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Bahrami F, Rossi RM, De Nys K, Joerger M, Radenkovic MC, Defraeye T. Implementing physics-based digital patient twins to tailor the switch of oral morphine to transdermal fentanyl patches based on patient physiology. Eur J Pharm Sci 2024; 195:106727. [PMID: 38360153 DOI: 10.1016/j.ejps.2024.106727] [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: 07/12/2023] [Revised: 12/20/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
Fentanyl transdermal patches are widely implemented for cancer-induced pain treatment due to the high potency of fentanyl and gradual drug release. However, transdermal fentanyl up-titration for opioid-naïve patients is difficult, which is why opioid treatment is often started with oral/iv morphine. Based on the daily dose of morphine, the initial dose of the fentanyl patch is decided upon. After reaching a stable level of pain, the switch is made from oral/iv morphine to transdermal fentanyl. There are standard calculation tools for transferring from oral/iv morphine to transdermal fentanyl, which is the same for all patients. By considering the variations in the physiology of the patients, a unique switching strategy cannot meet the needs of different patients. This study explores the outcome in terms of pain relief and minute ventilation during opioid therapy. For this, we used physics-based simulations on a virtually-generated population of patients, and we applied the same therapy to all patients. We could show that patients' physiology, such as gender, age, and weight, greatly impact the outcome of the therapy; as such, the correlation coefficient between pain intensity and age is 0.89, and the correlation coefficient between patient's weight and maximum plasma concentration of morphine and fentanyl is -0.98 and -0.97. Additionally, a different combination of the duration of overlap between morphine and fentanyl therapy with different doses of fentanyl was considered for the virtual patients to find the best opioid-switching strategy for each patient. We explored the impact of combining physiological features to determine the best-suited strategy for virtual patients. Our findings suggest that tailoring morphine and fentanyl therapy only based on a limited number of features is insufficient, and increasing the number of impactful physiological features positively influences the outcome of the therapy.
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Affiliation(s)
- Flora Bahrami
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, Lerchenfeldstrasse 5, St. Gallen CH-9014, Switzerland; ARTORG Center for Biomedical Engineering Research, University of Bern, Mittelstrasse 43, Bern CH-3012, Switzerland
| | - René Michel Rossi
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, Lerchenfeldstrasse 5, St. Gallen CH-9014, Switzerland
| | - Katelijne De Nys
- Kantonsspital St. Gallen, Palliativzentrum, Rorschacherstrasse 95, St. Gallen CH-9000, Switzerland; Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, ON2 Herestraat 49 - box 424, Leuven BE-3000, Belgium
| | - Markus Joerger
- Kantonsspital St. Gallen, Medizinische Onkologie und Hämatologie, Rorschacherstrasse 95, St. Gallen CH-9000, Switzerland
| | - Milena Cukic Radenkovic
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, Lerchenfeldstrasse 5, St. Gallen CH-9014, Switzerland
| | - Thijs Defraeye
- Laboratory for Biomimetic Membranes and Textiles, Empa, Swiss Federal Laboratories for Materials Science and Technology, Lerchenfeldstrasse 5, St. Gallen CH-9014, Switzerland.
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Al-Qurain AA, Williams DB, Mackenzie L, Roberts MS, Wiese MD. Simultaneous LC-MS/MS quantification of oxycodone, tramadol and fentanyl and their metabolites (noroxycodone, oxymorphone, O- desmethyltramadol, N- desmethyltramadol, and norfentanyl) in human plasma and whole blood collected via venepuncture and volumetric absorptive micro sampling. J Pharm Biomed Anal 2021; 203:114171. [PMID: 34087551 DOI: 10.1016/j.jpba.2021.114171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A range of opioids are commonly prescribed to manage chronic pain, but individual patient responses vary greatly, especially in older populations. One source of that variability are differences in absorption, metabolism and excretion, i.e. pharmacokinetics. Blood, plasma and serum concentrations of opioids allow that variability to be quantified and may be used to optimise opioid dosing. As an aid to that process, there is an unmet need to rapidly quantify several opioids and their metabolites in a single analytical method. AIMS To develop a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for simultaneous quantification of tramadol, oxycodone, fentanyl and their major metabolites in various human matrices. METHODS Sample preparation involved adding three deuterated internal standards followed by protein precipitation with 100 % acetonitrile, evaporation and reconstitution. Separation of analytes via LC was achieved on a reversed phase column via binary gradient elution using 0.005 % formic acid in water and 100 % acetonitrile as mobile phases. Analytes were detected via MS/MS with multiple reaction monitoring (MRM). RESULTS The method was accurate with the inter-day and intra-day accuracy of quality control samples (QCs) below 15 %. It was also precise with inter-day and intra-day coefficient of variation below 15 %. The lower limit of quantification (LLOQ) was 0.2 ng/mL for all analytes except tramadol and its metabolites, where the LLOQ was 10 ng/mL. Recovery was greater than 88 % for all analytes, except for O-desmethyltramadol (81 %). Analytes were stable over four freeze-thaw cycles, for 24 h on the bench top and for 24 h post-preparation. The inter- and intra-day variability of concentrations determined in blood and plasma were within 84-124%, whereas the inter- and intra-day variability for blood samples prepared using volumetric absorptive micro-sampling (VAMS) compared to those prepared from whole blood ranged between 83-122%. CONCLUSION A LC-MS/MS method is described that is able to accurately and precisely quantify a number of commonly prescribed opioids and their major metabolites in plasma and whole blood, including whole blood collected using VAMS.
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Affiliation(s)
- Aymen A Al-Qurain
- UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia; Basil Hetzel Institute for Translational Medical Research, The Queen Elizabeth Hospital, Woodville, Australia; Saudi Arabian Cultural Mission, Ministry of Education, Riyadh, Saudi Arabia; Health and Biomedical Innovation, University of South Australia, Adelaide, Australia.
| | - Desmond B Williams
- UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Lorraine Mackenzie
- UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia; Basil Hetzel Institute for Translational Medical Research, The Queen Elizabeth Hospital, Woodville, Australia
| | - Michael S Roberts
- UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia; Basil Hetzel Institute for Translational Medical Research, The Queen Elizabeth Hospital, Woodville, Australia; Therapeutics Research Centre, Diamantina Institute, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Michael D Wiese
- UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia; Health and Biomedical Innovation, University of South Australia, Adelaide, Australia
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Verscheijden LFM, Litjens CHC, Koenderink JB, Mathijssen RHJ, Verbeek MM, de Wildt SN, Russel FGM. Physiologically based pharmacokinetic/pharmacodynamic model for the prediction of morphine brain disposition and analgesia in adults and children. PLoS Comput Biol 2021; 17:e1008786. [PMID: 33661919 PMCID: PMC7963108 DOI: 10.1371/journal.pcbi.1008786] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 03/16/2021] [Accepted: 02/12/2021] [Indexed: 12/20/2022] Open
Abstract
Morphine is a widely used opioid analgesic, which shows large differences in clinical response in children, even when aiming for equivalent plasma drug concentrations. Age-dependent brain disposition of morphine could contribute to this variability, as developmental increase in blood-brain barrier (BBB) P-glycoprotein (Pgp) expression has been reported. In addition, age-related pharmacodynamics might also explain the variability in effect. To assess the influence of these processes on morphine effectiveness, a multi-compartment brain physiologically based pharmacokinetic/pharmacodynamic (PB-PK/PD) model was developed in R (Version 3.6.2). Active Pgp-mediated morphine transport was measured in MDCKII-Pgp cells grown on transwell filters and translated by an in vitro-in vivo extrapolation approach, which included developmental Pgp expression. Passive BBB permeability of morphine and its active metabolite morphine-6-glucuronide (M6G) and their pharmacodynamic parameters were derived from experiments reported in literature. Model simulations after single dose morphine were compared with measured and published concentrations of morphine and M6G in plasma, brain extracellular fluid (ECF) and cerebrospinal fluid (CSF), as well as published drug responses in children (1 day– 16 years) and adults. Visual predictive checks indicated acceptable overlays between simulated and measured morphine and M6G concentration-time profiles and prediction errors were between 1 and -1. Incorporation of active Pgp-mediated BBB transport into the PB-PK/PD model resulted in a 1.3-fold reduced brain exposure in adults, indicating only a modest contribution on brain disposition. Analgesic effect-time profiles could be described reasonably well for older children and adults, but were largely underpredicted for neonates. In summary, an age-appropriate morphine PB-PK/PD model was developed for the prediction of brain pharmacokinetics and analgesic effects. In the neonatal population, pharmacodynamic characteristics, but not brain drug disposition, appear to be altered compared to adults and older children, which may explain the reported differences in analgesic effect. Developmental processes in children can affect pharmacokinetics: “what the body does to the drug” as well as pharmacodynamics: “what the drug does to the body”. A typical example is morphine, of which the analgesic response is variable and particularly neonates suffer more often from respiratory depression, even when receiving doses corrected for differences in elimination. One way to mathematically incorporate developmental processes is by employing physiologically based pharmacokinetic/pharmacodynamic (PB-PK/PD) models, where physiological differences between individuals are incorporated. In this study, we developed a morphine PB-PK/PD model to predict brain drug disposition as well as analgesic response in adults and children, as both processes could potentially contribute to developmental variability in the effect of morphine. We found that age-related variation in BBB expression of the main morphine efflux transporter P-glycoprotein was not responsible for differences in brain exposure. In contrast, pharmacodynamic modelling suggested an increased sensitivity to morphine in neonates.
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Affiliation(s)
- Laurens F. M. Verscheijden
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Carlijn H. C. Litjens
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Jan B. Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Ron H. J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marcel M. Verbeek
- Departments of Neurology and Laboratory Medicine, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, Nijmegen, The Netherlands
| | - Saskia N. de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Frans G. M. Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
- * E-mail:
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Jutras M, Williamson D, Chassé M, Leclair G. Development and validation of a liquid chromatography coupled to tandem mass spectrometry method for the simultaneous quantification of five analgesics and sedatives, and six of their active metabolites in human plasma: Application to a clinical study on the determination of neurological death in the intensive care unit. J Pharm Biomed Anal 2020; 190:113521. [PMID: 32861167 DOI: 10.1016/j.jpba.2020.113521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/13/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022]
Abstract
A sensitive and selective high-performance liquid chromatographic method coupled to tandem mass spectrometry was developed and validated for the quantification of morphine, hydromorphone, fentanyl, midazolam and propofol and their metabolites morphine-3-β-d-glucuronide, morphine-6-β-d-glucuronide, hydromorphone-3-β-d-glucuronide, 1'-hydroxymidazolam-β-d-glucuronide, α-hydroxymidazolam and 4-hydroxymidazolam in human plasma using potassium oxalate/sodium fluoride mixture as anticoagulant. Human plasma samples (0.4 mL) to which were added a mixture of eleven deuterated internal standards were subjected to solid phase extraction using a mixed-mode polymeric Oasis PRiME MCX in 96-well format. Propofol was selectively eluted and further derivatized using 2-Fluoro-1-methylpyridinium p-toluenesulfonate, whereas the remaining 10 analytes were eluted separately and further concentrated. The derivatized propofol was analyzed separately in a second injection. The analytes were chromatographically separated on a Kinetex phenyl-hexyl analytical column in gradient elution mode, using a mobile phase consisting of aqueous ammonium formate/formic acid buffer and methanol. The overall run time was 8 min. Detection was performed using an AB/SCIEX 4000 QTRAP instrument with positive electrospray ionization employing scheduled multiple reaction monitoring mode. The lower limits of quantification ranged from 0.02 to 5 ng/mL depending on the analyte. Calibration curves covered a concentration range of 1000× in all cases but 1'-hydroxymidazolam-β-d-glucuronide where it covered a range of 500 × . The validated method was accurate and precise, the intra-day accuracy and precision of quality control samples (4 concentration levels, n = 6 each) being within 91.5-112 % and 1.3-13.2 % (coefficient of variation), respectively, and inter-day (n = 24; 4 days) accuracy and precision of quality control samples (3 concentration levels) being within 94.8-103.5 % and 3.2-11.2 % (coefficient of variation). Mean absolute extraction recoveries were above 60 % for all compounds, except for hydromorphone-3-β-d-glucuronide (44 %) and for 1'-hydroxymidazolam-β-d-glucuronide (33 %). Internal standard corrected matrix effect ranged from -4.8 to 3.8 % in normal plasma and in plasma containing 1 % hemolyzed blood. Analytes were stable (above 90 %) in plasma and blood for 19 h at 22 °C, in blood for 90 h at 5 °C, in plasma for 60 days at -20 °C, for 4 months at -70 °C and after three freeze-thaw cycles, and in the injection solvent for at least 3 days in the autosampler. The present method is successfully being applied in a multicenter clinical study for the analysis of plasma samples from patients in intensive care units from a number of Canadian hospitals.
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Affiliation(s)
- Martin Jutras
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
| | - David Williamson
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada; Research Center and Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, H4J 1C5, Canada.
| | - Michaël Chassé
- Faculty of Medecine, Université de Montréal, H3T 1J4, Canada; Research Center and Department of Medicine (Critical Care), Centre Hospitalier de l'Université de Montréal, H2X 0A9, Canada.
| | - Grégoire Leclair
- Platform of Biopharmacy, Faculty of Pharmacy, Université de Montréal, H3T 1J4, Canada.
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Rajaei M, Foroughi MM, Jahani S, Shahidi Zandi M, Hassani Nadiki H. Sensitive detection of morphine in the presence of dopamine with La3+ doped fern-like CuO nanoleaves/MWCNTs modified carbon paste electrode. J Mol Liq 2019. [DOI: 10.1016/j.molliq.2019.03.135] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Roda G, Faggiani F, Bolchi C, Pallavicini M, Dei Cas M. Ten Years of Fentanyl-like Drugs: a Technical-analytical Review. ANAL SCI 2019; 35:479-491. [PMID: 30686797 DOI: 10.2116/analsci.18r004] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Synthetic opioids, such as fentanyl and its analogues, are a new public health warning. Clandestine laboratories produce drug analogues at a faster rate than these compounds can be controlled or scheduled by drug agencies. Detection requires specific testing and clinicians may be confronted with a sequence of severe issues concerning the diagnosis and management of these contemporary opioid overdoses. This paper deals with methods for biological sample treatment, as well as the methodologies of analysis that have been reported, in the last decade, in the field of fentanyl-like compounds. From this analysis, it emerges that the gold standard for the identification and quantification of 4-anilinopiperidines is LC-MS/MS, coupled with liquid-liquid or solid-phase extraction. In the end, the return to the scene of illicit fentanyls can be considered as a critical problem that can be tackled only with a global multidisciplinary approach.
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Affiliation(s)
- Gabriella Roda
- Department of Pharmaceutical Sciences, University of Milan
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Bechakra M, Moerdijk F, van Rosmalen J, Koch BC, van der Rijt CC, Sillevis Smitt PA, Jongen JL. Opioid responsiveness of nociceptive versus mixed pain in clinical cancer patients. Eur J Cancer 2018; 105:79-87. [DOI: 10.1016/j.ejca.2018.09.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 09/22/2018] [Accepted: 09/25/2018] [Indexed: 01/28/2023]
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Kuip EJM, Oldenmenger WH, Oomen-de Hoop E, Verduijn GM, Thijs-Visser MF, de Bruijn P, van Meerten E, Koolen SLW, Mathijssen RHJ, van der Rijt CCD. Pharmacokinetics of Sublingually Delivered Fentanyl in Head and Neck Cancer Patients Treated with Curatively Aimed Chemo or Bioradiotherapy. Cancers (Basel) 2018; 10:cancers10110445. [PMID: 30445772 PMCID: PMC6266947 DOI: 10.3390/cancers10110445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 02/05/2023] Open
Abstract
Over 90% of patients treated for head and neck cancer with curatively aimed chemo or bioradiotherapy will develop painful mucositis and xerostomia. Sublingually delivered fentanyl (SDL) is a rapid acting opioid to treat breakthrough pain. It is unclear how SDL is absorbed by the mucosa of these patients. Therefore, the aim of this study was to investigate the effects of mucositis and xerostomia on the absorption of SDL. Thirteen patients who received chemo or bioradiotherapy (RT), were given a single dose of fentanyl: Before start of RT, 3 and 6 weeks after start of RT, and 6 weeks after finishing RT. Pharmacokinetic samples were taken. The primary endpoint was the relative difference (RD) between systemic exposure to fentanyl (area under the curve; AUC) at baseline (AUCbaseline) and fentanyl AUC in the presence of mucositis grade ≥2. The secondary endpoint was the RD between AUCbaseline and fentanyl AUC in the presence of xerostomia, which were analyzed by means of a paired t-test on log-transformed data. Mucositis resulted in a 12.7% higher AUC (n = 13; 95% CI: −10.7% to +42.2%, p = 0.29) compared to baseline levels and xerostomia resulted in a 22.4% lower AUC (n = 8; 95% CI: −51.9% to +25.3%, p = 0.25) compared to baseline levels. Mucositis grade ≥2 or xerostomia caused by chemo or bioradiotherapy does not significantly alter the systemic exposure to SDL. Patients with pain during and after chemo or bioradiotherapy may be safely treated with SDL.
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Affiliation(s)
- Evelien J M Kuip
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
- Department of Medical Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands.
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500 HB Nijmegen, The Netherlands.
| | - Wendy H Oldenmenger
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Gerda M Verduijn
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Martine F Thijs-Visser
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Esther van Meerten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT Utrecht, The Netherlands.
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