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Muriel J, Escorial M, Carratalá C, Margarit C, Barrachina J, López A, Gallardo E, Kringen MK, Peiró AM. Use of CYP2D6 substrates and inhibitors during pain management with analgesic opioids: Drug-drug interactions that lead to lack of analgesic effectiveness. Biomed Pharmacother 2024; 176:116882. [PMID: 38876046 DOI: 10.1016/j.biopha.2024.116882] [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: 02/13/2024] [Revised: 05/15/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Several opioids have pharmacogenetic and drug-drug interactions which may compromise their analgesic effectiveness, but are not routinely implemented into supportive pain management. We hypothesized that CYP2D6 phenotypes and concomitant use of CYP2D6 substrates or inhibitors would correlate with opioid analgesic outcomes. MATERIALS AND METHODS An observational cross-sectional study was conducted with 263 adult chronic non cancer pain (CNCP) patients from a real-world pain unit under long-term CYP2D6-related opioid treatment (tramadol, hydromorphone, tapentadol or oxycodone). Metabolizer phenotype (ultrarapid [UM], normal [NM], intermediate [IM] or poor [PM]) was determined by the CYP2D6 genotype. The socio-demographic (sex, age, employment status), clinical (pain intensity and relief, neuropathic component, quality of life, disability, anxiety and depression), pharmacological (opioid doses and concomitant pharmacotherapy) and safety (adverse events) variables were recorded. RESULTS The whole population (66 % female, 65 (14) years old, 70 % retired and 63 % attended for low back pain) were classified as PM (5 %), IM (32 %), NM (56 %) and UM (6 %). Multiple linear and logistic regressions showed higher pain intensity and neuropathic component at younger ages when using any CYP2D6 substrate (p = 0.022) or inhibitor (p = 0.030) drug, respectively, with poorer pain relief when CYP2D6 inhibitors (p=0.030) were present. CONCLUSION The concomitant use of CYP2D6 substrates or inhibitors during opioid therapy for CNCP may result in lack of analgesic effectiveness. This aspect could be relevant for pharmacological decision making during CNCP management.
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Affiliation(s)
- J Muriel
- Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, c/Pintor Baeza, 12, Alicante 03010, Spain
| | - M Escorial
- Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, c/Pintor Baeza, 12, Alicante 03010, Spain; Occupational Observatory, University Miguel Hernández, Avda. de la Universidad s/n, Elche 03202, Spain
| | - C Carratalá
- Occupational Observatory, University Miguel Hernández, Avda. de la Universidad s/n, Elche 03202, Spain
| | - C Margarit
- Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, c/Pintor Baeza, 12, Alicante 03010, Spain; Pain Unit, Dr. Balmis General University Hospital, c/ Pintor Baeza, 12, Alicante 03010, Spain
| | - J Barrachina
- Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, c/Pintor Baeza, 12, Alicante 03010, Spain
| | - A López
- Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, c/Pintor Baeza, 12, Alicante 03010, Spain; Occupational Observatory, University Miguel Hernández, Avda. de la Universidad s/n, Elche 03202, Spain
| | - E Gallardo
- Centro de Investigação em Ciências da Saúde, Universidade da Beira Interior (CICS-UBI), Av. Infante D. Henrique, Covilhã 6201-506, Portugal
| | - M K Kringen
- Department of Psychopharmacology, Diakonhjemmet Hospital, Forskningsveien 7, Oslo 0373, Norway
| | - A M Peiró
- Pharmacogenetic Unit, Clinical Pharmacology Department, Alicante Institute for Health and Biomedical Research (ISABIAL), Dr. Balmis General University Hospital, c/Pintor Baeza, 12, Alicante 03010, Spain; Pain Unit, Dr. Balmis General University Hospital, c/ Pintor Baeza, 12, Alicante 03010, Spain; Clinical Pharmacology, Toxicology and Chemical Safety Unit, Institute of Bioengineering, Miguel Hernández University, Avda. de la Universidad s/n, Elche 03202, Spain.
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2
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Formenti P, Umbrello M, Pignataro M, Sabbatini G, Dottorini L, Gotti M, Brenna G, Menozzi A, Terranova G, Galimberti A, Pezzi A. Managing Severe Cancer Pain with Oxycodone/Naloxone Treatment: A Literature Review Update. J Pers Med 2024; 14:483. [PMID: 38793067 PMCID: PMC11122522 DOI: 10.3390/jpm14050483] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Severe cancer pain substantially affects patients' quality of life, increasing the burden of the disease and reducing the disability-adjusted life years. Although opioid analgesics are effective, they may induce opioid-induced bowel dysfunction (OIBD). Oxycodone/naloxone combination therapy has emerged as a promising approach to mitigate opioid-induced constipation (OIC) while providing effective pain relief. This review provides an updated analysis of the literature of the last decade regarding the use of oxycodone/naloxone in the management of severe cancer pain. Through a comprehensive search of databases, studies focusing on the efficacy, safety, and patient experience of oxycodone/naloxone's prolonged release in severe cancer pain management were identified. Furthermore, the literature discusses the mechanism of action of naloxone in mitigating OIC without compromising opioid analgesia. Overall, the evidence suggests that oxycodone/naloxone combination therapy offers a valuable option for effectively managing severe cancer pain while minimizing opioid-induced constipation, thereby improving patients' quality of life. However, further research is needed to optimize dosing regimens, evaluate long-term safety, and assess patient outcomes in diverse cancer populations.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Michele Umbrello
- Department of Intensive Care, New Hospital of Legnano (Ospedale Nuovo di Legnano), 20025 Legnano, Italy
| | | | - Giovanni Sabbatini
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | | | - Miriam Gotti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Giovanni Brenna
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Alessandro Menozzi
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy
| | - Gaetano Terranova
- Anaesthesia and Intensive Care Department, Asst Gaetano Pini, 20100 Milano, Italy
| | - Andrea Galimberti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
| | - Angelo Pezzi
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, 20097 Milan, Italy
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3
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Dzierba AL, Stollings JL, Devlin JW. A pharmacogenetic precision medicine approach to analgesia and sedation optimization in critically ill adults. Pharmacotherapy 2023; 43:1154-1165. [PMID: 36680385 DOI: 10.1002/phar.2768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/22/2023]
Abstract
Precision medicine is a growing field in critical care. Research increasingly demonstrated pharmacogenomic variability to be an important determinant of analgesic and sedative drug response in the intensive care unit (ICU). Genome-wide association and candidate gene finding studies suggest analgesic and sedatives tailored to an individual's genetic makeup, environmental adaptations, in addition to several other patient- and drug-related factors, will maximize effectiveness and help mitigate harm. However, the number of pharmacogenetic studies in ICU patients remains small and no prospective studies have been published using pharmacogenomic data to optimize analgesic or sedative therapy in critically ill patients. Current recommendations for treating ICU pain and agitation are based on controlled studies having low external validity, including the failure to consider pharmacogenomic factors affecting response. Use of a precision medicine approach to individualize pharmacotherapy focused on optimizing ICU patient comfort and safety may improve the outcomes of critically ill adults. Additionally, benefits and risks of analgesic and/or sedative therapy in an individual may be informed with large, standardized datasets. The purpose of this review was to describe a precision medicine approach focused on optimizing analgesic and sedative therapy in individual ICU patients to optimize clinical outcomes and reduce safety concerns.
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Affiliation(s)
- Amy L Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, New York, New York, USA
- Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee, USA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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4
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Judy M, Sams D, Poulton S. Maximizing patient safety when prescribing opioids for pain management. JAAPA 2023; 36:1-6. [PMID: 37668489 DOI: 10.1097/01.jaa.0000947084.60262.4e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
ABSTRACT Cytochrome P450 enzyme metabolism is altered by environmental and genetic factors, which can affect the efficacy and safety of opioids. This article describes CYP polymorphisms and how pharmacogenetic testing could be used to help clinicians make safer decisions about opioid use in patients.
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Affiliation(s)
- Megan Judy
- Megan Judy practices in general surgery in Greensburg, Pa. David Sams is an assistant professor in the PA program at Marietta College and practices at OhioHealth CampusCare in Athens, Ohio. Stephon Poulton is an adjunct professor in the PA program at Marietta College and a clinical pharmacist with Genesis Healthcare Systems in Zanesville, Ohio. The authors have disclosed no potential conflicts of interest, financial or otherwise
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5
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Satkunananthan SE, Suppiah V, Toh GT, Yow HY. Pharmacogenomics of Cancer Pain Treatment Outcomes in Asian Populations: A Review. J Pers Med 2022; 12:1927. [PMID: 36422103 PMCID: PMC9694298 DOI: 10.3390/jpm12111927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 08/26/2023] Open
Abstract
In advanced cancer, pain is a poor prognostic factor, significantly impacting patients' quality of life. It has been shown that up to 30% of cancer patients in Southeast Asian countries may receive inadequate analgesia from opioid therapy. This significant under-management of cancer pain is largely due to the inter-individual variability in opioid dosage and relative efficacy of available opioids, leading to unpredictable clinical responses to opioid treatment. Single nucleotide polymorphisms (SNPs) cause the variability in opioid treatment outcomes, yet their association in Asian populations remains unclear. Therefore, this review aimed to evaluate the association of SNPs with variability in opioid treatment responses in Asian populations. A literature search was conducted in Medline and Embase databases and included primary studies investigating the association of SNPs in opioid treatment outcomes, namely pharmacokinetics, opioid dose requirements, and pain control among Asian cancer patients. The results show that CYP2D6*10 has the most clinical relevance in tramadol treatment. Other SNPs such as rs7439366 (UGT2B7), rs1641025 (ABAT) and rs1718125 (P2RX7) though significant have limited pharmacogenetic implications due to insufficient evidence. OPRM1 rs1799971, COMT rs4680 and ABCB1 (rs1045642, rs1128503, and rs2032582) need to be further explored in future for relevance in Asian populations.
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Affiliation(s)
| | - Vijayaprakash Suppiah
- Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA 5000, Australia
| | - Gaik-Theng Toh
- School of Medicine, Faculty of Health and Medical Sciences, Centre for Drug Discovery and Molecular Pharmacology, Taylor’s University, Subang Jaya 47500, Malaysia
| | - Hui-Yin Yow
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur 50603, Malaysia
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6
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Eapen-John D, Mohiuddin AG, Kennedy JL. A potential paradigm shift in opioid crisis management: The role of pharmacogenomics. World J Biol Psychiatry 2022; 23:411-423. [PMID: 34854362 DOI: 10.1080/15622975.2021.2012397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pharmacogenetic investigations into the opioid crisis suggest genetic variation could be a significant cause of opioid-related morbidity and mortality. Variability in opioid system genes, including single nucleotide polymorphisms, manifest after pharmacogenetic testing, as previously invisible risk factors for addiction and overdose. Pharmacodynamic genes regulate opioid-sensitive brain networks and neural reward circuitry. Pharmacokinetic genes expressed in drug metabolic pathways regulate blood levels of active vs. inactive opioid metabolites. Elucidating the complex interplay of genetic variations in pharmacokinetic and pharmacodynamic pathways will shed new light on the addictive and toxic properties of opioids. This narrative review serves to promote understanding of key genetic mechanisms affecting the metabolism and actions of opioids, and to explore causes of the recent surge in opioid-related mortality associated with COVID-19. Personalised treatment plans centred around an individual's genetic makeup could make opioid-based pain management and opioid use disorder (OUD) treatments safer and more effective at both the individual and system levels.
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Affiliation(s)
- David Eapen-John
- Molecular Brain Science, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Ayeshah G Mohiuddin
- Molecular Brain Science, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada
| | - James L Kennedy
- Molecular Brain Science, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
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7
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STOP Pain Project-Opioid Response in Pediatric Cancer Patients and Gene Polymorphisms of Cytokine Pathways. Pharmaceutics 2022; 14:pharmaceutics14030619. [PMID: 35335997 PMCID: PMC8953705 DOI: 10.3390/pharmaceutics14030619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Moderate to severe cancer pain treatment in children is based on the use of weak and strong opioids. Pharmacogenetics play a central role in developing personalized pain therapies, as well as avoiding treatment failure and/or intolerable adverse drug reactions. This observational study aimed to investigate the association between IL-6, IL-8, and TNFα genetic single nucleotide polymorphisms (SNPs) and response to opioid therapy in a cohort of pediatric cancer patients. Pain intensity before treatment (PIt0) significantly differed according to IL-6 rs1800797 SNP, with a higher PI for A/G and G/G individuals (p = 0.017), who required a higher dose of opioids (p = 0.047). Moreover, compared to G/G subjects, heterozygous or homozygous individuals for the A allele of IL-6 rs1800797 SNP had a lower risk of having a PIt0 > 4. Dose24h and Dosetot were both higher in G/G individuals for TNFα rs1800629 (p = 0.010 and p = 0.031, respectively), while risk of having a PIt0 > 4 and a ∆VAS > 2 was higher for G/G subjects for IL-6 rs1800795 SNP compared to carriers of the C allele. No statistically significant association between genotypes and safety outcomes was found. Thus, IL-6 and TNFα SNPs could be potential markers of baseline pain intensity and opioid dose requirements in pediatric cancer patients.
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8
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Drug Interactions. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Gavidia R, Emenike A, Meng A, Jansen EC, Hershner S, Goldstein C, Fetterolf J, Dunietz GL. The influence of opioids and nonopioid central nervous system active medications on central sleep apnea: a case-control study. J Clin Sleep Med 2021; 17:55-60. [PMID: 32964833 DOI: 10.5664/jcsm.8826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVES Opioids are known to contribute to central sleep apnea (CSA), but the influence of nonopioid central nervous system active medications (CNSAMs) on CSA remains unclear. In light of the hypothesized impact of nonopioid CNSAMs on respiration, we examined the relationships between the use of opioids only, nonopioid CNSAMs alone, and their combination with CSA. METHODS Among all adults who underwent polysomnography testing at the University of Michigan's sleep laboratory between 2013 and 2018 (n = 10,606), we identified 212 CSA cases and randomly selected 300 controls. Participants were classified into four groups based on their medication use: opioids alone, nonopioid CNSAMs only, their combination, and a reference group, including those who did not use any of these medications. We defined CSA as a binary outcome and as a continuous variable using central apnea index data. Logistic and linear regression were used to examine associations between medication use, CSA diagnosis, and central apnea index. RESULTS Study participants included 58% men, and mean age was 50 (± 14 standard deviation years. Nearly half of the study participants did not use opioids or nonopioid CNSAMs, 6% used opioids alone, 27% nonopioid CNSAMs alone, and 16% used a combination of these medications. In adjusted analyses, opioids-only users had a nearly twofold increase in CSA odds, whereas those who used a combination of opioids and nonopioid CNSAMs had fivefold higher odds of CSA relative to the reference group. In contrast, the use of nonopioid CNSAMs alone had protective associations with CSA. CONCLUSIONS This report showed increased odds of CSA, particularly among patients with sleep complaints who were prescribed opioids in combination with nonopioid CNSAMs compared with those who did not use any of these medications.
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Affiliation(s)
- Ronald Gavidia
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Amara Emenike
- Tallahassee Memorial Hospital Sleep Disorders Center, Tallahassee, Florida
| | - Anran Meng
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Erica C Jansen
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Shelley Hershner
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Cathy Goldstein
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Judy Fetterolf
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
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A functional polymorphism in the ATP-Binding Cassette B1 transporter predicts pharmacologic response to combination of nortriptyline and morphine in neuropathic pain patients. Pain 2021; 161:619-629. [PMID: 31738228 DOI: 10.1097/j.pain.0000000000001750] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Many genetic markers have been associated with variations in treatment response to analgesics, but none have been assessed in the context of combination therapies. In this study, the treatment effects of nortriptyline and morphine were tested for an association with genetic markers relevant to pain pathways. Treatment effects were determined for single and combination therapies. A total of 24 functional single nucleotide polymorphisms were tested within the gene loci of mu-opioid receptor (OPRM1) gene locus, ATP-Binding Cassette B1 Transporter (ABCB1), Cytochrome P450 gene family (CYP2C19 and CYP2D6), catecholamine inactivator Catechol-O-Methyl Transferase (COMT), and serotonin receptor 2A (HTR2A). Genotyping was performed in a population of neuropathic pain patients who previously participated in a clinical trial. For monotherapy, neither nortriptyline nor morphine responses were associated with single nucleotide polymorphisms. However, for nortriptyline + morphine combination therapy, the single nucleotide polymorphism rs1045642 within the drug efflux pump ABCB1 transporter significantly predicted analgesic response. The presence of the C allele accounted for 51% of pain variance in this subgroup in response to combination treatment. The T-allele homozygotes demonstrated only 20% improvement in pain scores, whereas the C-allele homozygotes 88%. There was no significant contribution of rs1045642 to the medication side effects under all treatment conditions. The UK Biobank data set was then used to validate this genetic association. Here, patients receiving similar combination therapy (opioid + tricyclic antidepressant) carrying the C allele of rs1045642 displayed 33% fewer body pain sites than patients without that allele, suggesting better pain control. In all, our results show a robust effect of the rs1045642 polymorphism in response to chronic pain treatment with a nortriptyline + morphine combination.
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11
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Slepukhina MA, Ivashchenko DV, Sheina MA, Muradian AA, Blagovestnov DA, Sychev DA. Pain pharmacogenetics. Drug Metab Pers Ther 2020; 35:dmpt-2020-2939. [PMID: 32776897 DOI: 10.1515/dmpt-2020-2939] [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: 10/15/2019] [Accepted: 03/16/2020] [Indexed: 11/15/2022]
Abstract
Pain is a significant problem in medicine. The use of PGx markers to personalize postoperative analgesia can increase its effectiveness and avoid undesirable reactions. This article describes the mechanisms of nociception and antinociception and shows the pathophysiological mechanisms of pain in the human body. The main subject of this article is pharmacogenetic approach to the selection of anesthetics. Current review presents data for local and general anesthetics, opioids, and non-steroidal anti-inflammatory drugs. None of the anesthetics currently has clinical guidelines for pharmacogenetic testing. This literature review summarizes the results of original research available, to date, and draws attention to this area.
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Affiliation(s)
| | - Dmitriy V Ivashchenko
- Child Psychiatry and Psychotherapy Department, Department of Personalized Medicine, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Maria A Sheina
- Department of Anesthesiology and Intensive Care, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | | | - Dmitriy A Sychev
- Department of Clinical Pharmacology and Therapeutics, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
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What Explains Poor Health-related Quality of Life Associated With Opioid Use Among Adults With Chronic Noncancer Pain Conditions? A Blinder-Oaxaca Decomposition. ADDICTIVE DISORDERS & THEIR TREATMENT 2020. [DOI: 10.1097/adt.0000000000000201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Incidence and predictors of drug overdoses among a cohort of >10,000 patients treated for substance use disorder. Drug Alcohol Depend 2020; 206:107714. [PMID: 31753733 DOI: 10.1016/j.drugalcdep.2019.107714] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Drug overdoses remain a significant public health burden throughout the world. This study assessed the incidence and predictors of non-fatal and fatal drug overdoses among patients with an opioid use, treated for drug use disorders (DUD) at public treatment centers in Denmark. METHODS A consecutive cohort of patients (n = 11,199) were tracked from date of first registered enrollment between the year 2000 and 2010 to first registered drug overdose, death or December 31st 2010, whichever occurred first. Competing-risks regression models were fitted to estimate the sub hazard ratios (SHRs) of non-fatal and fatal drug overdoses and confounding risk factors. RESULTS A total of 3186 (28%) patients experienced a non-fatal drug overdose during follow-up, and 572 (6%) died from an overdose. Use of benzodiazepines (SHR: 1.15 95% CI 1.03, 1.28) was significantly associated with non-fatal overdose. Intravenous drug use and previous hospitalization for a non-fatal overdose increased the risk of later non-fatal (SHR: 1.57 95% CI 1.42, 1.73) and fatal overdoses (SHR: 1.43 95% CI 1.12, 1.82). CONCLUSIONS Patients who use opioids remain at risk of overdoses for a long time after discharge from drug treatment. Besides relevant monitoring and psychosocial support in opioid maintenance treatment, there is a need for informing and educating opioid users in risk factors and preventive measures in settings where they are often difficult to access for traditional treatment services.
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14
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Dunn KE, Barrett FS, Brands B, Marsh DC, Bigelow GE. Individual differences in human opioid abuse potential as observed in a human laboratory study. Drug Alcohol Depend 2019; 205:107688. [PMID: 31710994 PMCID: PMC7219469 DOI: 10.1016/j.drugalcdep.2019.107688] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Opioids have high abuse potential and pose a major public health concern. Yet, a large percentage of individuals exposed to opioids do not develop problematic use. Individual differences in opioid abuse potential are not well understood. METHODS This within-subject (N = 16), double-blind, double-dummy, human laboratory study evaluated individual differences in response to dose (placebo, low, medium, high) following administration of heroin and hydromorphone through intravenous and subcutaneous routes, in opioid-experienced but non physically-dependent participants. Outcomes were self-reported visual analog scale (VAS) ratings (High, Liking, Drug Effect, Good Effect, Rush), pupil diameter change from baseline, and crossover point on the Drug vs. Money questionnaire. The degree to which results were consistent across measures within an individual was assessed using a mixed-effects model from which an intraclass correlation coefficient measure of between and within-subject variance was derived. RESULTS The mixed effects model fit was significant (p < 0.0001) and revealed that 85.5% of the explainable variance was due to between-subject effects, suggesting the responses within an individual were highly consistent. Visual inspection reveals a myriad response pattern across participants, with some demonstrating classic dose-effect responses and others not differentiating any active doses from placebo. CONCLUSIONS Data suggest the abuse potential of opioids is significantly different between individuals but that the experience within an individual is highly consistent. Research to prospectively characterize and evaluate mechanisms underlying these differences is warranted and may provide a foundation to help identify persons at heightened risk of transitioning from opioid exposure to misuse and/or opioid use disorder.
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Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, United States.
| | - Frederick S Barrett
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, United States
| | - Bruna Brands
- Health Canada, Canada; Centre for Addiction and Mental Health, Canada; University of Toronto, Canada
| | | | - George E Bigelow
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, United States
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15
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Shah M, Yates D, Hunt J, Murrell J. Comparison between methadone and buprenorphine within the QUAD protocol for perioperative analgesia in cats undergoing ovariohysterectomy. J Feline Med Surg 2019; 21:723-731. [PMID: 30215269 PMCID: PMC10814303 DOI: 10.1177/1098612x18798840] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the analgesic efficacy of methadone vs buprenorphine within the QUAD protocol for anaesthesia in cats undergoing ovariohysterectomy. METHODS One hundred and twenty cats were recruited to an assessor-blinded, randomised clinical trial. Cats received either methadone (5 mg/m2) or buprenorphine (180 µg/m2) combined with ketamine, midazolam and medetomidine intramuscularly. Anaesthesia was maintained with isoflurane in oxygen. Atipamezole was administered at extubation. Pain was assessed using the feline Composite Measure Pain Scale (CMPS-F), a dynamic interactive visual analogue scale (DIVAS) and mechanical nociceptive threshold (MNT). Sedation, pain, heart rate and respiratory rate were measured prior to QUAD administration, before intubation, and 2, 4, 6 and 8 h post-QUAD administration. If indicated by the CMPS-F, rescue analgesia was provided with 0.5 mg/kg of methadone administered intramuscularly. Meloxicam was administered after the last assessment. Differences in pain scores between groups were compared using a two-way repeated-measures ANOVA and requirement for rescue analgesia was compared using a χ2 test. RESULTS Cats administered methadone had lower CMPS-F scores over time (P = 0.04). Eighteen of 60 cats required rescue analgesia in the methadone group vs 29/60 in the buprenorphine group (P = 0.028). All cats that received rescue analgesia required it within 6 h post-QUAD administration. There were no differences between groups in MNT or pain measured using the DIVAS. CONCLUSIONS AND RELEVANCE Methadone produced clinically superior postoperative analgesia for the first 8 h after neutering than buprenorphine when used within the QUAD protocol.
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Affiliation(s)
| | - David Yates
- Greater Manchester RSPCA Hospital, Salford, UK
| | - James Hunt
- Cave Veterinary Specialists, George’s Farm, West Buckland, Wellington, UK
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Current Biomedical Applications of 3D Printing and Additive Manufacturing. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9081713] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Additive manufacturing (AM) has emerged over the past four decades as a cost-effective, on-demand modality for fabrication of geometrically complex objects. The ability to design and print virtually any object shape using a diverse array of materials, such as metals, polymers, ceramics and bioinks, has allowed for the adoption of this technology for biomedical applications in both research and clinical settings. Current advancements in tissue engineering and regeneration, therapeutic delivery, medical device fabrication and operative management planning ensure that AM will continue to play an increasingly important role in the future of healthcare. In this review, we outline current biomedical applications of common AM techniques and materials.
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ATP-Binding Cassette Transporters in the Clinical Implementation of Pharmacogenetics. J Pers Med 2018; 8:jpm8040040. [PMID: 30563187 PMCID: PMC6313650 DOI: 10.3390/jpm8040040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 02/07/2023] Open
Abstract
ATP-binding cassette (ABC) transporters are involved in a large number of processes and contribute to various human genetic diseases. Among other functions, ABC proteins are involved in the transport of multiple drugs through cells. Most of the genes coding for these transporters are highly polymorphic and DNA variants in these genes can affect the normal functioning of these proteins, affecting the way drugs are transported, increasing or decreasing drug levels. These changes in the intracellular and extracellular drug levels may be associated with altered drug effectiveness or severe drug-induced adverse events. This review presents a state-of-art of the most pharmacogenetics clinically relevant ABC transporters closed to the clinical implementation.
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Dagostino C, Allegri M, Napolioni V, D'Agnelli S, Bignami E, Mutti A, van Schaik RH. CYP2D6 genotype can help to predict effectiveness and safety during opioid treatment for chronic low back pain: results from a retrospective study in an Italian cohort. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:179-191. [PMID: 30425549 PMCID: PMC6205525 DOI: 10.2147/pgpm.s181334] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Opioids are widely used for chronic low back pain (CLBP); however, it is still unclear how to predict their effectiveness and safety. Codeine, tramadol and oxycodone are metabolized by CYP/CYP450 2D6 (CYP2D6), a highly polymorphic enzyme linked to allele-specific related differences in metabolic activity. Purpose CYP2D6 genetic polymorphisms could potentially help to predict the effectiveness and safety of opioid-based drugs in clinical practice, especially in the treatment of CLBP. Patients and methods A cohort of 224 Italian patients with CLBP treated with codeine or oxycodone was retrospectively evaluated to determine whether adverse reactions and effectiveness were related to CYP2D6 single-nucleotide polymorphisms. CYP2D6 genotyping was performed using the xTAG® CYP2D6 Kit v3 (Luminex) to determine CYP2D6 metabolizer phenotype (poor, intermediate, rapid and ultrarapid). Subjects from the cohort were categorized into two groups according to the occurrence of side effects (Case) or benefit (Control) after chronic analgesic treatment. The impact of CYP2D6 polymorphism on treatment outcome was tested at the metabolizer phenotype, diplotype and haplotype levels. Results CYP2D6 polymorphism was significantly associated with opioid treatment outcome (Omnibus P=0.018, for both global haplotype and diplotype distribution test). CYP2D6*6 and *9 carriers, alleles characterized by a reduced (*9) or absent (*6) enzymatic activity, were significantly (P<0.05) associated with therapeutic failure. CYP2D6 ultrarapid metabolizers (CYP2D6*2N patients) showed an increased risk of side effects, as would be predicted. Despite their low frequency, CYP2D6 *1/*11, *4/*6 and *41/* 2N diplotypes showed significant (P<0.05) associations of efficacy and side effects with chronic opioid treatment. Conclusion Our results showed that reduced CYP2D6 activity is correlated with lack of therapeutic effect. We found that the pharmacogenetic analysis of CYP2D6 could be helpful in foreseeing the safety and effectiveness of codeine or oxycodone treatment in CLBP.
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Affiliation(s)
- Concetta Dagostino
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy, .,Study In Multidisciplinary Pain Research (SIMPAR), Milan 20100, Italy,
| | - Massimo Allegri
- Study In Multidisciplinary Pain Research (SIMPAR), Milan 20100, Italy, .,Anesthesia and Intensive Care Department, IRCCS Multi Medica Hospital, Milan 20099, Italy.,Italian Pain Institute, Milan 20100, Italy
| | - Valerio Napolioni
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, USA
| | - Simona D'Agnelli
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy,
| | - Elena Bignami
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy,
| | - Antonio Mutti
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy,
| | - Ron Hn van Schaik
- Department of Clinical Chemistry, Erasmus MC, 3000 Rotterdam, The Netherlands
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Chincholkar M, Ireland K, Rajan J. Comment on 'Association between intraoperative opioid administration and 30-day readmission: a pre-specified analysis of registry data from a healthcare network in New England' (Br J Anaesth 2018;120:1090-1102). Br J Anaesth 2018; 121:986-987. [PMID: 30236273 DOI: 10.1016/j.bja.2018.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 11/25/2022] Open
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Abstract
Pain is an unpleasant feeling usually resulting from tissue damage that can persist along weeks, months, or even years after the injury, turning into pathological chronic pain, the leading cause of disability. Currently, pharmacology interventions are usually the first-line therapy but there is a highly variable analgesic drug response. Pharmacogenetics (PGx) offers a means to identify genetic biomarkers that can predict individual analgesic response opening doors to precision medicine. PGx analyze the way in which the presence of variations in the DNA sequence (single-nucleotide polymorphisms, SNPs) could be responsible for portions of the population reaching different levels of pain relief (phenotype) due to gene interference in the drug mechanism of action (pharmacodynamics) and/or its concentration at the place of action (pharmacokinetics). SNPs in the cytochrome P450 enzymes genes (CYP2D6) influence metabolism of codeine, tramadol, hydrocodone, oxycodone, and tricyclic antidepressants. Blood concentrations of some NSAIDs depend on CYP2C9 and/or CYP2C8 activity. Additional candidate genes encode for opioid receptors, transporters, and other molecules important for pharmacotherapy in pain management. However, PGx studies are often contradictory, slowing the uptake of this information. This is likely due, in large part, to a lack of robust evidence demonstrating clinical utility and to its polygenic response modulated by other exogenous or epigenetics factors. Novel therapies, including targeting of epigenetic changes and gene therapy-based approaches, broaden future options to improve understanding of pain and the treatment of people who suffer it.
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Affiliation(s)
- Ana M Peiró
- Clinical Pharmacology Unit, Department of Health of Alicante-General Hospital, Alicante, Spain; Neuropharmacology on Pain (NED), Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.
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Breivik H. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities. Scand J Pain 2017; 17:189-190. [PMID: 29065371 DOI: 10.1016/j.sjpain.2017.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Harald Breivik
- University of Oslo, Faculty of Medicine, Oslo, Norway; Oslo University Hospital, Department of Pain Management and Research, Oslo, Norway; Oslo University Hospital, Department of Anaesthesiology, Oslo, Norway.
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