1
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Robinson KM, Eum S, Desta Z, Tyndale RF, Gaedigk A, Crist RC, Haidar CE, Myers AL, Samer CF, Somogyi AA, Zubiaur P, Iwuchukwu OF, Whirl-Carrillo M, Klein TE, Caudle KE, Donnelly RS, Kharasch ED. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2B6 Genotype and Methadone Therapy. Clin Pharmacol Ther 2024. [PMID: 38863207 DOI: 10.1002/cpt.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/22/2024] [Indexed: 06/13/2024]
Abstract
Methadone is a mu (μ) opioid receptor agonist used clinically in adults and children to manage opioid use disorder, neonatal abstinence syndrome, and acute and chronic pain. It is typically marketed as a racemic mixture of R- and S-enantiomers. R-methadone has 30-to 50-fold higher analgesic potency than S-methadone, and S-methadone has a greater adverse effect (prolongation) on the cardiac QTc interval. Methadone undergoes stereoselective metabolism. CYP2B6 is the primary enzyme responsible for catalyzing the metabolism of both enantiomers to the inactive metabolites, S- and R-2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (S- and R-EDDP). Genetic variation in the CYP2B6 gene has been investigated in the context of implications for methadone pharmacokinetics, dose, and clinical outcomes. Most CYP2B6 variants result in diminished or loss of CYP2B6 enzyme activity, which can lead to higher plasma methadone concentrations (affecting S- more than R-methadone). However, the data do not consistently indicate that CYP2B6-based metabolic variability has a clinically significant effect on methadone dose, efficacy, or QTc prolongation. Expert analysis of the published literature does not support a change from standard methadone prescribing based on CYP2B6 genotype (updates at www.cpicpgx.org).
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Affiliation(s)
- Katherine M Robinson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Seenae Eum
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel F Tyndale
- Department of Pharmacology & Toxicology, and Psychiatry, The Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Richard C Crist
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Alan L Myers
- Department of Diagnostic & Biomedical Sciences, The University of Texas Health Science Center, Houston, Texas, USA
| | - Caroline F Samer
- Department of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Pablo Zubiaur
- Department of Clinical Pharmacology, Hospital Universitario de la Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, Spain
| | - Otito F Iwuchukwu
- Department of Pharmaceutical Sciences, School of Pharmacy and Health Sciences, Farleigh Dickinson University, Florham Park, New Jersey, USA
| | | | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Kelly E Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Roseann S Donnelly
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, USA
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine | Bermaride LLC, Durham, North Carolina, USA
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2
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Gerhart JG, Carreño FO, Ford JL, Edginton A, Perrin EM, Watt KM, Muller WJ, Atz AM, Al‐Uzri A, Delmore P, Gonzalez D, Benjamin DK, Hornik C, Zimmerman K, Kennel P, Beci R, Dang Hornik C, Kearns GL, Laughon M, Paul IM, Sullivan J, Wade K, Delmore P, Taylor‐Zapata P, Lee J, Anand R, Sharma G, Simone G, Kaneshige K, Taylor L, Al‐Uzri A, Hornik C, Sokol G, Speicher D, Sullivan J, Mourani P, Mendley S, Meyer M, Atkins R, Flynn J, Vaughns J, Sherwin C, Delmore P, Goldstein S, Rathore M, Melloni C, Muller W, Delmore P, Tremoulet A, James L, Mendley S, Blackford M, Atz A, Adu‐Darko M, Mourani P, Watt K, Hornik C, Al‐Uzri A, Sullivan J, Laughon M, Brian Smith P, Watt K, Cheifetz I, Atz A, Bhatt‐Mehta V, Fernandez A, Lowry J. Use of
physiologically‐based
pharmacokinetic modeling to inform dosing of the opioid analgesics fentanyl and methadone in children with obesity. CPT Pharmacometrics Syst Pharmacol 2022; 11:778-791. [PMID: 35491971 PMCID: PMC9197535 DOI: 10.1002/psp4.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 11/12/2022] Open
Abstract
Obesity is an increasingly alarming public health threat, with nearly 20% of children classified as obese in the United States today. Children with obesity are commonly prescribed the opioids fentanyl and methadone, and accurate dosing is critical to reducing the risk of serious adverse events associated with overexposure. However, pharmacokinetic studies in children with obesity are challenging to conduct, so there is limited information to guide fentanyl and methadone dosing in these children. To address this clinical knowledge gap, physiologically‐based pharmacokinetic models of fentanyl and methadone were developed in adults and scaled to children with and without obesity to explore the interplay of obesity, age, and pharmacogenomics. These models included key obesity‐induced changes in physiology and pharmacogenomic effects. Model predictions captured observed concentrations in children with obesity well, with an overall average fold error of 0.72 and 1.08 for fentanyl and methadone, respectively. Model simulations support a reduced fentanyl dose (1 vs. 2 μg/kg/h) starting at an earlier age (6 years) in virtual children with obesity, highlighting the importance of considering both age and obesity status when selecting an infusion rate most likely to achieve steady‐state concentrations within the target range. Methadone dosing simulations highlight the importance of considering genotype in addition to obesity status when possible, as cytochrome P450 (CYP)2B6*6/*6 virtual children with obesity required half the dose to match the exposure of wildtype children without obesity. This physiologically‐based pharmacokinetic modeling approach can be applied to explore dosing of other critical drugs in children with obesity.
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Affiliation(s)
- Jacqueline G. Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Fernando O. Carreño
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Jennifer L. Ford
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | | | - Eliana M. Perrin
- Department of Pediatrics, School of Medicine and School of Nursing Johns Hopkins University Baltimore Maryland USA
| | - Kevin M. Watt
- Division of Pediatric Clinical Pharmacology, School of Medicine University of Utah Salt Lake City Utah USA
| | - William J. Muller
- Ann and Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Andrew M. Atz
- Medical University of South Carolina Children's Hospital Charleston South Carolina USA
| | - Amira Al‐Uzri
- Oregon Health and Science University Portland Oregon USA
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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3
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Antoniou T, McCormack D, Tadrous M, Juurlink DN, Gomes T. The Risk of Ventricular Dysrhythmia or Sudden Death in Patients Receiving Serotonin Reuptake Inhibitors With Methadone: A Population-Based Study. Front Pharmacol 2022; 13:861953. [PMID: 35517813 PMCID: PMC9065276 DOI: 10.3389/fphar.2022.861953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Methadone is associated with ventricular dysrhythmias and sudden death. Serotonin reuptake inhibitors (SRIs) may increase the risk of these events either by inhibiting metabolism of methadone’s proarrhythmic (S)-enantiomer, additive QT interval prolongation, or both. We sought to determine whether certain SRIs were associated with a higher risk of methadone-related ventricular dysrhythmias or sudden death. Methods: We conducted a nested case-control study of Ontario residents receiving methadone between April 1, 1996 and December 31, 2017. Cases, defined as patients who died of sudden cardiac death or were hospitalized with a ventricular dysrhythmia while on methadone, were matched with up to four controls who also received methadone on age, sex, and a disease risk score. We determined the odds ratio (OR) and p-value functions for the association between methadone-related cardiotoxicity and treatment with SRIs known to inhibit metabolism of (S)-methadone (paroxetine, fluvoxamine, sertraline) or prolong the QT interval (citalopram and escitalopram). Patients who were not treated with an SRI served as the reference group. Results: During the study period, we identified 626 cases and 2,299 matched controls. Following multivariable adjustment, we found that recent use of sertraline, fluvoxamine or paroxetine (adjusted OR 1.30; 95% confidence intervals [CI] 0.90–1.86) and citalopram and escitalopram (adjusted OR 1.26; 95% CI 0.97–1.63) were associated with small increases in the risk methadone-related cardiac toxicity, an assertion supported by the corresponding p-value functions. Interpretation: Certain SRIs may be associated with a small increase in cardiac toxicity in methadone-treated patients.
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Affiliation(s)
- Tony Antoniou
- Department of Family and Community Medicine, Unity Health Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | | | - Mina Tadrous
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - David N Juurlink
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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4
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Flanagan R, Shepherd R. Methadone-related death in detention. J Forensic Leg Med 2022; 88:102356. [DOI: 10.1016/j.jflm.2022.102356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
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5
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Guo D, Tan Z, Lou X, Shi S, Shu Y, Zhou H, Yu L, Yang H. A genetic-based population PK/PD modeling of methadone in Chinese opiate dependence patients. Eur J Clin Pharmacol 2022; 78:565-578. [PMID: 35013802 DOI: 10.1007/s00228-021-03227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/25/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The full potential of methadone maintenance treatment (MMT) is often limited by the large inter-individual variability in both pharmacokinetics (PK) and pharmacodynamics (PD), and by the risk of torsade de pointes, a severe adverse effect caused by QTc prolongation. The current study aims to quantitate the contribution of genetic polymorphisms and other variables in PK/PD variability, and their contribution to the QTc interval prolongation in Chinese MMT patients. METHODS Population PK models were developed to fit (R)- and (S)-methadone PK data. Hierarchical models were tested to characterize the PK profile, the concentration-QTc relationship, and concentration-urinalysis illicit drug testing relationship, with demographics and genetic variants being included as covariates. Simulation based on the developed PK/PD models was performed to assess the effect of methadone dose and genetic variants on QTc interval prolongation. RESULTS The PK data were best-fit by a one-compartment, first-order absorption model. Clearance of (R)- and (S)-methadone was both affected by the weighted activity score derived from genetic variants. A linear model was used to describe both the methadone concentration-urinalysis illicit drug testing relationship and the methadone concentration-QTc relationship. Concentration of (R)- and (S)-methadone exhibits a comparable effect on QTc prolongation. Simulation showed that the percentage of QTc higher than 450 ms was almost doubled in the lowest clearance group as compared the highest when methadone dose was greater than 120 mg. CONCLUSIONS The large variability in PK/PD profiles can be partially explained by the genetic variants in an extent different from other population, which confirmed the necessity to conduct such a study in the specific Chinese patients.
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Affiliation(s)
- Dong Guo
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland at Baltimore, Baltimore, MD, USA
| | - Zhirong Tan
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xiaoya Lou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,Department of Pharmacy, The First Hospital of Changsha, Changsha, 410008, Hunan, China
| | - Shan Shi
- Nanning Red Cross Hospital, Nanning, 530000, Guangxi, China
| | - Yan Shu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland at Baltimore, Baltimore, MD, USA
| | - Honghao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Li Yu
- Guangxi University of Chinese Medicine, Nanning, 530000, Guangxi, China.
| | - Hong Yang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China. .,Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland at Baltimore, Baltimore, MD, USA.
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6
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Magarbeh L, Gorbovskaya I, Le Foll B, Jhirad R, Müller DJ. Reviewing pharmacogenetics to advance precision medicine for opioids. Biomed Pharmacother 2021; 142:112060. [PMID: 34523422 DOI: 10.1016/j.biopha.2021.112060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Adequate opioid prescribing is critical for therapeutic success of pain management. Despite the widespread use of opioids, optimized opioid therapy remains unresolved with risk of accidental lethal overdosing. With the emergence of accumulating evidence linking genetic variation to opioid response, pharmacogenetic based treatment recommendations have been proposed. OBJECTIVE The aim of this review is to evaluate pharmacogenetic evidence and provide an overview on genes involved in the pharmacokinetics and pharmacodynamics of opioids. METHODS For this review, a systematic literature search of published articles was used in PubMed®, with no language restriction and between the time period of January 2000 to December 2020. We reviewed randomized clinical studies, study cohorts and case reports that investigated the influence of genetic variants on selected opioid pharmacokinetics and pharmacodynamics. In addition, we reviewed current CPIC clinical recommendations for pharmacogenetic testing. RESULTS Results of this review indicate consistent evidence supporting the association between selected genetic variants of CYP2D6 for opioid metabolism. CPIC guidelines include recommendations that indicate the avoidance of tramadol use, in addition to codeine, in CYP2D6 poor metabolizers and ultrarapid metabolizers, and to monitor intermediate metabolizers for less-than-optimal response. While there is consistent evidence for OPRM1 suggesting increased postoperative morphine dosing requirements in A118G G-allele carriers, the clinical relevance remains limited. CONCLUSION There is emerging evidence of clinical relevance of CYP2D6 and, to a lesser extent, OPRM1 polymorphism in personalized opioid drug dosing. As a result, first clinics have started to implement pharmacogenetic guidelines for CYP2D6 and codeine.
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Affiliation(s)
- Leen Magarbeh
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Ilona Gorbovskaya
- Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Reuven Jhirad
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Office of the Chief Coroner and Ontario Forensic Pathology Service, Toronto, ON, Canada
| | - Daniel J Müller
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada.
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7
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Aruldhas BW, Quinney SK, Overholser BR, Heathman MA, Masters AR, Ly RC, Gao H, Packiasabapathy S, Sadhasivam S. Pharmacokinetic modeling of R and S-Methadone and their metabolites to study the effects of various covariates in post-operative children. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2021; 10:1183-1194. [PMID: 34435753 PMCID: PMC8520746 DOI: 10.1002/psp4.12687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022]
Abstract
Methadone is a synthetic opioid used as an analgesic and for the treatment of opioid abuse disorder. The analgesic dose in the pediatric population is not well-defined. The pharmacokinetics (PKs) of methadone is highly variable due to the variability in alpha-1 acid glycoprotein (AAG) and genotypic differences in drug-metabolizing enzymes. Additionally, the R and S enantiomers of methadone have unique PK and pharmacodynamic properties. This study aims to describe the PKs of R and S methadone and its metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) in pediatric surgical patients and to identify sources of inter- and intra-individual variability. Children aged 8-17.9 years undergoing orthopedic surgeries received intravenous methadone 0.1 mg/kg intra-operatively followed by oral methadone 0.1 mg/kg postoperatively every 12 h. Pharmacokinetics of R and S methadone and EDDP were determined using liquid chromatography tandem mass spectrometry assays and the data were modeled using nonlinear mixed-effects modeling in NONMEM. R and S methadone PKs were well-described by two-compartment disposition models with first-order absorption and elimination. EDDP metabolites were described by one compartment disposition models with first order elimination. Clearance of both R and S methadone were allometrically scaled by bodyweight. CYP2B6 phenotype was a determinant of the clearance of both the enantiomers in an additive gene model. The intronic CYP3A4 single-nucleotide polymorphism (SNP) rs2246709 was associated with decreased clearance of R and S methadone. Concentrations of AAG and the SNP of AAG rs17650 independently increased the volume of distribution of both the enantiomers. The knowledge of these important covariates will aid in the optimal dosing of methadone in children.
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Affiliation(s)
- Blessed W. Aruldhas
- Department of AnesthesiaIndiana University School of MedicineIndianapolisIndianaUSA
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Pharmacology and Clinical PharmacologyChristian Medical CollegeVelloreIndia
| | - Sara K. Quinney
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Obstetrics and GynecologyIndiana University School of MedicineIndianapolisIndianaUSA
- Center for Computational Biology and BioinformaticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Brian R. Overholser
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Pharmacy PracticePurdue University College of PharmacyIndianapolisIndianaUSA
| | | | - Andrea R. Masters
- Clinical Pharmacology Analytical CoreIndiana University Simon Comprehensive Cancer CenterIndiana University School of MedicineIndianapolisIndianaUSA
| | - Reynold C. Ly
- Division of Clinical PharmacologyDepartment of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Hongyu Gao
- Department of Medical and Molecular GeneticsCenter for Medical GenomicsIndiana University School of MedicineIndianapolisIndianaUSA
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8
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Langmia IM, Just KS, Yamoune S, Brockmöller J, Masimirembwa C, Stingl JC. CYP2B6 Functional Variability in Drug Metabolism and Exposure Across Populations-Implication for Drug Safety, Dosing, and Individualized Therapy. Front Genet 2021; 12:692234. [PMID: 34322158 PMCID: PMC8313315 DOI: 10.3389/fgene.2021.692234] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022] Open
Abstract
Adverse drug reactions (ADRs) are one of the major causes of morbidity and mortality worldwide. It is well-known that individual genetic make-up is one of the causative factors of ADRs. Approximately 14 million single nucleotide polymorphisms (SNPs) are distributed throughout the entire human genome and every patient has a distinct genetic make-up which influences their response to drug therapy. Cytochrome P450 2B6 (CYP2B6) is involved in the metabolism of antiretroviral, antimalarial, anticancer, and antidepressant drugs. These drug classes are commonly in use worldwide and face specific population variability in side effects and dosing. Parts of this variability may be caused by single nucleotide polymorphisms (SNPs) in the CYP2B6 gene that are associated with altered protein expression and catalytic function. Population variability in the CYP2B6 gene leads to changes in drug metabolism which may result in adverse drug reactions or therapeutic failure. So far more than 30 non-synonymous variants in CYP2B6 gene have been reported. The occurrence of these variants show intra and interpopulation variability, thus affecting drug efficacy at individual and population level. Differences in disease conditions and affordability of drug therapy further explain why some individuals or populations are more exposed to CYP2B6 pharmacogenomics associated ADRs than others. Variabilities in drug efficacy associated with the pharmacogenomics of CYP2B6 have been reported in various populations. The aim of this review is to highlight reports from various ethnicities that emphasize on the relationship between CYP2B6 pharmacogenomics variability and the occurrence of adverse drug reactions. In vitro and in vivo studies evaluating the catalytic activity of CYP2B6 variants using various substrates will also be discussed. While implementation of pharmacogenomic testing for personalized drug therapy has made big progress, less data on pharmacogenetics of drug safety has been gained in terms of CYP2B6 substrates. Therefore, reviewing the existing evidence on population variability in CYP2B6 and ADR risk profiles suggests that, in addition to other factors, the knowledge on pharmacogenomics of CYP2B6 in patient treatment may be useful for the development of personalized medicine with regards to genotype-based prescription.
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Affiliation(s)
- Immaculate M. Langmia
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Katja S. Just
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Sabrina Yamoune
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Collen Masimirembwa
- African Institute of Biomedical Science and Technology (AiBST), Harare, Zimbabwe
| | - Julia C. Stingl
- Institute of Clinical Pharmacology, University Hospital of Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
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9
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Packiasabapathy S, Aruldhas BW, Zhang P, Overholser BR, Quinney SK, Sadhasivam S. Novel associations between CYP2B6 polymorphisms, perioperative methadone metabolism and clinical outcomes in children. Pharmacogenomics 2021; 22:591-602. [PMID: 34100292 PMCID: PMC8238023 DOI: 10.2217/pgs-2021-0039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Methadone exhibits significant variability in clinical response. This study explores the genetic influence of variable methadone pharmacokinetics. Methods: This is a prospective study of methadone in children undergoing major surgery. CYP2B6 genotyping, plasma methadone and metabolite levels were obtained. Clinical outcomes include pain scores and postoperative nausea and vomiting (PONV). Results: CYP2B6 poor metabolizers (*6/*6) had >twofold lower methadone metabolism compared with normal/rapid metabolizers. The incidence of PONV was 4.7× greater with CYP2B6 rs1038376 variant. AG/GG variants of rs2279343 SNP had 2.86-fold higher incidence of PONV compared with the wild variant (AA). Nominal associations between rs10500282, rs11882424, rs4803419 and pain scores were observed. Conclusion: We have described novel associations between CYP2B6 genetic variants and perioperative methadone metabolism, and associations with pain scores and PONV.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Blessed W Aruldhas
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, 632 004, India
| | - Pengyue Zhang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Brian R Overholser
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN 46202, USA
| | - Sara K Quinney
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Center for Computational Biology & Bioinformatics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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10
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Brandl E, Halford Z, Clark MD, Herndon C. Pharmacogenomics in Pain Management: A Review of Relevant Gene-Drug Associations and Clinical Considerations. Ann Pharmacother 2021; 55:1486-1501. [PMID: 33771051 DOI: 10.1177/10600280211003875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To provide an overview of clinical recommendations regarding genomic medicine relating to pain management and opioid use disorder. DATA SOURCES A literature review was conducted using the search terms pain management, pharmacogenomics, pharmacogenetics, pharmacokinetics, pharmacodynamics, and opioids on PubMed (inception to February 1, 2021), CINAHL (2016 through February 1, 2021), and EMBASE (inception through February 1, 2021). STUDY SELECTION AND DATA EXTRACTION All relevant clinical trials, review articles, package inserts, and guidelines evaluating applicable pharmacogenotypes were considered for inclusion. DATA SYNTHESIS More than 300 Food and Drug Administration-approved medications contain pharmacogenomic information in their labeling. Genetic variability may alter the therapeutic effects of commonly prescribed pain medications. Pharmacogenomic-guided therapy continues to gain traction in clinical practice, but a multitude of barriers to widespread pharmacogenomic implementation exist. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Pain is notoriously difficult to treat given the need to balance safety and efficacy when selecting pharmacotherapy. Pharmacogenomic data can help optimize outcomes for patients with pain. With improved technological advances, more affordable testing, and a better understanding of genomic variants resulting in treatment disparities, pharmacogenomics continues to gain popularity. Unfortunately, despite these and other advancements, pharmacogenomic testing and implementation remain underutilized and misunderstood in clinical care, in part because of a lack of health care professionals trained in assessing and implementing test results. CONCLUSIONS A one-size-fits-all approach to pain management is inadequate and outdated. With increasing genomic data and pharmacogenomic understanding, patient-specific genomic testing offers a comprehensive and personalized treatment alternative worthy of additional research and consideration.
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Affiliation(s)
- Emily Brandl
- Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | | | - Matthew D Clark
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chris Herndon
- Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, USA.,St Louis University School of Medicine, MO, USA
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11
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Titus-Lay EN, Jaynes HA, Tomaselli Muensterman E, Walroth TA, Ott CA, Desta Z, Williams G, Moe PR, Wilbrandt M, Tisdale JE. Methadone-associated QT interval prolongation in patients undergoing maintenance therapy in an urban opioid treatment program. Pharmacotherapy 2021; 41:238-246. [PMID: 33345336 DOI: 10.1002/phar.2498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/27/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE Methadone is associated with QT interval prolongation and torsades de pointes. The objective of this study was to (a) determine the incidence of QT interval prolongation among patients on maintenance methadone therapy in an urban opioid treatment program (OTP), (b) compare characteristics of patients who developed methadone-associated QT prolongation with those who did not develop QT prolongation, and (c) investigate the relationship between QT interval prolongation and stereospecific serum methadone and metabolite [2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP)] concentrations. DESIGN Prospective study. SETTING Urban opioid treatment program (OTP). PATIENTS n = 93 patients on maintenance methadone therapy in an urban OTP. INTERVENTION Patients underwent a 12-lead electrocardiogram (ECG) prior to initiating methadone and again during steady-state maintenance methadone therapy. In a subset (n = 43), blood was obtained to determine serum (S)- and (R)-methadone and (S)- and (R)-EDDP concentrations, which were compared in patients who developed Bazett's-corrected QT (QTc) prolongation [≥470 ms (men) or ≥480 ms (women) and/or ≥60 ms lengthening from pretreatment value] with those who did not have QTc prolongation. MEASUREMENTS AND MAIN RESULTS Mean [± standard deviation (SD)] age was 36 ± 12 years; 73% were female, and 74% were white. QTc prolongation occurred in 14 (15.1%) patients. Patients who developed QTc prolongation were older (41 ± 13 vs. 35 ± 9 years, p = 0.03) and had a longer pre-methadone QTc compared with those who did not have QTc prolongation (429 ± 11 vs. 420 ± 20 ms, respectively, p = 0.02). Serum (S)-methadone concentrations were higher in patients with QTc prolongation compared to patients without prolongation (199 ± 81 vs. 128 ± 68 ng/ml, respectively, p = 0.01), whereas the difference in serum (R)-methadone concentrations between the groups did not reach significance (189 ± 68 vs. 125 ± 60 ng/ml, respectively, p = 0.08). Serum (R)-methadone concentrations correlated with QTc intervals [R2 = 0.15 (95% confidence interval (CI) 0.11-0.62, p = 0.0009)]. The correlation between serum (S)-methadone concentrations and QTc did not reach significance [R2 = 0.08 (95% CI -0.01 to 0.54, p = 0.06)]. Serum (S)-and (R)-EDDP concentrations were not significantly different between the groups and did not significantly correlate with QTc intervals. CONCLUSIONS Approximately 15% of patients taking maintenance methadone therapy developed QT interval prolongation. Both serum (S)- and (R)-methadone concentrations, but not (S)- or (R)-EDDP, contribute to methadone-associated QT prolongation.
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Affiliation(s)
- Erika N Titus-Lay
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA.,College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,College of Pharmacy, California Northstate University, Elk Grove, California, USA
| | - Heather A Jaynes
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA
| | - Elena Tomaselli Muensterman
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,AbbVie Inc., North Chicago, Illinois, USA
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA
| | - Carol A Ott
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA.,College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | | | - Paul R Moe
- Sandra Eskenazi Health Mental Health Center Opioid Treatment Program, Indianapolis, Indiana, USA
| | - Michelle Wilbrandt
- Sandra Eskenazi Health Mental Health Center Opioid Treatment Program, Indianapolis, Indiana, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,School of Medicine, Indiana University, Indianapolis, Indiana, USA
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12
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Guidi M, Csajka C, Buclin T. Parametric Approaches in Population Pharmacokinetics. J Clin Pharmacol 2020; 62:125-141. [DOI: 10.1002/jcph.1633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/09/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Monia Guidi
- Center for Research and Innovation in Clinical Pharmaceutical Sciences Lausanne University Hospital and University of Lausanne Lausanne Switzerland
- Service of Clinical Pharmacology Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences Lausanne University Hospital and University of Lausanne Lausanne Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland University of Geneva University of Lausanne Geneva Lausanne Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology Lausanne University Hospital and University of Lausanne Lausanne Switzerland
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13
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Terrier J, Daali Y, Fontana P, Csajka C, Reny JL. Towards Personalized Antithrombotic Treatments: Focus on P2Y 12 Inhibitors and Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 58:1517-1532. [PMID: 31250210 DOI: 10.1007/s40262-019-00792-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oral anticoagulants and antiplatelet drugs are commonly prescribed to lower the risk of cardiovascular diseases, such as venous and arterial thrombosis, which represent the leading causes of mortality worldwide. A significant percentage of patients taking antithrombotics will nevertheless experience bleeding or recurrent ischemic events, and this represents a major public health issue. Cardiovascular medicine is now questioning the one-size-fits-all policy, and more personalized approaches are increasingly being considered. However, the available tools are currently limited and they are only moderately able to predict clinical events or have a significant impact on clinical outcomes. Predicting concentrations of antithrombotics in blood could be an effective means of personalization as they have been associated with bleeding and recurrent ischemia. Target concentration interventions could take advantage of physiologically based pharmacokinetic (PBPK) and population-based pharmacokinetic (POPPK) models, which are increasingly used in clinical settings and have attracted the interest of governmental regulatory agencies, to propose dosages adapted to specific population characteristics. These models have the benefit of combining parameters from different sources, such as experimental in vitro data and patients' demographic, genetic, and physiological in vivo data, to characterize the dose-concentration relationships of compounds of interest. As such, they can be used to predict individual drug exposure. In the near future, these models could therefore be a valuable means of predicting personalized antithrombotic blood concentrations and, hopefully, of preventing clinical non-response or bleeding in a given patient. Existing approaches for personalization of antithrombotic prescriptions will be reviewed using practical examples for P2Y12 inhibitors and direct oral anticoagulants. The review will additionally focus on the existing PBPK and POPPK models for these two categories of drugs. Lastly, we address potential scenarios for their implementation in clinics, along with the main limitations and challenges.
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Affiliation(s)
- Jean Terrier
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland.,Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Youssef Daali
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Clinical Pharmacology and Toxicology Service, Anesthesiology, Pharmacology and Intensive Care Department, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Chantal Csajka
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Jean-Luc Reny
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland. .,Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland. .,Division of Internal Medicine and Rehabilitation, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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14
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Seguí HA, Melin K, Quiñones DS, Duconge J. A review of the pharmacogenomics of buprenorphine for the treatment of opioid use disorder. JOURNAL OF TRANSLATIONAL GENETICS AND GENOMICS 2020; 4:263-277. [PMID: 33274315 PMCID: PMC7709797 DOI: 10.20517/jtgg.2020.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
As the opioid epidemic continues to grow across the United States, the number of patients requiring treatment for opioid use disorder continues to climb. Although medication-assisted treatment presents a highly effective tool that can help address this epidemic, its use has been limited. Nonetheless, with easier dosing protocols (compared to the more complex dosing required of methadone due to its long and variable half-life) and fewer prescribing limitations (may be prescribed outside the setting of federally approved clinics), the increase in buprenorphine use in the United States has been dramatic in recent years. Despite buprenorphine's demonstrated efficacy, patient-specific factors can alter the response to the medications, which may lead to treatment failure in some patients. Clinical characteristics (sex, concurrent medications, and mental health comorbidities) as well as social determinants of health (housing status, involvement with the criminal justice system, and socioeconomic status) may impact treatment outcomes. Furthermore, a growing body of data suggests that genetic variations can alter pharmacological effects and influence therapeutic response. This review will cover the available pharmacogenomic data for the use of buprenorphine in the management of opioid use disorders. Pharmacogenomic determinants that affect opioid receptors, the dopaminergic system, metabolism of buprenorphine, and adverse events are discussed. Although much of the existing data comes from observational studies, clinical research is ongoing. Nevertheless, the development of pharmacogenomic-guided strategies has the potential to reduce opioid misuse, improve clinical outcomes, and save healthcare resources.
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Affiliation(s)
| | - Kyle Melin
- Department of Pharmacy Practice, School of Pharmacy, University of Puerto Rico Medical Sciences Campus, San Juan, PR 00936, USA
| | - Darlene Santiago Quiñones
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Puerto Rico Medical Sciences Campus, San Juan, PR 00936, USA
| | - Jorge Duconge
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Puerto Rico Medical Sciences Campus, San Juan, PR 00936, USA
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15
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Packiasabapathy S, Aruldhas BW, Horn N, Overholser BR, Quinney SK, Renschler JS, Sadhasivam S. Pharmacogenomics of methadone: a narrative review of the literature. Pharmacogenomics 2020; 21:871-887. [PMID: 32705966 DOI: 10.2217/pgs-2020-0040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background: Methadone, a synthetic opioid with longer duration of action and lower abuse potential compared with morphine, is used to prevent opioid withdrawal, as well as to manage chronic and acute surgical pain. The variability in response to methadone has been widely recognized. The purpose of this article is to review the literature on the pharmacogenetic factors underlying this variability. Materials & methods: This is a narrative overview of the literature on the genetic variants affecting pharmacodynamics and pharmacokinetics of methadone, retrieved from searches of databases such as PubMed and google scholar. Discussion: Clinical responses to methadone may be affected by genetic variants in the opioidergic, dopaminergic and neurotrophic pathways. Polymorphisms in genes related to disposition and elimination of methadone alter the pharmacokinetics, and possibly pharmacodynamics of methadone. Cytochrome P450 enzymes and P-glycoprotein variants contribute to the interindividual variability in methadone pharmacokinetics. Evidence for single gene variants affecting methadone response remains weak. Multiple genetic variants must be considered in conjunction to improve predictive ability. Conclusion: Evidence remains scarce at this time, to recommend pharmacogenetic testing before methadone administration. Well-powered clinical studies are needed with population pharmacokinetic-pharmacodynamic modeling and multigenetic signature-based predictions to enable tailored use of methadone in clinical practice.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Blessed W Aruldhas
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, 632002, India
| | - Nicole Horn
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Brian R Overholser
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN 47907, USA
| | - Sara K Quinney
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Center for Computational Biology & Bioinformatics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Janelle S Renschler
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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16
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Kelty E, Hulse G, Joyce D, Preen DB. Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality. CNS Drugs 2020; 34:629-642. [PMID: 32215842 DOI: 10.1007/s40263-020-00719-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.
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Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia.
| | - Gary Hulse
- Division of Psychiatry, Medical School, The University of Western Australia, Perth, WA, Australia.,Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
| | - David Joyce
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia
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17
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Victorri-Vigneau C, Verstuyft C, Bouquié R, Laforgue EJ, Hardouin JB, Leboucher J, Le Geay B, Dano C, Challet-Bouju G, Grall-Bronnec M. Relevance of CYP2B6 and CYP2D6 genotypes to methadone pharmacokinetics and response in the OPAL study. Br J Clin Pharmacol 2019; 85:1538-1543. [PMID: 30907440 DOI: 10.1111/bcp.13936] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/07/2019] [Accepted: 03/17/2019] [Indexed: 02/07/2023] Open
Abstract
AIMS Our study aimed to evaluate the impacts of the cytochrome P450 (CYP) 2B6-G516T and CYP2D6 genetic polymorphisms on pharmacokinetic and clinical parameters in patients receiving methadone maintenance treatment. METHODS Opioid PhArmacoLogy (OPAL) was a clinical survey of the sociodemographic characteristics, history and consequences of pathology associated with methadone maintenance treatment response and current addictive comorbidities. A subgroup of 72 methadone patients was genotyped. RESULTS When comparing the three CYP2B6 genotype groups, the methadone (R)- and (S)-methadone enantiomer concentrations/doses (concentrations relative to doses) were different (P = .029, P = .0019). The CYP2D6 phenotypes did not seem to be relevant with regard to methadone levels. On multivariate analysis, neither the CYP2B6 genotype nor the CYP2D6 phenotype explained the (R)-methadone concentration/dose values (P = .92; P = .86); the (S)-methadone concentration/dose values (P = .052; P = .95 [although there was a difference between the TT group and GT and GG groups {P = .019}]); or opiate cessation (P = .12; P = .90). CONCLUSION The genotyping of CYP2B6 G516T could be an interesting tool to explore methadone intervariability.
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Affiliation(s)
- Caroline Victorri-Vigneau
- INSERM UMR_S1178, Team "Depression and Antidepressants", Medicine Faculty, CESP, Paris-Sud University, Le Kremlin Bicêtre, France.,INSERM UMR 1246, SPHERE, Methods in Patient-Centered Outcomes and Health Research, Nantes and Tours University, Nantes and Tours, France.,Clinical Pharmacology Department, CHU Nantes, Nantes, France
| | - Céline Verstuyft
- INSERM UMR_S1178, Team "Depression and Antidepressants", Medicine Faculty, CESP, Paris-Sud University, Le Kremlin Bicêtre, France.,Molecular Genetics, Pharmacogenetics and Hormonology Departments, Bicêtre Hospital, Group Paris-Sud, AP-HP, Le Kremlin Bicêtre, France
| | - Régis Bouquié
- Clinical Pharmacology Department, CHU Nantes, Nantes, France
| | - Edouard-Jules Laforgue
- INSERM UMR 1246, SPHERE, Methods in Patient-Centered Outcomes and Health Research, Nantes and Tours University, Nantes and Tours, France.,Clinical Pharmacology Department, CHU Nantes, Nantes, France.,Addictology and Psychiatry Department, CHU Nantes, Nantes, France
| | - Jean-Benoit Hardouin
- INSERM UMR 1246, SPHERE, Methods in Patient-Centered Outcomes and Health Research, Nantes and Tours University, Nantes and Tours, France
| | | | | | - Corine Dano
- Addictology department, CHU Angers, Angers, France
| | - Gaëlle Challet-Bouju
- INSERM UMR 1246, SPHERE, Methods in Patient-Centered Outcomes and Health Research, Nantes and Tours University, Nantes and Tours, France.,Addictology and Psychiatry Department, CHU Nantes, Nantes, France
| | - Marie Grall-Bronnec
- INSERM UMR 1246, SPHERE, Methods in Patient-Centered Outcomes and Health Research, Nantes and Tours University, Nantes and Tours, France.,Addictology and Psychiatry Department, CHU Nantes, Nantes, France
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Abstract
Opioid use disorder (OUD) is a significant health problem in the United States and many other countries. A combination of issues, most notably increased prescription of opioid analgesics, has resulted in climbing rates of opioid abuse and overdose over the last decade. This ongoing epidemic has produced a growing population of patients requiring treatment for OUD. Medications such as methadone and buprenorphine have well documented success rates in treating the disorder compared with placebo. However, significant percentages of the population still fail to maintain abstinence or reduce illicit opioid use while using such medications. Genetic variation may play a role in this variability in outcome through pharmacokinetic or pharmacodynamic effects on OUD medications, or by affecting the rate of negative side effects and adverse events. This review focuses on the existing literature on the pharmacogenetics of OUD treatment, with specific focus on medication metabolism, treatment outcomes, and adverse events.
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Ahmad T, Valentovic MA, Rankin GO. Effects of cytochrome P450 single nucleotide polymorphisms on methadone metabolism and pharmacodynamics. Biochem Pharmacol 2018; 153:196-204. [PMID: 29458047 DOI: 10.1016/j.bcp.2018.02.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/14/2018] [Indexed: 01/11/2023]
Abstract
Methadone is a synthetic, long-acting opioid with a single chiral center forming two enantiomers, (R)-methadone and (S)-methadone, each having specific pharmacological actions. Concentrations of (R)- and (S)-methadone above therapeutic levels have the ability to cause serious, life-threatening, and fatal side effects. This toxicity can be due in part to the pharmacogenetics of an individual, which influences the pharmacokinetic and pharmacodynamic properties of the drug. Methadone is primarily metabolized in the liver by cytochrome P450 (CYP) enzymes, predominately by CYP2B6, followed by CYP3A4, 2C19, 2D6, and to a lesser extent, CYP2C18, 3A7, 2C8, 2C9, 3A5, and 1A2. Single nucleotide polymorphisms (SNPs) located within CYPs have the potential to play an important role in altering methadone metabolism and pharmacodynamics. Several SNPs in the CYP2B6, 3A4, 2C19, 2D6, and 3A5 genes result in increases in methadone plasma concentrations, decreased N-demethylation, and decreased methadone clearance. In particular, carriers of CYP2B6*6/*6 may have a greater risk for detrimental adverse effects, as methadone metabolism and clearance are diminished in these individuals. CYP2B6*4, on the other hand, has been observed to decrease plasma concentrations of methadone due to increased methadone clearance. The involvement, contribution, and understanding the role of SNPs in CYP2B6, and other CYP genes, in methadone metabolism can improve the therapeutic uses of methadone in patient outcome and the development of personalized medicine.
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Affiliation(s)
- Taha Ahmad
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA
| | - Monica A Valentovic
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA
| | - Gary O Rankin
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25755-9310, USA.
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21
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Mijatović V, Samojlik I, Petković S, Vukmirović S, Uvelin A, Dickov A. Cardiovascular effects of methadone and concomitant use of diazepam during methadone maintenance treatment induction: low concentration risk. Expert Opin Drug Saf 2017; 16:1323-1328. [PMID: 28934555 DOI: 10.1080/14740338.2017.1382470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim is to evaluate the role of diazepam concentrations in development of low-concentration-methadone-associated QTc prolongation in patients with opioid use disorder during methadone maintenance treatment (MMT) induction. RESEARCH DESIGN AND METHODS Individuals with addiction disorder on MMT were studied before the beginning of MMT and after one and six months of MMT. Serum concentrations of methadone, diazepam, electrolytes and ECG were analyzed. RESULTS Thirty patients were enrolled. The mean methadone concentration at time points was 177 ± 119 ng/ml and 343 ± 182 ng/ml, while the mean diazepam concentration was 561 ± 437 ng/ml and 1045 ± 933 ng/ml. The QTc interval before the introduction of MMT, after 1 and 6 months of MMT were 412 ± 27 ms, 425 ± 18 ms and 424 ± 15 ms, respectively, showing statistically significant increase in the length of QTc interval after 1 and 6 months of MMT. Statistically significant correlation between the concentration of methadone and QTc interval length at observed time points (R2 = 0.239, p = 0.018; R2 = 0.513, p = 0.006) was shown, and it remained so if the concentration of diazepam was included (R2 = 0.347, p = 0.026, R2 = 0.513, p = 0.009). CONCLUSIONS The prolongation of QTc below the risk threshold in low methadone therapeutic doses has been recorded and concomitant use of diazepam could be a co-factor in such issue.
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Affiliation(s)
- Vesna Mijatović
- a Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine , University of Novi Sad , Novi Sad , Serbia
| | - Isidora Samojlik
- a Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine , University of Novi Sad , Novi Sad , Serbia
| | - Stojan Petković
- b Department of Forensic Medicine, Faculty of Medicine , University of Novi Sad , Novi Sad , Serbia
| | - Saša Vukmirović
- a Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine , University of Novi Sad , Novi Sad , Serbia
| | - Arsen Uvelin
- c Department of Anesthesia and Perioperative Medicine, Faculty of Medicine , University of Novi Sad , Novi Sad , Serbia
| | - Aleksandra Dickov
- d Department of Psychiatry, Faculty of Medicine , University of Novi Sad , Novi Sad , Serbia
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22
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Bogen DL, Hanusa BH, Perel JM, Sherman F, Mendelson MA, Wisner KL. Corrected QT Interval and Methadone Dose and Concentrations in Pregnant and Postpartum Women. J Clin Psychiatry 2017; 78:e1013-e1019. [PMID: 28994902 PMCID: PMC7044002 DOI: 10.4088/jcp.16m11318] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/02/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Methadone is a standard treatment for opioid dependence in pregnancy; however, its impact on maternal corrected QT interval (QTc) has not been evaluated. We studied the association between methadone dose and enantiomer-specific plasma concentrations and QTc among pregnant and postpartum women and newborns. We assessed the relevance of QTc screening guidelines for pregnant women and infants. METHODS From 2006 to 2008, plasma methadone concentrations were measured during pregnancy, postpartum, and in cord blood in women treated for opioid dependence at a single treatment program. Electrocardiograms (ECGs) were obtained at peak methadone concentrations in mothers and within 48 hours of birth for infants. Pearson correlations were performed at each time point for QTc and R-methadone, S-methadone, and total methadone concentrations and ratio of R-methadone/S-methadone concentrations. RESULTS Mean (SD) daily methadone dose for the 25 women was 94.2 (39.1) mg during pregnancy and 112.5 (46.6) mg postpartum. During the third trimester, higher methadone dose and R-methadone concentration correlated with longer QTc (Pearson r = 0.67, P < .001 and Pearson r = 0.49, P = .02, respectively), while S-methadone concentration, R-methadone/S-methadone concentration ratio, and total methadone concentration did not. Postpartum, QTc did not significantly correlate with dose or enantiomer concentrations. Infant QTc did not correlate with maternal dose at delivery or enantiomer-specific cord methadone concentrations. In pregnant and postpartum women, 13% and 17%, respectively, had QTc ≥ 450 ms, as did 19% of infants. CONCLUSIONS QTc correlated with dose and R-methadone concentration during the third trimester. However, longer QTc was common among women during and after pregnancy. Given the relatively high rate of QTc > 450 ms, an ECG before and after methadone initiation is advisable for pregnant and postpartum women.
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Affiliation(s)
- Debra L. Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania,Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania,Corresponding author: Debra L. Bogen, MD, FAAP, FABM, University of Pittsburgh School of Medicine, Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, 3414 Fifth Ave, CHOB 3rd floor, Pittsburgh, PA 15213 ()
| | - Barbara H. Hanusa
- Department of Pediatrics, University of Pittsburgh School of Medicine, Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - James M. Perel
- Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
| | - Frederick Sherman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Division of Pediatric Cardiology, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marla A. Mendelson
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katherine L. Wisner
- Department of Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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