Morphine-3-glucuronide: hyperglycemic and neuroendocrine potentiating effects

Differences in absorption, distribution, metabolism and excretion of xenobiotics between the paediatric and adult populations

In children, the therapeutic benefits and potential risks associated with drug treatment may be different from those in adults and will depend on the exposure, receptor sensitivity and relationship between effect and exposure. In this paper, key factors undergoing maturational changes accounting for differences in drug metabolism and disposition in the paediatric population compared with adults are reviewed. Gastric and duodenal pH, gastric emptying time, intestinal transit time, secretion and activity of bile and pancreatic fluid, bacterial colonisation and transporters, such as P-glycoprotein (P-gp), are important factors for drug absorption, whereas key factors explaining differences in drug distribution between the paediatric population and adults are organ size, membrane permeability, plasma protein concentration and characteristics, endogenous substances in plasma, total body and extracellular water, fat content, regional blood flow and transporters such as P-gp, which is present not only in the gut, but also in liver, kidney, brain and other tissues. As far as drug metabolism is concerned, important differences have been found in the paediatric population compared with adults both for phase I enzymes (oxidative [e.g., cytochrome P450 (CYP)1A2, and CYP3A7 versus -3A4], reductive and hydrolytic enzymes) and phase II enzymes (e.g., N-methyltransferases and glucuronosyltransferases). Generally, the major enzyme differences observed in comparison with the adult age are in newborn infants, although for some enzymes (e.g., glucuronosyltransferases and other phase II enzymes) important differences still exist between infants and toddlers and adults. Finally, key factors undergoing maturational changes accounting for differences in renal excretion in the paediatric population compared with adults are glomerular filtration and tubular secretion. The ranking of the key factors varies according to the chemical structure and physicochemical properties of the drug examined, as well as to the characteristics of its formulation. It would be important to generate additional information on the developmental aspects of renal P-gp and of other renal transporters, as has been done and is still being done with the different -isozymes involved in drug metabolism.

Single- and Multiple-Dose Pharmacokinetic and Dose-Proportionality Study of??Oxymorphone Immediate-Release Tablets

INTRODUCTION

Oxymorphone hydrochloride (referred to as oxymorphone), a semisynthetic mu-opioid agonist, is known to produce a more rapid onset of action and greater analgesic potency compared with its parent compound, morphine. Until recently, oxymorphone has been available only in suppository and intravenous formulations. This study examined the pharmacokinetics and dose proportionality of a new immediate-release (IR) tablet formulation of oxymorphone and its metabolites (6-OH-oxymorphone and oxymorphone-3-glucuronide) following single- and multiple-dose administration in healthy volunteers.

STUDY DESIGN

A randomised, three-way crossover design was employed, with a target sample size of 24 healthy men and women.

METHODS

A single dose of oxymorphone IR (5, 10 and 20mg) was administered on day 1. After drug washout on day 2, study participants then received the same dose every 6 hours (22 total doses) on days 3 to 8. Treatment periods were separated by a 7-day washout. Naltrexone hydrochloride was coadministered to prevent opioid-related adverse events. Blood was collected up to 48 hours after day 1 to determine single-dose pharmacokinetics and up to 6 hours after the last dose for determination of pharmacokinetics at steady state.

RESULTS

Twenty-three of 24 enrolled subjects (12 men, 11 women) completed the study. Following a single dose of 5, 10 or 20mg, the oxymorphone IR mean area under the plasma concentration versus time curve from time zero to infinity ([AUC(infinity)] 4.5, 9.1 and 20.1 microg . h/L, respectively) and maximum plasma concentration ([C(max)] 1.1, 1.9 and 4.4 microg/L, respectively) confirmed dose proportionality. 6-OH-oxymorphone and oxymorphone-3-glucuronide also increased in an approximate 2-fold fashion. Similar results were observed for AUC and C(max) of oxymorphone and its metabolites at steady state. Steady state was achieved within 3 days of 6-hourly administration. The median t(max) (time to reach C(max)) was 0.5 hours for all single doses of oxymorphone and at steady state, and the terminal elimination half-life (t(1/2)) was approximately 7.3-9.4 hours. Adverse events were generally mild, and no clinically significant changes in laboratory or other safety variables were noted.

DISCUSSION

Because successful pain management often requires careful drug titration across a wide therapeutic dose range, it is important that opioid formulations provide predictable increases in drug concentration with increasing dose. The single-dose and steady-state pharmacokinetic profiles of oxymorphone IR tablets were linear and dose proportional across the dose range from 5 to 20mg.

Morphine metabolites as novel analgesic drugs?

PURPOSE OF REVIEW

Morphine metabolites have attracted continuing interest for their contribution to the desired and unwanted effects of morphine. Among the metabolites of morphine, morphine-6-glucuronide has been given most scientific attention. It accounts for 10% of the morphine metabolism, acts as an agonist at mu-opioid receptors and exerts antinociceptive effects. This review summarizes the recent findings on morphine-6-glucuronide and discusses its potential use as an analgesic.

RECENT FINDINGS

Morphine-6-glucuronide has a very long delay between the time course of its plasma concentrations and the time course of its central nervous effects, with 6-8 h probably the longest transfer half-life between plasma and effect site of all opioids administered in humans. This complicates the control of morphine-6-glucuronide therapy when used as an intravenous analgesic, and the long duration of action confers no advantage over other opioids because long-lasting opioid analgesia can be readily obtained with sustained release formulations of other opioids. During acute treatment, however, morphine-6-glucuronide appears to be sufficiently potent to exert peripheral analgesic effects, without exerting major central nervous opioid side effects for a short period of time. The side effects profile does not clearly separate morphine-6-glucuronide from morphine, with reports of similar side effects. There are contrasting reports, however, about similar or less respiratory depression and other side effects compared with morphine after systemic injection.

SUMMARY

Morphine-6-glucuronide might qualify as an analgesic but it has several pharmacological properties that make it far from ideal for therapeutic use. Whether it will be a useful addition to the currently established analgesics has yet to be demonstrated.

Differential responses of brain, liver, and muscle glycogen to opiates and surgical stress

We examined the effects of intracerebroventricular (ICV) cannula implantation followed by the administration of morphine sulfate (MOR) and its metabolite, morphine-6-glucuronide (M6G), on the glycogen content of the brain, liver, and muscle. ICV cannulation resulted in nearly a 30% reduction in brain glycogen, and ICV MOR resulted in a 36% reduction in liver glycogen content compared to time-matched controls, but it had no additional effect on either the brain or muscle glycogen content. ICV M6G showed a more significant reduction, to 50% of liver glycogen, but it had no effect on either brain or muscle glycogen. Neither IV MOR nor M6G produced any significant alteration in tissue glycogen content. These results indicate that the stress response associated with neurosurgery, especially the placement of the ICV cannula, is associated with a decrement in brain glycogen. The activation of opioid receptors in the brain results in enhanced hepatic glycogenolysis but has no additional effect on the brain glycogen content.

Central opiate modulation of growth hormone and insulin-like growth factor-I

The effects of central administration of morphine-sulfate (MOR:80 micrograms) and morphine-6-glucuronide (M6G:1 microgram) on the growth hormone (GH)/insulin-like growth factor (IGF) system were assessed. MOR and M6G were injected intracerebroventricularly (ICV) in chronically catheterized 24 h fasted rats; time-matched control animals received H2O (5 microliters). MOR increased plasma GH concentrations 3-fold 2 h after i.c.v. injection, and transiently increased the plasma concentration and liver content of IGF-I (60% and 90%, respectively) 30 min after i.c.v injection. M6G did not produce any significant alterations in plasma GH and IGF-I levels at the time-points measured. Both MOR and M6G increased the concentration of IGF binding protein-1 (IGFBP-1) in plasma and liver 2 h after injection. However, MOR showed 2- to 2.5-fold greater effect than M6G in stimulating plasma and liver IGFBP-1. MOR and M6G produced similar increases in plasma epinephrine (5-fold), norepinephrine (3-fold) and corticosterone (1.5-fold). Neither opiate significantly altered circulating insulin levels. These findings suggest that opiate modulation of GH and IGF may be hormone-independent and centrally modulated. We speculate that differential affinities of MOR and M6G to the different opiate receptor subtypes might be responsible for their distinct effects on GH/IGF-I system.