three of the studies were of high quality and three of medium quality. External validity was assessed to be high, medium, and low (in one, three, and two studies, respectively). The meta-analysis suggests that daily doses of 40-100mg are superior to placebo; however, the estimate (reduction of pain intensity compared with placebo) of the treatment effect is imprecise (95% confidence interval -17.08, -8.69). Limited evidence suggests that oxymorphone is effective for pain control in patients with cancer. No significant differences between oxymorphone and oxycodone at equipotent doses were found. In conclusion, oxymorphone is superior to placebo. There is no evidence that the efficacy of oxymorphone differs from other opioids.
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Affiliation(s)
- Fadia Mayyas
- Pain and Palliation Research Group, Norwegian University of Science and Technology, 7489Trondheim, Norway
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26
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Nieminen TH, Hagelberg NM, Saari TI, Neuvonen M, Laine K, Neuvonen PJ, Olkkola KT. St John's wort greatly reduces the concentrations of oral oxycodone. Eur J Pain 2010; 14:854-9. [PMID: 20106684 DOI: 10.1016/j.ejpain.2009.12.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 11/29/2009] [Accepted: 12/21/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chronic pain is associated with depression. Self-treatment of depression with herbal over-the-counter medicine St John's wort makes pain patients prone to drug interactions. AIMS The aim of this study was to assess the potential of St John's wort to alter the CYP3A-mediated metabolism of a mu-opioid receptor agonist, oxycodone. METHODS The study design was placebo-controlled, randomized, cross-over with two phases at intervals of 4 weeks and was conducted with 12 healthy participants. St John's wort (Jarsin) or placebo was administered t.i.d. for 15 days and oral oxycodone hydrochloride 15 mg on day 14. Oxycodone pharmacokinetics and pharmacodynamics were compared after St John's wort or placebo. Behavioural and analgesic effects were assessed with subjective visual analogue scales and cold pressor test. Plasma drug concentrations were measured from 0 to 48 h, behavioural and analgesic effects from 0 to 12 h. RESULTS Following St John's wort administration the oxycodone AUC decreased 50% (p<0.001). Oxycodone elimination half-life shortened from a mean+/-SD 3.8+/-0.7 to 3.0+/-0.4h (p<0.001). The self-reported drug effect of oxycodone as measured by AUEC(0-12) decreased significantly (p=0.004). Differences between St John's wort and placebo phases in cold pain threshold and intensity AUEC(0-12) were not observed. CONCLUSIONS St John's wort greatly reduced the plasma concentrations of oral oxycodone. The self-reported drug effect of oxycodone decreased significantly. This interaction may potentially be of some clinical significance when treating patients with chronic pain.
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Affiliation(s)
- Tuija H Nieminen
- Department of Anesthesiology, Intensive Care, Emergency Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland.
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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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29
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Brennan MJ. Summary of Short-term and Long-term Oxymorphone Efficacy (Pain) Studies in Low Back Pain, Cancer Pain, Osteoarthritis, and Neuropathic Pain. PAIN MEDICINE 2009. [DOI: 10.1111/j.1526-4637.2009.00595.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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30
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Fishbain DA. Oxymorphone Status. PAIN MEDICINE 2009. [DOI: 10.1111/j.1526-4637.2009.00593.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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KuKanich B, Schmidt BK, Krugner-Higby LA, Toerber S, Smith LJ. Pharmacokinetics and behavioral effects of oxymorphone after intravenous and subcutaneous administration to healthy dogs. J Vet Pharmacol Ther 2009; 31:580-3. [PMID: 19000282 DOI: 10.1111/j.1365-2885.2008.00987.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- B KuKanich
- PharmCATS Bioanalytical Laboratory, Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
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Coller JK, Christrup LL, Somogyi AA. Role of active metabolites in the use of opioids. Eur J Clin Pharmacol 2008; 65:121-39. [PMID: 18958460 DOI: 10.1007/s00228-008-0570-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 09/16/2008] [Indexed: 11/26/2022]
Abstract
The opioid class of drugs, a large group, is mainly used for the treatment of acute and chronic persistent pain. All are eliminated from the body via metabolism involving principally CYP3A4 and the highly polymorphic CYP2D6, which markedly affects the drug's function, and by conjugation reactions mainly by UGT2B7. In many cases, the resultant metabolites have the same pharmacological activity as the parent opioid; however in many cases, plasma metabolite concentrations are too low to make a meaningful contribution to the overall clinical effects of the parent drug. These metabolites are invariably more water soluble and require renal clearance as an important overall elimination pathway. Such metabolites have the potential to accumulate in the elderly and in those with declining renal function with resultant accumulation to a much greater extent than the parent opioid. The best known example is the accumulation of morphine-6-glucuronide from morphine. Some opioids have active metabolites but at different target sites. These are norpethidine, a neurotoxic agent, and nordextropropoxyphene, a cardiotoxic agent. Clinicians need to be aware that many opioids have active metabolites that will become therapeutically important, for example in cases of altered pathology, drug interactions and genetic polymorphisms of drug-metabolizing enzymes. Thus, dose individualisation and the avoidance of adverse effects of opioids due to the accumulation of active metabolites or lack of formation of active metabolites are important considerations when opioids are used.
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Affiliation(s)
- Janet K Coller
- Discipline of Pharmacology, School of Medical Sciences, University of Adelaide, Adelaide, 5005, Australia
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Abstract
Pain ranges in prevalence from 14-100% among cancer patients and occurs in 50-70% of those in active treatment. Cancer pain may result from direct invasion of tumor into nerves, bones, soft tissue, ligaments, and fascia, and may induce visceral pain through distension and obstruction. Cancer pain is multifaceted. Clinicians may describe cancer pain as acute, chronic, nociceptive (somatic), visceral, or neuropathic. Despite implementation of the WHO guidelines, reports of undertreatment of cancer pain persist in various clinical settings and in spite of decades of work to reduce unnecessary discomfort. Substantial obstacles to adequate pain relief with opioids include specific concerns of patients themselves, their family members, physicians, nurses, and the healthcare system. The WHO analgesic ladder serves as the mainstay of treatment for the relief of cancer pain in concert with tumoricidal, surgical, interventional, radiotherapeutic, psychological, and rehabilitative modalities. This multidimensional approach offers the greatest potential for maximizing analgesia and minimizing adverse effects. Primary therapies are directed at the source of the cancer pain and may enhance a patient's function, longevity, and comfort. Adjuvant therapies include nonopioids that confer analgesic effects in certain medical conditions but primarily treat conditions that do not involve pain. Nonopioid medications (over-the-counter agents) are useful in the management of mild to moderate pain, and their continuation through step 3 of the WHO ladder is an option after weighing a drug's risks and benefits in individual patients. Symptomatic treatment of severe cancer pain should begin with an opioid, regardless of the mechanism of the pain. They are very effective analgesics, titrate easily, and offer a favorable risk/benefit ratio. Cancer pain remains inadequately controlled despite the diagnostic and therapeutic means of ensuring that patients feel comfortable during their illness. Therefore, all practitioners need to make control of cancer pain a professional duty, even if they can only use the most basic and least expensive analgesic medications, such as morphine, codeine, and acetaminophen, to reduce human suffering.
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Affiliation(s)
- Paul J Christo
- Department of Anesthesiology & Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Rauck R, Ma T, Kerwin R, Ahdieh H. Titration with Oxymorphone Extended Release to Achieve Effective Long-Term Pain Relief and Improve Tolerability in Opioid-Naive Patients with Moderate to Severe Pain. PAIN MEDICINE 2008; 9:777-85. [DOI: 10.1111/j.1526-4637.2007.00390.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Miller DA, Dinunzio JC, Williams RO. Advanced formulation design: improving drug therapies for the management of severe and chronic pain. Drug Dev Ind Pharm 2008; 34:117-33. [PMID: 18302030 DOI: 10.1080/03639040701542200] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic pain is a condition affecting a vast patient population and resulting in billions of dollars in associated health care costs annually. Sufferers from severe chronic pain often require [correction of requite] twenty-four hour drug treatment through intrusive means and/or repeated oral dosing. Although the oral route of administration is most preferred, conventional immediate release oral dosage forms lead to inconvenient and suboptimal drug therapies for the treatment of chronic pain. Effective drug therapies for the management of chronic pain therefore require advanced formulation design to optimize the delivery of potent analgesic agents. Ideally, these advanced delivery systems provide efficacious pain therapy with minimal side effects via a simple and convenient dosing regime. In this article, currently commercialized and developing drug products for pain management are reviewed with respect to dosage form design as well as clinical efficacy. The drug delivery systems reviewed herein represent advanced formulation designs that are substantially improving analgesic drug therapies.
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Affiliation(s)
- Dave A Miller
- College of Pharmacy, University of Texas at Austin, Austin, Texas 78712, USA
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Kadiev E, Patel V, Rad P, Thankachan L, Tram A, Weinlein M, Woodfin K, Raffa RB, Nagar S. Role of pharmacogenetics in variable response to drugs: focus on opioids. Expert Opin Drug Metab Toxicol 2007; 4:77-91. [DOI: 10.1517/17425255.4.1.77] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- James F. Cleary
- Department of Medicine, University of Wisconsin, Madison Wisconsin
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Abstract
Opana ER (oxymorphone extended release [ER]) is a new oral long-acting formulation indicated for the treatment of moderate to severe chronic pain. Because the ER matrix slowly releases oxymorphone over 12 h, consistent plasma levels are produced with low peak-to-trough fluctuations. Oxymorphone ER is the only long-acting opioid that contains oxymorphone, which exhibits some distinct pharmacologic properties compared with most other opioids, including a longer half-life, higher affinity for the micro-opioid receptor, and lack of interaction with the CYPP450 drug-metabolizing system. With a safety and tolerability profile similar to other opioids and documented efficacy in several models of chronic pain (low back, cancer, and osteoarthritis), oxymorphone ER provides a new option for clinicians and patients in the treatment of chronic pain.
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Portenoy RK, Messina J, Xie F, Peppin J. Fentanyl buccal tablet (FBT) for relief of breakthrough pain in opioid-treated patients with chronic low back pain: a randomized, placebo-controlled study. Curr Med Res Opin 2007; 23:223-33. [PMID: 17207304 DOI: 10.1185/030079906x162818] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Short-acting opioids are commonly used to treat breakthrough pain (BTP) and rapid-onset formulations are being developed to improve the effectiveness of this approach. Fentanyl buccal tablet (FBT) is a new formulation of fentanyl that enhances transbuccal drug delivery via an effervescent reaction and may provide relatively rapid-onset analgesia. FBT was evaluated for BTP in opioid-treated patients with chronic low back pain--the first such study in a population with chronic non-cancer pain. DESIGN Randomized, double-blind, placebo-controlled. PATIENTS AND SETTING Patients with chronic low back pain receiving long-term opioid therapy at 16 pain treatment centers in the United States. PROCEDURES Following open-label titration to identify an effective FBT dose, patients were randomly assigned to one of three double-blind dose sequences (six doses of FBT, three placebo) to treat nine BTP episodes. Pain intensity (PI), measured on an 11-point scale (0 = no pain; 10 = worst pain), and other outcomes were assessed for 2 h after dosing. DATA ANALYSIS The primary efficacy measure was the sum of pain intensity differences (PIDs) for the first 60 min (SPID60); secondary efficacy measures included PIDs at other time points, pain relief (PR), meaningful PR, time to meaningful PR, use of supplementary BTP medication, and self/investigator-reported adverse events. RESULTS Of the 124 patients screened, 105 patients were enrolled, 84 identified an effective FBT dose, and 77 entered the double-blind phase. SPID60 significantly favored FBT (p < 0.0001). All secondary measures also favored FBT, with PIDs and PR showing significant differences versus placebo as early as 10 and 15 min, respectively. An improvement in PI score of > or = 33% occurred in a significantly larger proportion of FBT-treated episodes versus placebo from 15 min (20% vs. 11%, p < 0.01) through 2 h (65% vs. 28%, p < 0.0001). Patients were approximately four times more likely to require supplemental opioids for BTP episodes following administration of placebo compared with episodes treated with FBT. AEs were typical for opioids, and were mostly reported during dose titration. Limitations of this study may be related to its open-label dose-titration phase (which has the potential to compromise blinding) and the recruitment of patients from pain clinics, which could potentially yield a study population that is not representative of the general population with BTP. CONCLUSIONS FBT was efficacious and well tolerated in the treatment of BTP in opioid-treated patients with chronic low back pain.
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Affiliation(s)
- Russell K Portenoy
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY 0003, USA.
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Laser literature watch. Photomed Laser Surg 2006; 24:537-71. [PMID: 16942439 DOI: 10.1089/pho.2006.24.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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