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Wu A, Raack EJ, Ross CJD, Carleton BC. Implementation and Evaluation Strategies for Pharmacogenetic Testing in Hospital Settings: A Scoping Review. Ther Drug Monit 2024:00007691-990000000-00266. [PMID: 39264345 DOI: 10.1097/ftd.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/01/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Pharmacogenetic testing in clinical settings has improved the safety and efficacy of drug treatment. There is a growing number of studies evaluating pharmacogenetic implementation and identifying barriers and facilitators. However, no review has focused on bridging the gap between identifying barriers and facilitators of testing and the clinical strategies adopted in response. This review was conducted to understand the implementation and evaluation strategies of pharmacogenetic testing programs. METHODS A PRISMA-compliant scoping review was conducted. The included studies discussed pharmacogenetic testing programs implemented in a hospital setting. Quantitative, qualitative, and mixed design methods were included. RESULTS A total of 232 of the 7043 articles that described clinical pharmacogenetic programs were included. The most common specialties that described pharmacogenetic implementation were psychiatry (26%) and oncology (16%), although many studies described institutional programs implemented across multiple specialties (19%). Different specialties reported different clinical outcomes, but all reported similar program performance indicators, such as test uptake and the number of times the test recommendations were followed. There were benefits and drawbacks to delivering test results through research personnel, pharmacists, and electronic alerts, but active engagement of physicians was necessary for the incorporation of pharmacogenetic results into clinical decision making. CONCLUSIONS Further research is required on the maintenance and sustainability of pharmacogenetic testing initiatives. These findings provide an overview of the implementation and evaluation strategies of different specialties that can be used to improve pharmacogenetic testing.
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Affiliation(s)
- Angela Wu
- Department of Experimental Medicine, University of British Columbia
- BC Children's Hospital Research Institute
| | - Edward J Raack
- BC Children's Hospital Research Institute
- Department of Medical Genetics, University of British Columbia
| | - Colin J D Ross
- BC Children's Hospital Research Institute
- Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia; and
| | - Bruce C Carleton
- BC Children's Hospital Research Institute
- Department of Medical Genetics, University of British Columbia
- Division of Translational Therapeutics, Department of Pediatrics, University of British Columbia; and
- Therapeutic Evaluation Unit, Provincial Health Services Authority, Vancouver, British Columbia, Canada
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2
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Qin W, Zhang L, Wang X, Liu B, Xu L, Liu L, Fan B. ABCB1 genetic polymorphisms affect opioid requirement by altering function of the intestinal P-glycoprotein. Biomed Pharmacother 2024; 176:116897. [PMID: 38850645 DOI: 10.1016/j.biopha.2024.116897] [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: 04/15/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/10/2024] Open
Abstract
The association between polymorphisms of the human ATP binding cassette subfamily B member 1 (ABCB1) gene and opioid response has attracted intense attention recently. As the ABCB1 gene encodes for the transporter P-glycoprotein in the brain and intestine involved in the pharmacokinetics of opioids, we investigated the effects of ABCB1 genetic polymorphisms on doses of opioids for pain relief and determined which pharmacokinetic process was affected in cancer pain patients. Sixty-eight cancer pain patients admitted for intrathecal therapy (ITT) were included. The association between ABCB1 genetic polymorphisms (C3435T, C1236T, G2677T/A and A61G) and systemic doses of opioids before ITT were investigated. Concentrations of oxycodone in plasma and cerebrospinal fluid (CSF) were determined by HPLC-MS/MS in 17 patients treated with oral oxycodone before ITT, and the influences of ABCB1 genetic polymorphisms on plasma-concentration to oral-dose ratios and CSF-concentration to plasma-concentration ratios of oral oxycodone were further analyzed. ABCB1 C3435T and G2677T/A polymorphisms were significantly associated with systemic doses of opioids before ITT, which coincided with the influences of ABCB1 C3435T and G2677T/A polymorphisms on the ratios of plasma-concentration to oral-dose. However, no significant difference was found in ratios of CSF-concentration to plasma-concentration among ABCB1 SNP genotypes. The present study provided the first evidence that ABCB1 C3435T and G2677T/A polymorphisms affect opioid requirement in cancer pain patients via altering transportation function of P-glycoprotein in the intestine, which will further expand our knowledge about pharmacokinetics of opioids and could contribute to the individualization of opioids use.
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Affiliation(s)
- Wangjun Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing 100029, China
| | - Lei Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xiaoxue Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing 100029, China
| | - Botao Liu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing 100029, China
| | - Liyuan Xu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing 100029, China
| | - Lihong Liu
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing 100029, China.
| | - Bifa Fan
- Department of Pain Management, China-Japan Friendship Hospital, Beijing 100029, China.
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3
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Lewandrowski KU, Sharafshah A, Elfar J, Schmidt SL, Blum K, Wetzel FT. A Pharmacogenomics-Based In Silico Investigation of Opioid Prescribing in Post-operative Spine Pain Management and Personalized Therapy. Cell Mol Neurobiol 2024; 44:47. [PMID: 38801645 PMCID: PMC11129978 DOI: 10.1007/s10571-024-01466-5] [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: 12/07/2023] [Accepted: 02/26/2024] [Indexed: 05/29/2024]
Abstract
Considering the variability in individual responses to opioids and the growing concerns about opioid addiction, prescribing opioids for postoperative pain management after spine surgery presents significant challenges. Therefore, this study undertook a novel pharmacogenomics-based in silico investigation of FDA-approved opioid medications. The DrugBank database was employed to identify all FDA-approved opioids. Subsequently, the PharmGKB database was utilized to filter through all variant annotations associated with the relevant genes. In addition, the dpSNP ( https://www.ncbi.nlm.nih.gov/snp/ ), a publicly accessible repository, was used. Additional analyses were conducted using STRING-MODEL (version 12), Cytoscape (version 3.10.1), miRTargetLink.2, and NetworkAnalyst (version 3). The study identified 125 target genes of FDA-approved opioids, encompassing 7019 variant annotations. Of these, 3088 annotations were significant and pertained to 78 genes. During variant annotation assessments (VAA), 672 variants remained after filtration. Further in-depth filtration based on variant functions yielded 302 final filtered variants across 56 genes. The Monoamine GPCRs pathway emerged as the most significant signaling pathway. Protein-protein interaction (PPI) analysis revealed a fully connected network comprising 55 genes. Gene-miRNA Interaction (GMI) analysis of these 55 candidate genes identified miR-16-5p as a pivotal miRNA in this network. Protein-Drug Interaction (PDI) assessment showed that multiple drugs, including Ibuprofen, Nicotine, Tramadol, Haloperidol, Ketamine, L-Glutamic Acid, Caffeine, Citalopram, and Naloxone, had more than one interaction. Furthermore, Protein-Chemical Interaction (PCI) analysis highlighted that ABCB1, BCL2, CYP1A2, KCNH2, PTGS2, and DRD2 were key targets of the proposed chemicals. Notably, 10 chemicals, including carbamylhydrazine, tetrahydropalmatine, Terazosin, beta-methylcholine, rubimaillin, and quinelorane, demonstrated dual interactions with the aforementioned target genes. This comprehensive review offers multiple strong, evidence-based in silico findings regarding opioid prescribing in spine pain management, introducing 55 potential genes. The insights from this report can be applied in exome analysis as a pharmacogenomics (PGx) panel for pain susceptibility, facilitating individualized opioid prescribing through genotyping of related variants. The article also points out that African Americans represent an important group that displays a high catabolism of opioids and suggest the need for a personalized therapeutic approach based on genetic information.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Division of Personalized Pain Therapy Research & Education, Center for Advanced Spine Care of Southern Arizona, Arizona, USA.
- Department of Orthopaedics, Fundación Universitaria Sanitas and Member of Colombian National Academy of Medicine, Bogotá, DC, Colombia.
- Department of Orthopedics, Doctor honoris causa Hospital Universitário Gaffree Guinle Universidade Federal do Estado do Rio de Janeiro, and Member of the Brazilian National Academy of Medicine, Rio de Janeiro, Brazil.
- Center for Advanced Spine Care of Southern Arizona, 4787 E Camp Lowell Drive, Tucson, USA.
| | - Alireza Sharafshah
- Cellular and Molecular Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - John Elfar
- Department of Orthopaedics and Sports Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Sergio Luis Schmidt
- Department of Neurology, Federal University of Rio de Janeiro (UNIRIO), University Hospital, Rua Mariz e Barros 750, Tijuca, Rio de Janeiro, RJ, Brazil
| | - Kenneth Blum
- Division of Nutrigenomics, SpliceGen, Therapeutics, Inc., Austin, TX, 78701, USA
- Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, OH, 45435, USA
- Division of Addiction Research & Education, Center for Sports, Exercise, & Mental Health, Western University Health Sciences, Pomona, CA, 91766, USA
- The Kenneth Blum Behavioral & Neurogenetic Institute, LLC., Austin, TX, 78701, USA
| | - Franklin Todd Wetzel
- Department of Orthopaedic Surgery & Sports Medicine, Director of Musculoskeletal Services Bassett Healthcare Network 1 Atwell Road, Cooperstown, NY, 13326, USA
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Wixson RL, Dunnenberger HM, Dickerson DM, Tauchen AJ, Heshmat CM, Koh JL. Pain and Opioid use Following Total Knee Arthroplasty: Psycho-Social Factors are More Predictive Than Pharmacogenomics. J Arthroplasty 2024; 39:1214-1219. [PMID: 38081553 DOI: 10.1016/j.arth.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND This prospective, observational study was designed to assess the phenotype variation of the genes associated with pain and opioid use following total knee arthroplasty (TKA) in comparison to psycho-social elements. METHODS Preoperative demographic data and Patient-Reported Outcomes Measurement Information System-43 scores were obtained on 305 elective TKA patients. Patient visual analog scale pain scores and opioid use were extracted from the hospital record. Following discharge, participants completed a daily log of visual analog scale pain score, and medications used over 30 days. Pharmacogenomic testing was performed for three genes, CYP2D6, COMT, and OPRM1, which are involved in the opioid pathway and pain modulation. RESULTS Other than increased pain seen in the COMT high activity group while in the hospital, none of the phenotype variations of the three genes were significantly associated with the participants' pain or opioid use. The Patient-Reported Outcomes Measurement Information System-43 domains of pain interference and anxiety were significantly associated with pain and opioid use using multiple logistic regression. CONCLUSIONS Pharmacogenomic testing in this study was not predictive of pain and opioid use following TKA compared with psycho-social variables.
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Affiliation(s)
- Richard L Wixson
- NorthShore Orthopaedic and Spine Institute, NorthShore University Health System, Skokie, Illinois
| | - Henry M Dunnenberger
- Mark R Neaman Center for Personalized Medicine, NorthShore University Health System, Evanston, Illinois
| | - David M Dickerson
- NorthShore Orthopaedic and Spine Institute, NorthShore University Health System, Skokie, Illinois
| | | | - Claire M Heshmat
- Biostatistics Division, Research Institute, NorthShore University Health System, Evanston, Illinois
| | - Jason L Koh
- NorthShore Orthopaedic and Spine Institute, NorthShore University Health System, Skokie, Illinois
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Ferreira do Couto ML, Fonseca S, Pozza DH. Pharmacogenetic Approaches in Personalized Medicine for Postoperative Pain Management. Biomedicines 2024; 12:729. [PMID: 38672085 PMCID: PMC11048650 DOI: 10.3390/biomedicines12040729] [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: 01/31/2024] [Revised: 03/08/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Despite technical and pharmacological advancements in recent years, including optimized therapies and personalized medicine, postoperative pain management remains challenging and sometimes undertreated. This review aims to summarize and update how genotype-guided therapeutics within personalized medicine can enhance postoperative pain management. Several studies in the area have demonstrated that genotype-guided therapy has the ability to lower opioid consumption and improve postoperative pain. Gene mutations, primarily OPRM1, CYP2D6, CYP2C9, COMT and ABCB1, have been shown to exert nuanced influences on analgesic response and related pharmacological outcomes. This review underscores the integration of pharmacogenetic-guided personalized medicine into perioperative care, particularly when there is uncertainty regarding opioid prescriptions. This approach leads to superior outcomes in terms of postoperative pain relief and reduced morbidity for numerous patients.
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Affiliation(s)
- Maria Leonor Ferreira do Couto
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, 4200-319 Porto, Portugal;
| | - Sara Fonseca
- Anesthesiology Department, São João University Hospital Centre, 4200-135 Porto, Portugal;
| | - Daniel Humberto Pozza
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, 4200-319 Porto, Portugal;
- Institute for Research and Innovation in Health and IBMC (i3S), University of Porto, 4200-135 Porto, Portugal
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Kraus MB, Bingham JS, Kekic A, Erickson C, Grilli CB, Seamans DP, Upjohn DP, Hentz JG, Clarke HD, Spangehl MJ. Does Preoperative Pharmacogenomic Testing of Patients Undergoing TKA Improve Postoperative Pain? A Randomized Trial. Clin Orthop Relat Res 2024; 482:291-300. [PMID: 37594401 PMCID: PMC10776165 DOI: 10.1097/corr.0000000000002767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/09/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Pharmacogenomics is an emerging and affordable tool that may improve postoperative pain control. One challenge to successful pain control is the large interindividual variability among analgesics in their efficacy and adverse drug events. Whether preoperative pharmacogenomic testing is worthwhile for patients undergoing TKA is unclear. QUESTIONS/PURPOSES (1) Are the results of preoperative pharmacogenetic testing associated with lower postoperative pain scores as measured by the Overall Benefit of Analgesic Score (OBAS)? (2) Do the results of preoperative pharmacogenomic testing lead to less total opioids given? (3) Do the results of preoperative pharmacogenomic testing lead to changes in opioid prescribing patterns? METHODS Participants of this randomized trial were enrolled from September 2018 through December 2021 if they were aged 18 to 80 years and were undergoing primary TKA under general anesthesia. Patients were excluded if they had chronic kidney disease, a history of chronic pain or narcotic use before surgery, or if they were undergoing robotic surgery. Preoperatively, patients completed pharmacogenomic testing (RightMed, OneOME) and a questionnaire and were randomly assigned to the experimental group or control group. Of 99 patients screened, 23 were excluded, one before randomization; 11 allocated patients in each group did not receive their allocated interventions for reasons such as surgery canceled, patients ultimately undergoing spinal anesthesia, and change in surgery plan. Another four patients in each group were excluded from the analysis because they were missing an OBAS report. This left 30 patients for analysis in the control group and 38 patients in the experimental group. The control and experimental groups were similar in age, gender, and race. Pharmacogenomic test results for patients in the experimental group were reviewed before surgery by a pharmacist, who recommended perioperative medications to the clinical team. A pharmacist also assessed for clinically relevant drug-gene interactions and recommended drug and dose selection according to guidelines from the Clinical Pharmacogenomics Implementation Consortium for each patient enrolled in the study. Patients were unaware of their pharmacogenomic results. Pharmacogenomic test results for patients in the control group were not reviewed before surgery; instead, standard perioperative medications were administered in adherence to our institutional care pathways. The OBAS (maximum 28 points) was the primary outcome measure, recorded 24 hours postoperatively. A two-sample t-test was used to compare the mean OBAS between groups. Secondary measures were the mean 24-hour pain score, total morphine milligram equivalent, and frequency of opioid use. Postoperatively, patients were assessed for pain with a VAS (range 0 to 10). Opioid use was recorded preoperatively, intraoperatively, in the postanesthesia care unit, and 24 hours after discharge from the postanesthesia care unit. Changes in perioperative opioid use based on pharmacogenomic testing were recorded, as were changes in prescription patterns for postoperative pain control. Preoperative characteristics were also compared between patients with and without various phenotypes ascertained from pharmacogenomic test results. RESULTS The mean OBAS did not differ between groups (mean ± SD 4.7 ± 3.7 in the control group versus 4.2 ± 2.8 in the experimental group, mean difference 0.5 [95% CI -1.1 to 2.1]; p = 0.55). Total opioids given did not differ between groups or at any single perioperative timepoint (preoperative, intraoperative, or postoperative). We found no difference in opioid prescribing pattern. After adjusting for multiple comparisons, no difference was observed between the treatment and control groups in tramadol use (41% versus 71%, proportion difference 0.29 [95% CI 0.05 to 0.53]; nominal p = 0.02; adjusted p > 0.99). CONCLUSION Routine use of pharmacogenomic testing for patients undergoing TKA did not lead to better pain control or decreased opioid consumption. Future studies might focus on at-risk populations, such as patients with chronic pain or those undergoing complex, painful surgical procedures, to test whether pharmacogenomic results might be beneficial in certain circumstances. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Molly B. Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Colby Erickson
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | | | - David P. Seamans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - David P. Upjohn
- Center for Regenerative Biotherapeutics, Mayo Clinic, Phoenix, AZ, USA
| | - Joseph G. Hentz
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Henry D. Clarke
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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7
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Khanna AK, Gan TJ. Perioperative Precision Medicine and Bedside Decision Making: Still a Case of Great Expectations? Anesth Analg 2022; 134:896-899. [PMID: 35427262 DOI: 10.1213/ane.0000000000006001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ashish K Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
| | - Tong J Gan
- Outcomes Research Consortium, Cleveland, Ohio
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Zhao J, Cai S, Zhang L, Rao Y, Kang X, Feng Z. Progress, Challenges, and Prospects of Research on the Effect of Gene Polymorphisms on Adverse Reactions to Opioids. Pain Ther 2022; 11:395-409. [PMID: 35429333 PMCID: PMC9098754 DOI: 10.1007/s40122-022-00374-0] [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: 01/01/2022] [Accepted: 03/07/2022] [Indexed: 11/28/2022] Open
Abstract
The abuse of opioids has become one of the most serious concerns in the world. Opioid use can cause serious adverse reactions, including respiratory depression, postoperative nausea and vomiting, itching, and even death. These adverse reactions are also important complications of clinical application of opioid drugs that may affect patient safety and recovery. Due to the fear of adverse reactions of opioids, clinicians often do not dare to use opioids in an adequate or appropriate amount, thus affecting the clinical medication strategy and the quality of treatment for patients. The prediction of adverse reactions to opioids is one of the most concerned problems in clinical practice. At present, the correlation between gene polymorphism and the efficacy of opiates has been widely studied and preliminarily confirmed, but the research on the effect of gene polymorphism on the adverse reactions of opiates is relatively limited. Existing studies have made encouraging progress in predicting the incidence and severity of adverse opioid reactions and clinical management by using genetic testing, but most of these studies are single-center, small-sample clinical studies or animal experiments, which have strong limitations. When the same receptor or enzyme is studied by different experimental methods, different or even opposite conclusions can be drawn. These phenomena indicate that the correlation between gene polymorphism and adverse opioid reaction still needs further research and demonstration. At present, it is still too early to use genetic testing to predict opioid adverse reactions in clinic. In this paper, the correlation between gene polymorphism and adverse opioid reactions and a small number of clinical applications were reviewed in terms of pharmacokinetics and pharmacodynamics, in order to provide some suggestions for future research and clinical drug decision making.
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Morozova TE, Shatsky DA, Shikh NV, Shikh EV, Andrushchyshina TB, Lukina MV, Kachanova AA, Sozaeva ZA, Shuev GN, Denisenko NP, Grishina EA, Sychev DA. Evaluation of the Influence of CYP2C9* 2, CYP2C9*3 Gene Polymorphisms on the Efficacy and Safety of Postoperative Analgesia with Ketoprofen in Patients after Cardiac Surgery. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-08-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim. The aim of the study was to evaluate the efficacy and safety of ketoprofen as an analgesic therapy in patients with CYP2C9*2 (430C>T) rs179985 and CYP2C9*3 (1075A>C) rs1057910 gene polymorphisms after cardiac surgery.Material and methods. The study included 90 patients. Postoperative analgesia was perfomed by ketoprofen 100 mg intramuscularly twice daily. The evaluation of pain was determined daily by Numeric Rating Scale for 5 days after cardiac surgery. The safety of ketoprofen was determined by assessing the severity of gastroenterological symptoms using the Gastrointestinal Symptom Rating Scale questionnaire and determining the frequency of episodes of acute kidney injury. The material for DNA was venous blood. To determine the single nucleotide genetic polymorphisms CYP2C9*2 (430C>T) rs179985 and CYP2C9*3 (1075A>C) rs1057910, the real-time polymerase chain reaction was used.Results. In patients with the AA genotype of CYP2C9*3 polymorphism, the intensity of pain on the numeric rating scale scale (points) was significantly higher than in patients with the AC genotype: 7 [6; 8] vs 6 [5; 6] (р=0,003), 7 [6; 8] vs 6 [5; 6] (р=0,04), 6 [5; 7] vs 5 [4; 5] (р=0,04), 5 [3; 6] vs 3 [3; 4] points (р=0,02) on days 1, 2, 3 and 5 of the postoperative period, respectively. The severity of gastroenterological symptoms was higher in patients with a heterozygous CT genotype for the allelic variant CYP2C9*2 than in patients with a wild CС genotype and amounted to 19 [19; 22] vs 18 [16; 20] points, respectively, (p=0,04). The distribution of genotypes for CYP2C9*2 polymorphisms and CYP2C9*3 polymorphisms between the groups of acute renal injury did not differ significantly.Conclusion. Associations of polymorphisms CYP2C9*3 with a lower intensity of pain syndrome and CYP2C9*2 with a greater severity of gastroenterological symptoms were revealed.
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Affiliation(s)
| | | | - N. V. Shikh
- I.M. Sechenov First Moscow State Medical University
| | - E. V. Shikh
- I.M. Sechenov First Moscow State Medical University
| | | | - M. V. Lukina
- I.M. Sechenov First Moscow State Medical University
| | - A. A. Kachanova
- Russian Medical Academy of Continuing Professional Education
| | - Zh. A. Sozaeva
- Russian Medical Academy of Continuing Professional Education
| | - G. N. Shuev
- Russian Medical Academy of Continuing Professional Education
| | - N. P. Denisenko
- Russian Medical Academy of Continuing Professional Education
| | - E. A. Grishina
- Russian Medical Academy of Continuing Professional Education
| | - D. A. Sychev
- Russian Medical Academy of Continuing Professional Education
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10
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Rodriguez Cairoli F, Appiani F, Sambade JM, Comandé D, Camacho Arteaga L, Ciapponi A. Efficacy and safety of opioid therapy guided by pharmacogenetics: a systematic review. Pharmacogenomics 2021; 22:573-586. [PMID: 34013775 DOI: 10.2217/pgs-2021-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim: To perform a systematic review to determine the efficacy/safety of PGx-guided opioid therapy for chronic/postoperative pain. Materials & methods: We searched PubMed and other specialized databases. Articles were considered if they compared the efficacy/safety of PGx-guided opioid therapy versus usual care. The risk of bias assessment was performed using Cochrane tools. Results: A total of 3794 records were retrieved. Only five were included for data extraction. A lower requirement of analgesics during postoperative in the PGx-guided intervention arm was reported in two studies. Also, two studies reported significant pain improvement in favor of the PGx-guided therapy when analyzing the subgroup of patients with a high-risk CYP2D6 phenotype. Conclusion: Despite the findings described, information on the efficacy/safety of this intervention is scarce.
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Affiliation(s)
- Federico Rodriguez Cairoli
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani, Buenos Aires, 2024 (C1014CPV), Argentina.,Neuropsychopharmacology Unit, Pharmacology Division, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Francisco Appiani
- Neuropsychopharmacology Unit, Pharmacology Division, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Juan Manuel Sambade
- Servicio de Clínica Médica, Hospital "Prof. Dr. Bernardo Houssay" Asociado a la Universidad de Buenos Aires, Municipalidad de Vicente Lopez, Buenos Aires, Argentina
| | - Daniel Comandé
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani, Buenos Aires, 2024 (C1014CPV), Argentina
| | - Lina Camacho Arteaga
- Department of Clinical Pharmacology, University Hospital Hall d' Hebron, Barcelona, Spain
| | - Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani, Buenos Aires, 2024 (C1014CPV), Argentina
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11
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Weckwerth GM, Dionísio TJ, Costa YM, Zupelari-Gonçalves P, Oliveira GM, Torres EA, Bonjardim LR, Faria FAC, Calvo AM, Moore T, Absher DM, Santos CF. Multifocal Analysis of Acute Pain After Third Molar Removal. Front Pharmacol 2021; 12:643874. [PMID: 33935738 PMCID: PMC8082138 DOI: 10.3389/fphar.2021.643874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To analyze the pain modulation capacity profile in a Brazilian population, the relationship between opioid receptor (OPRM1) and Catechol-O-methyltransferase (COMT) 1polymorphisms and pain modulation capacity was determined through preoperative pain modulation tests and acute postoperative pain control evaluation, swelling, and trismus in 200 volunteers undergoing lower third molar removal. Methods: Psychologic and clinical parameters were measured. Patient DNA was sequenced for single nucleotide polymorphisms in OPRM1 and COMT, and the salivary concentration of interleukin (IL)-2 (IL)-6, interferon (IFN)-γ and tumor necrosis factor (TNF)-α was evaluated. Primary outcomes were the influence of all predictors on the fluctuation of pain intensity using a visual analogue scale (VAS), and swelling and trismus on the 2nd and 7th postoperative days. Preoperative pain modulation capacity (CPM), pain catastrophizing scale (PCS), body mass index (BMI), and surgery duration and difficulty were evaluated. Results: Salivary concentration of IFN-γ and IL-2 as well as the duration of surgery influenced the fluctuation of postoperative pain in the VAS, and in the sum of the differences in pain intensity test at 8, 48, and 96 h. BMI influenced swelling, while both BMI and COMT haplotype influenced trismus on the 2nd postoperative day. Conclusion: Polymorphisms in COMT, salivary concentrations of IL-2 and IFN-γ, BMI, and duration of surgery were predictors for pain fluctuation, swelling, and trismus on the 2nd day after lower third molar extraction. This therapy was effective in controlling inflammatory symptomatology after lower third molar extraction and ibuprofen was well tolerated by patients. Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03169127.
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Affiliation(s)
- Giovana Maria Weckwerth
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Thiago José Dionísio
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Yuri Martins Costa
- Department of Biosciences, Piracicaba Dental School, University of Campinas, Piracicaba, Brazil
| | - Paulo Zupelari-Gonçalves
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Gabriela Moraes Oliveira
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Elza Araújo Torres
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | | | | | - Adriana Maria Calvo
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
| | - Troy Moore
- Kailos Genetics Inc., HudsonAlpha Institute for Biotechnology, Huntsville, AL, United States
| | | | - Carlos Ferreira Santos
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, Brazil
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12
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Weckwerth GM, Dionísio TJ, Costa YM, Colombini-Ishiquiriama BL, Oliveira GM, Torres EA, Bonjardim LR, Calvo AM, Moore T, Absher DM, Santos CF. CYP450 polymorphisms and clinical pharmacogenetics of ibuprofen after lower third molar extraction. Eur J Clin Pharmacol 2020; 77:697-707. [PMID: 33205280 DOI: 10.1007/s00228-020-03046-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/13/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE This study hypothesized that drugs accumulate in the bloodstream of poor-metabolizing patients and may have more adverse effects and different pain perceptions and aimed to investigate the influence of CYP450 polymorphisms on acute postoperative pain, swelling, and trismus controlled by ibuprofen (600 mg) in 200 volunteers after dental extraction. In addition, surgical outcomes can determine pain, edema, and trismus and indicate inflammatory reactions after oral surgeries. METHODS Genetic sequencing was performed to identify CYP450 polymorphisms and the surgical parameters evaluated: pre and postoperative swelling, trismus, and temperature; self-reported postoperative pain with visual analog scale (VAS); rescue medication consumed; and severity of adverse reactions. RESULTS A multiple linear regression model with independent variables [single nucleotide polymorphisms (SNPs), BMI (body mass index), duration, and difficulty of surgery] and dependent variables [postoperative pain by sum of pain intensity difference (SPID), trismus, and swelling] was used for analysis. The duration of surgery was a predictor for pain at 8 h and 96 h after surgery, and BMI was a predictor for both swelling and trismus on the 2nd postoperative day. When evaluating CYP2C8 and C9 genotyped SNPs, it was observed that normal metabolizers showed higher pain levels than the intermediate/poor metabolizers on the postoperative periods as compared with time 0 h. In another analysis, the poor metabolizers for CYP2C8 and C9 presented lower levels of postoperative pain after 8 h and used rescue medication earlier than normal metabolizers. CONCLUSION Ibuprofen 600 mg was very effective in controlling inflammatory pain after lower third molar surgeries, without relevant adverse reactions; although in a very subtle way, patients with poor metabolism had higher levels of pain in the first hours, and no longer after 8 h, and used pain relief medication earlier. TRIAL REGISTRATION The study was registered with ClinicalTrials.gov ID (NCT03169127), on March 16th, 2017.
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Affiliation(s)
- Giovana M Weckwerth
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil
| | - Thiago J Dionísio
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil
| | - Yuri M Costa
- Piracicaba Dental School, Department of Physiological Sciences, University of Campinas, Piracicaba, SP, Brazil
| | - Bella L Colombini-Ishiquiriama
- Bauru School of Dentistry, Department of Pediatric Dentistry, Orthodontics and Community Health, University of São Paulo, Bauru, SP, Brazil
| | - Gabriela M Oliveira
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil
| | - Elza A Torres
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil
| | - Leonardo R Bonjardim
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil
| | - Adriana M Calvo
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil
| | - Troy Moore
- Kailos Genetics Inc., Huntsville, AL, USA
| | - Devin M Absher
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, USA
| | - Carlos F Santos
- Discipline of Pharmacology, Bauru School of Dentistry, Department of Biological Sciences, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, SP, 17012-901, Brazil.
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13
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Rollason V, Lloret-Linares C, Lorenzini KI, Daali Y, Gex-Fabry M, Piguet V, Besson M, Samer C, Desmeules J. Evaluation of Phenotypic and Genotypic Variations of Drug Metabolising Enzymes and Transporters in Chronic Pain Patients Facing Adverse Drug Reactions or Non-Response to Analgesics: A Retrospective Study. J Pers Med 2020; 10:E198. [PMID: 33121061 PMCID: PMC7711785 DOI: 10.3390/jpm10040198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 12/11/2022] Open
Abstract
This retrospective study evaluates the link between an adverse drug reaction (ADR) or a non-response to treatment and cytochromes P450 (CYP), P-glycoprotein (P-gp) or catechol-O-methyltransferase (COMT) activity in patients taking analgesic drugs for chronic pain. Patients referred to a pain center for an ADR or a non-response to an analgesic drug between January 2005 and November 2014 were included. The genotype and/or phenotype was obtained for assessment of the CYPs, P-gp or COMT activities. The relation between the event and the result of the genotype and/or phenotype was evaluated using a semi-quantitative scale. Our analysis included 243 individual genotypic and/or phenotypic explorations. Genotypes/phenotypes were mainly assessed because of an ADR (n = 145, 59.7%), and the majority of clinical situations were observed with prodrug opioids (n = 148, 60.9%). The probability of a link between an ADR or a non-response and the genotypic/phenotypic status of the patient was evaluated as intermediate to high in 40% and 28.2% of all cases, respectively. The drugs in which the probability of an association was the strongest were the prodrug opioids, with an intermediate to high link in 45.6% of the cases for occurrence of ADRs and 36.0% of the cases for non-response. This study shows that the genotypic and phenotypic approach is useful to understand ADRs or therapeutic resistance to a usual therapeutic dosage, and can be part of the evaluation of chronic pain patients.
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Affiliation(s)
- Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Célia Lloret-Linares
- Ramsay Générale de Santé, Hôpital Privé Pays de Savoie, Maladies Nutritionnelles et Métaboliques, 74000 Annemasse, France;
| | - Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Marianne Gex-Fabry
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Geneva University Hospitals, 1226 Thônex, Switzerland;
| | - Valérie Piguet
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
| | - Marie Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Emergency Medicine and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland; (K.I.L.); (Y.D.); (V.P.); (M.B.); (C.S.); (J.D.)
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
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Petersen MJ, Adams KW, Siparsky NF. Avoiding Opioid Misuse After Surgery in the Era of the Opioid Epidemic. Am Surg 2020; 86:1565-1572. [DOI: 10.1177/0003134820939933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Chronic pain patients at risk of addiction can be identified through pre-prescription screening with the opioid risk tool (ORT); there is no equivalent for surgical patients. Our aims were to validate the ORT in the surgical population and assess the impact of patient education on compliance with proper storage and disposal (S&D) of unused opioid therapy (UOT). Methods Each subject completed the ORT, prevideo and postvideo surveys, educational video viewing, and compliance survey. Aberrant behavior was assessed by questionnaire, chart review, and Illinois Prescription Monitoring Program review. Results We recruited 24 subjects who underwent emergency surgery; 18 (of 24) were prescribed an opioid on discharge and 15 (of 18) were followed for 1 month. Before education, 38% (n = 9 of 24) of subjects identified proper UOT disposal and 63% (n = 15 of 24) identified safe handling of opioids. After education, 75% (n = 18 of 24) identified proper S&D. On ORT, 9 of 24 subjects (38%) scored moderate-risk to high-risk for opioid misuse. Half of subjects who demonstrated aberrant behavior (n = 7 of 12, 58%) scored in the low-risk range on ORT; 67% of subjects (n = 10 of 15) retained UOT, and 67% (n = 10 of 15) safely stored UOT. Few subjects (30%; n = 3 of 10) who stored their UOT reported proper disposal of UOT. Discussion The ORT is not useful in identifying acute pain surgical patients at risk for aberrant behavior. An educational video increased awareness of, but not compliance with, safe S&D of UOT. Opioid overprescription continues to contribute to opioid misuse.
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Chaturvedi R, Alexander B, A'Court AM, Waterman RS, Burton BN, Urman RD, Gabriel RA. Genomics testing and personalized medicine in the preoperative setting: Can it change outcomes in postoperative pain management? Best Pract Res Clin Anaesthesiol 2020; 34:283-295. [PMID: 32711834 DOI: 10.1016/j.bpa.2020.05.008] [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: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
Postoperative pain and opioid use are major challenges in perioperative medicine. Pain perception and its response to opioid use are multi-faceted and include pharmacological, psychological, and genetic components. Precision medicine is a unique approach to individualized health care in which decisions in management are based on genetics, lifestyle, and environment of each person. Genetic variations can have an impact on the perception of pain and response to treatment. This can have an effect on pain management in both acute and chronic settings. Although there is currently not enough evidence for making recommendations about genetic testing to guide pain management in the acute care setting, there are some known polymorphisms that play a role in surgical pain and opioid-related postoperative adverse outcomes. In this review, we describe the potential use of pharmacogenomics (PGx) for improving perioperative pain management. We first review a number of genotypes that have shown correlations with pain and opioid use and then describe the importance of PGx-guided analgesic protocols and implementation of screening in a preoperative evaluation clinical setting.
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Affiliation(s)
- Rahul Chaturvedi
- School of Medicine, University of California, San Diego, La Jolla, CA, USA.
| | - Brenton Alexander
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA.
| | - Alison M A'Court
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.
| | - Ruth S Waterman
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.
| | - Brittany N Burton
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School/Brigham and Women's Hospital, Boston, MA, USA.
| | - Rodney A Gabriel
- Department of Anesthesiology and Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA.
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16
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Sartori A, Botteri E, Agresta F, Gerardi C, Vettoretto N, Arezzo A, Pisanu A, Di Saverio S, Campanelli G, Podda M. Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis. Hernia 2020; 25:501-521. [PMID: 32683579 DOI: 10.1007/s10029-020-02262-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Although many studies assessing enhanced recovery after surgery (ERAS) pathways in abdominal wall reconstruction (AWR) have recently demonstrated lower rates of postoperative morbidity and a decrease in postoperative length of stay compared to standard practice, the utility of ERAS in AWR remains largely unknown. METHODS A systematic literature search for randomized and non-randomized studies comparing ERAS (ERAS +) pathways and standard protocols (Control) as an adopted practice for patients undergoing AWR was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EMBASE databases. A predefined search strategy was implemented. The included studies were reviewed for primary outcomes: overall postoperative morbidity, abdominal wall morbidity, surgical site infection (SSI), and length of hospital stay; and for secondary outcome: operative time, estimated blood loss, time to discontinuation of narcotics, time to urinary catheter removal, time to return to bowel function, time to return to regular diet, and readmission rate. Standardized mean difference (SMD) was calculated for continuous variables and Odds Ratio for dichotomous variables. RESULTS Five non-randomized studies were included for qualitative and quantitative synthesis. 840 patients were allocated to either ERAS + (382) or Control (458). ERAS + and Control groups showed equivalent results with regard to the incidence of postoperative morbidity (OR 0.73, 95% CI 0.32-1.63; I2= 76%), SSI (OR 1.17, 95% CI 0.43-3.22; I2= 54%), time to return to bowel function (SMD - 2.57, 95% CI - 5.32 to 0.17; I2= 99%), time to discontinuation of narcotics (SMD - 0.61, 95% CI - 1.81 to 0.59; I2= 97%), time to urinary catheter removal (SMD - 2.77, 95% CI - 6.05 to 0.51; I2= 99%), time to return to regular diet (SMD - 0.77, 95% CI - 2.29 to 0.74; I2= 98%), and readmission rate (OR 0.82, 95% CI 0.52-1.27; I2= 49%). Length of hospital stay was significantly shorter in the ERAS + compared to the Control group (SMD - 0.93, 95% CI - 1.84 to - 0.02; I2= 97%). CONCLUSIONS The introduction of an ERAS pathway into the clinical practice for patients undergoing AWR may cause a decreased length of hospitalization. These results should be interpreted with caution, due to the low level of evidence and the high heterogeneity.
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Affiliation(s)
- A Sartori
- Department of General Surgery, Montebelluna Civil Hospital, ULSS 2 Marca Trevigiana, Montebelluna, Italy.
| | - E Botteri
- Department of General Surgery, Montichiari Hospital, Montichiari, Italy
| | - F Agresta
- Department of General Surgery, Adria and Trecenta Civil Hospitals, ULSS 19, Adria, Italy
| | - C Gerardi
- Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - N Vettoretto
- Department of General Surgery, Montichiari Hospital, Montichiari, Italy
| | - A Arezzo
- Department of Surgical Sciences, Università di Torino, Turin, Italy
| | - A Pisanu
- Department of Surgery, General and Emergency Surgery Unit, Azienda Ospedaliero-Universitaria, Cagliari University Hospital "Duilio Casula" University of Cagliari, Cagliari, Italy
| | - S Di Saverio
- Department of Surgery, University of Insubria, Varese, Italy
| | - G Campanelli
- Department of Medicine and Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - M Podda
- Department of Surgery, General and Emergency Surgery Unit, Azienda Ospedaliero-Universitaria, Cagliari University Hospital "Duilio Casula" University of Cagliari, Cagliari, Italy
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17
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Saiz-Rodríguez M, Ochoa D, Román M, Zubiaur P, Koller D, Mejía G, Abad-Santos F. Involvement of CYP2D6 and CYP2B6 on tramadol pharmacokinetics. Pharmacogenomics 2020; 21:663-675. [PMID: 32538291 DOI: 10.2217/pgs-2020-0026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This study included 24 healthy volunteers who received a single 37.5 mg oral dose of tramadol. We analyzed 18 polymorphisms within CYP2D6, CYP2B6, CYP3A, COMT, ABCB1, SLC22A1 and OPRM1 genes by quantitative PCR, to study whether these polymorphisms affect its pharmacokinetics, pharmacodynamics and safety. CYP2D6 intermediate metabolizers (n = 6) showed higher tramadol plasma concentrations and lower clearance compared with normal and ultrarapid metabolizers. CYP2B6 G516T T/T (n = 2) genotype was also associated to higher tramadol plasma levels. No other polymorphism affected tramadol pharmacokinetics. Three volunteers experienced a prolonged QTc not associated with the genetic variants studied or altered phamacokinetic parameters. The correlation of CYP2B6 genotype with higher tramadol concentrations is remarkable since its influence on its elimination is also relevant and has been less studied to date. However, given our small sample size, it is important to interpret our results with caution.
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Affiliation(s)
- Miriam Saiz-Rodríguez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain
| | - Dolores Ochoa
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain.,UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Reseach Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain
| | - Manuel Román
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain.,UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Reseach Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain
| | - Dora Koller
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain
| | - Gina Mejía
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain.,UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Reseach Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid (UAM), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain.,UICEC Hospital Universitario de La Princesa, Plataforma SCReN (Spanish Clinical Reseach Network), Instituto de Investigación Sanitaria La Princesa (IP), Madrid, 28006, Spain.,Pharmacology Department, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, 28049, Spain
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Hamilton WG, Gargiulo JM, Parks NL. Using pharmacogenetics to structure individual pain management protocols in total knee arthroplasty. Bone Joint J 2020; 102-B:73-78. [DOI: 10.1302/0301-620x.102b6.bjj-2019-1539.r1] [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: 11/05/2022]
Abstract
Aims The purpose of this study was to use pharmacogenetics to determine the frequency of genetic variants in our total knee arthroplasty (TKA) patients that could affect postoperative pain medications. Pharmacogenetic testing evaluates patient DNA to determine if a drug is expected to have a normal clinical effect, heightened effect, or no effect at all on the patient. It also predicts whether patients are likely to experience side effects from medicine. We further sought to determine if changing the multimodal programme based on these results would improve pain control or reduce side effects. Methods In this pilot study, buccal samples were collected from 31 primary TKA patients. Pharmacogenetics testing examined genetic variants in genes OPRM1, CYP1A2, CYP2B6, CYP2C19, CYP3A4, CYP2C9, and CYP2D6. These genes affect the pharmacodynamics and pharmacokinetics of non-steroidal anti-inflammatory drugs and opioids. We examined the frequency of genetic variants to any of the medications we prescribed including celecoxib, hydrocodone, and tramadol. Patients were randomized to one of two groups: the control group received the standard postoperative pain regimen, and the study group received a customized regimen based on the pharmacogenetic results. For the first ten postoperative days, patients recorded pain scores, medication, and side effects. Results Genetic variants involving one or more medications in the multimodal pain protocol occurred in 13 of the 31 patients (42%). In total, eight patients (26%) had variants affecting more than one of the medications. For the 25 patients who recorded pain and medication logs, the mean pain levels and morphine equivalents (MEQs) consumed in the first ten days were higher in the control group than in the custom-guided group (p = 0.019 for pain and p = 0.655 for MEQ). Conclusion Overall, 42% of patients had a variant involving one of the pain medications prescribed in our perioperative pain program for TKA. Ongoing research will help determine if using these data to modify a patient’s medication will improve outcomes. Cite this article: Bone Joint J 2020;102-B(6 Supple A):73–78.
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Affiliation(s)
| | | | - Nancy L. Parks
- Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA
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Gabriel RA, Burton BN, Urman RD, Waterman RS. Genomics Testing and Personalized Medicine in the Preoperative Setting. Surg Oncol Clin N Am 2020; 29:73-86. [DOI: 10.1016/j.soc.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Dunn KE, Weerts EM, Huhn AS, Schroeder JR, Tompkins DA, Bigelow GE, Strain EC. Preliminary evidence of different and clinically meaningful opioid withdrawal phenotypes. Addict Biol 2020; 25:e12680. [PMID: 30295400 PMCID: PMC6546557 DOI: 10.1111/adb.12680] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/06/2018] [Accepted: 08/25/2018] [Indexed: 11/28/2022]
Abstract
Opioid use disorder (OUD) is a public health crisis. Differences in opioid withdrawal severity that predict treatment outcome could facilitate the process of matching patients to treatments. This is a secondary analysis of a randomized controlled trial (RCT) that enrolled treatment seeking heroin-users (N = 89, males = 78) into a residential study. Participants maintained on morphine (30 mg, subcutaneous, four-times daily) underwent a naloxone (0.4 mg, IM = intramuscular) challenge session to precipitate withdrawal. Area-under-the-curve (AUC) values from self-reported withdrawal ratings during the challenge session were analyzed using K-means clustering, revealing two phenotype groups. Withdrawal and retention from the subsequent 14-day double-blind, double-dummy RCT comparing three study medications (clonidine, tramadol-ER, and buprenorphine) were evaluated as a function of phenotype. Cluster analyses suggested HIGH (N = 37; mean [SD] subjective opiate withdrawal scale [SOWS]-AUC 123.7 [65.8]) and LOW (N = 52; SOWS-AUC 68.0 [47.7]) withdrawal phenotype groups. HIGH participants were significantly more female and had lower body mass indices than LOW participants; no drug-use variables were significant. Regarding RCT outcomes, HIGH phenotype participants were less likely to be retained in the study (P = 0.02) and had higher mean self-reported withdrawal (P = 0.05) than LOW phenotype participants. A significant interaction in RCT retention was observed between phenotype (P = 0.02) and study medication (P < 0.01). Self-reported withdrawal was significant for phenotype (P = 0.02); study medication trended towards significance (P = 0.07). Results suggest patients have meaningfully different experiences of opioid withdrawal that may predict differential response to opioid pharmacotherapies during supervised withdrawal. Additional prospective research to replicate and more thoroughly evaluate withdrawal phenotype correlates and sex differences is warranted.
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Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elise M Weerts
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrew S Huhn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer R Schroeder
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Andrew Tompkins
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - George E Bigelow
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric C Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 391] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Abstract
Pharmacogenomics (PGx) is the study of how individuals' personal genotypes may affect their responses to various pharmacologic agents. The application of PGx principles in perioperative medicine is fairly novel. Challenges in executing PGx programs into health care systems include physician buy-in and integration into usual clinical workflow, including the electronic health record. This article discusses the current evidence highlighting the potential of PGx with various drug categories (including opioids, nonopioid analgesics, sedatives, β-blockers, antiemetics, and anticoagulants) used in the perioperative process and the challenges of integrating PGx into a health care system and relevant workflows.
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24
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The opioid epidemic and patient satisfaction: a review of one institution’s experience. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Saiz-Rodríguez M, Ochoa D, Herrador C, Belmonte C, Román M, Alday E, Koller D, Zubiaur P, Mejía G, Hernández-Martínez M, Abad-Santos F. Polymorphisms associated with fentanyl pharmacokinetics, pharmacodynamics and adverse effects. Basic Clin Pharmacol Toxicol 2018; 124:321-329. [PMID: 30281924 DOI: 10.1111/bcpt.13141] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/20/2018] [Indexed: 12/28/2022]
Abstract
Fentanyl is an agonist of the μ-opioid receptor commonly used in the treatment of moderate-severe pain. In order to study whether pharmacogenetics explains some of the variability in the response to fentanyl, several genes related to fentanyl receptors, transporters and metabolic enzymes have been analysed. Thirty-five healthy volunteers (19 men and 16 women) receiving a single 300 μg oral dose of fentanyl were genotyped for 9 polymorphisms in cytochrome P450 (CYP) enzymes (CYP3A4 and CYP3A5), ATP-binding cassette subfamily B member 1 (ABCB1), opioid receptor mu 1 (OPRM1), catechol-O-methyltransferase (COMT) and adrenoceptor beta 2 (ADRB2) by real-time PCR. Fentanyl concentrations were measured by ultra-performance liquid chromatography combined with tandem mass spectrometry (UPLC-MS/MS). Fentanyl pharmacokinetics is affected by sex. Carriers of the CYP3A4*22 allele, which is known to reduce the mRNA expression, showed higher area under the concentration-time curve (AUC) and lower clearance (Cl) values. Although this finding might be of importance, its validity needs to be confirmed in other similar settings. Furthermore, carriers of the ABCB1 C1236T T/T genotype presented a lower AUC and higher Cl, as well as lower half-life (T1/2 ). As volunteers were blocked with naltrexone, the effect of fentanyl on pharmacodynamics might be biased; however, we could observe that fentanyl had a hypotensive effect. Moreover, ADRB2 C523A A allele carriers showed a tendency towards reducing systolic blood pressure. Likewise, OPRM1 and COMT minor allele variants were risk factors for the development of somnolence. CYP3A5*3, ABCB1 C3435T and ABCB1 G2677T/A were not associated with fentanyl's pharmacokinetics, pharmacodynamics and safety profile.
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Affiliation(s)
- Miriam Saiz-Rodríguez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Dolores Ochoa
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa (IP), Plataforma SCReN (Spanish Clinical Research Network), UICEC Hospital Universitario de La Princesa, Madrid, Spain
| | - Coral Herrador
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Carmen Belmonte
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa (IP), Plataforma SCReN (Spanish Clinical Research Network), UICEC Hospital Universitario de La Princesa, Madrid, Spain
| | - Manuel Román
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa (IP), Plataforma SCReN (Spanish Clinical Research Network), UICEC Hospital Universitario de La Princesa, Madrid, Spain
| | - Enrique Alday
- Anesthesiology Department, Instituto de Investigación Sanitaria la Princesa (IP), Hospital Universitario de La Princesa, Madrid, Spain
| | - Dora Koller
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Gina Mejía
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa (IP), Plataforma SCReN (Spanish Clinical Research Network), UICEC Hospital Universitario de La Princesa, Madrid, Spain
| | - María Hernández-Martínez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa (IP), Plataforma SCReN (Spanish Clinical Research Network), UICEC Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Affiliation(s)
- Elizabeth B Habermann
- Departments of Surgery and Health Sciences Research, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Wardhan R, Chelly J. Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy. F1000Res 2017; 6:2065. [PMID: 29225793 PMCID: PMC5710326 DOI: 10.12688/f1000research.12286.1] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 12/29/2022] Open
Abstract
In this review, we discuss advances in acute pain management, including the recent report of the joint American Pain Society and American Academy of Pain Medicine task force on the classification of acute pain, the role of psychosocial factors, multimodal pain management, new non-opioid therapy, and the effect of the “opioid epidemic”. In this regard, we propose that a fundamental principle in acute pain management is identifying patients who are most at risk and providing an “opioid free anesthesia and postoperative analgesia”. This can be achieved by using a multimodal approach that includes regional anesthesia and minimizing the dose and the duration of opioid prescription. This allows prescribing medications that work through different mechanisms. We shall also look at the recent pharmacologic and treatment advances made in acute pain and regional anesthesia.
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Affiliation(s)
- Richa Wardhan
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jacques Chelly
- Department of Anesthesiology, Posner Pain Center, University of Pittsburgh Medical Center, UPMC Presbyterian-Shadyside Hospital, Pittsburgh, USA
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30
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Gabriel RA, Ehrenfeld JM, Urman RD. Preoperative Genetic Testing and Personalized Medicine: Changing the Care Paradigm. J Med Syst 2017; 41:185. [PMID: 29039620 DOI: 10.1007/s10916-017-0835-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA
| | | | - Richard D Urman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 02115, USA.
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31
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Nimmo SM, Foo ITH, Paterson HM. Enhanced recovery after surgery: Pain management. J Surg Oncol 2017; 116:583-591. [PMID: 28873505 DOI: 10.1002/jso.24814] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 12/13/2022]
Abstract
Effective pain management is fundamental to enhanced recovery after surgery. Selection of strategies should be tailored to patient and operation. As well as improving the quality of recovery, effective analgesia reduces the host stress response, facilitates mobilization and allows resumption of oral intake. Multi-modal regimens combining paracetamol, non-steroidal anti-inflammatory agents where indicated, a potent opioid and a local anaesthetic technique achieve effective analgesia while limiting the dose and thereby side effects of any one agent.
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Affiliation(s)
- Susan M Nimmo
- Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital, Edinburgh, Scotland
| | - Irwin T H Foo
- Department of Anaesthesia, Critical Care and Pain Medicine, Western General Hospital, Edinburgh, Scotland
| | - Hugh M Paterson
- Colorectal Surgery Unit, Western General Hospital, University of Edinburgh, Edinburgh, Scotland
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32
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Calvo AM, Zupelari-Gonçalves P, Dionísio TJ, Brozoski DT, Faria FA, Santos CF. Efficacy of piroxicam for postoperative pain after lower third molar surgery associated with CYP2C8*3 and CYP2C9. J Pain Res 2017; 10:1581-1589. [PMID: 28740425 PMCID: PMC5505550 DOI: 10.2147/jpr.s138147] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Nonsteroidal anti-inflammatory drugs (NSAIDs) are metabolized by the cytochrome P450 enzymes (CYPs), predominantly CYP2C8 and CYP2C9. The aim of this study was to evaluate the possible association of polymorphisms in the CYP2C8*3 and CYP2C9 genes with the clinical efficacy of oral piroxicam (20 mg daily for 4 days) after lower third molar surgeries with regard to postoperative pain, swelling, trismus, adverse reactions, need for rescue medication and the volunteer’s overall satisfaction. Materials and methods For this purpose, 102 volunteers were genotyped for CYP2C8*3 and CYP2C9 polymorphisms. Briefly, genomic DNA was isolated from saliva collected from volunteers subjected to invasive lower third molar surgeries, and the preoperative, intraoperative and postoperative parameters were collected and analyzed. Results An equal amount of piroxicam sufficiently managed postoperative pain and inflammatory symptoms, with visual analog pain scores typically <40 mm for all genotypes investigated. Furthermore, only two out of 102 volunteers heterozygous for CYP2C8*3 and CYP2C9*3 reported adverse side effects. Conclusion In general, slow metabolizers of piroxicam, who were volunteers with mutant alleles, were indifferent from normal metabolizers with the wild-type alleles and therefore did not require specialized piroxicam doses to manage postoperative pain and inflammation.
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Affiliation(s)
- Adriana Maria Calvo
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Paulo Zupelari-Gonçalves
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Thiago José Dionísio
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Daniel Thomas Brozoski
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Flávio Augusto Faria
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Carlos Ferreira Santos
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
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