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Tremonti C, Celemajer DS, Marel C, Mills K, Foo S, Wilson J, Slade T, Teesson M, Haber P. Low Risk of Cardiac Complications during Long-Term Follow-Up of Opioid Dependence. J Addict Med 2024:01271255-990000000-00330. [PMID: 38941157 DOI: 10.1097/adm.0000000000001317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
OBJECTIVES To prospectively assess rates of QT prolongation, arrhythmia, syncope, and sudden cardiac death (SCD) in a cohort of people with heroin dependence. METHODS To estimate rates of QT prolongation, arrhythmia, and syncope, a subcohort (n = 130) from the Australian Treatment Outcomes Study, a prospective longitudinal cohort study of 615 people with heroin dependence, underwent medical history, venepuncture, and ECG at the 18- to 20-year follow-up.To estimate rates of SCD, probabilistic matching for the entire cohort was undertaken with the Australian Institute of Health and Welfare National Death Index. Deaths were classified into suicide, accidental overdose, trauma, unknown, and disease, which were then further subclassified by probability of SCD. SCD rate was the number of possible or probable SCDs divided by total patient years from the cohort. RESULTS From the subcohort, 4 participants (3%) met the criteria for QT prolongation; 3 were prescribed methadone. Seven participants (5%) reported history of arrhythmia, including 2 transferred from methadone to buprenorphine. Thirty participants (23%) reported a previous syncopal event-14 diagnosed as nonarrhythmic syncope and 13 not investigated. In the previous 12 months, 66 participants (51%) reported heroin use; 55 participants (42%) were prescribed methadone. No participant had QTc greater than 500 milliseconds.There were 3 possible SCDs, translating to an estimated SCD rate of 0.29 (CI: 0.05, 0.8) events per 1000 patient years. More cohort members died of overdose (n = 50), suicide (n = 11), and hepatitis C (n = 4). CONCLUSIONS Low rates of QT prolongation, arrhythmia, syncope, and SCD in the cohort despite high rates of heroin use and methadone treatment.
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Affiliation(s)
- Chris Tremonti
- From the Alcohol and Drug Services, St Vincent's Hospital, Sydney, Australia (CT); Drug and Alcohol Department RPA Hospital, Sydney, Australia (CT); Faculty of Medicine and Health, University of Sydney (CT, DSC); Department of Cardiology, RPA Hospital (DS); Heart Research Institute (DSC); University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW, Australia (CM, KM, JW, TS, MT); Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (SF); Department of Cardiology, North Shore Hospital, Auckland, New Zealand (SF); Macquarie University (TS); Black Dog Institute (TS); and Drug Health Services RPA Hospital, Faculty of Health and Medicine University of Sydney, Sydney, Australia (PH)
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Ouchi R, Suzuki H, Kurata N, Watanabe T, Nagao M, Suzuki S, Yamagata T, Chiba M, Usui K, Murai Y, Koyama K, Okada K. A Case of Esophagogastric Junction Cancer Treated with Pain Control by Administering Methadone Tablets Through a Gastrostomy. J Palliat Med 2024. [PMID: 38916644 DOI: 10.1089/jpm.2024.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
Introduction: Methadone is used to treat intractable cancer pain when other opioid analgesics are ineffective. Methadone tablets may be difficult to administer in cases of gastrointestinal passage obstruction. However, changing the route of methadone tablet administration is possible. Case Description: The patient, diagnosed with esophagogastric junction cancer with multiple metastases, continued to receive methadone tablets even after not being longer able to take oral medication. Method: Methadone tablets were administered using a simple suspension method via gastrostomy. We measured the respiratory rate during sleep daily. We also measured weekly QTc values using a 12-lead electrocardiogram and methadone blood concentration periodically. No side effects were observed. Conclusion: Using a simple suspension method to administer methadone is a safe pain management method when accompanied by careful monitoring. To date, no study has examined the tube administration safety of methadone tablets. Thus, this case report is of important clinical significance.
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Affiliation(s)
- Ryusuke Ouchi
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Hiroyuki Suzuki
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
- Division of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Naoko Kurata
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Takashi Watanabe
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Munenori Nagao
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Shinju Suzuki
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Toshihiro Yamagata
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Mie Chiba
- Department of Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Kensuke Usui
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Yuriko Murai
- Division of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kaori Koyama
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
| | - Kouji Okada
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Japan
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Ouchi R, Nagao M, Suzuki S, Yamagata T, Chiba M, Kurata N, Usui K, Watanabe T, Koyama K, Okada K. A case with a trend of QT interval prolongation due to the introduction of methadone to a pancreatic cancer patient on levofloxacin. J Pharm Health Care Sci 2024; 10:4. [PMID: 38167143 PMCID: PMC10763223 DOI: 10.1186/s40780-023-00322-w] [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: 08/30/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND As methadone can prevent the development of opioid resistance, it has application in alleviating cancer-related pain that proves challenging to manage with other opioids. QT interval prolongation is a serious side effect of methadone treatment, with some reported deaths. In particular, owing to the increased risk of QT interval prolongation, caution should be exercised when using it in combination with drugs that also prolong the QT interval. CASE PRESENTATION This study presents a case in which methadone was introduced to a patient (a man in his 60s) already using levofloxacin, which could prolong the QT interval-a serious side effect of methadone treatment-and whose QTc value tended to increase. Given that levofloxacin can increase the risk of QT interval prolongation, we considered switching to other antibacterial agents before introducing methadone. However, because the neurosurgeon judged that controlling a brain abscess was a priority, low-dose methadone was introduced with continuing levofloxacin. Owing to the risks, we performed frequent electrocardiograms. Consequently, we responded before the QTc increased enough to meet the diagnostic criteria for QT interval prolongation. Consequently, we prevented the occurrence of drug-induced long QT syndrome. CONCLUSIONS When considering the use of methadone for intractable cancer pain, it is important to eliminate possible risk factors for QT interval prolongation. However, as it may be difficult to discontinue concomitant drugs owing to comorbidities, there could be cases in which the risk of QT interval prolongation could increase, even with the introduction of low-dose methadone. In such cases, frequent monitoring, even with simple measurements such as those used in this case, is likely to prevent progression to more serious conditions.
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Affiliation(s)
- Ryusuke Ouchi
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan.
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan.
| | - Munenori Nagao
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Shinju Suzuki
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Toshihiro Yamagata
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Mie Chiba
- Department of Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Naoko Kurata
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kensuke Usui
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Takashi Watanabe
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kaori Koyama
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kouji Okada
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
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Soeiro T, Pradel V, Lapeyre-Mestre M, Micallef J. Systematic assessment of non-medical use of prescription drugs using doctor-shopping indicators: A nation-wide, repeated cross-sectional study. Addiction 2023; 118:1984-1993. [PMID: 37203878 DOI: 10.1111/add.16261] [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: 10/13/2022] [Accepted: 05/04/2023] [Indexed: 05/20/2023]
Abstract
AIMS The aim of this study was to present the first nation-wide, systematic, repeated assessment of doctor-shopping (i.e. visiting multiple physicians to be prescribed the same drug) during 10 years for more than 200 psychoactive prescription drugs in the 67 million inhabitants in France. DESIGN This was a nation-wide, repeated cross-sectional study. SETTING AND PARTICIPANTS Data are from the French National Health Data System in 2010, 2015 and 2019 for 214 psychoactive prescription drugs (i.e. anaesthetics, analgesics, antiepileptics, anti-Parkinson drugs, psycholeptics, psychoanaleptics, other nervous system drugs and antihistamines for systemic use). MEASUREMENTS The detection and quantification of doctor-shopping relied upon an algorithm that detects overlapping prescriptions from repeated visits to different physicians. We used two doctor-shopping indicators aggregated at population level for each drug dispensed to more than 5000 patients: (i) the quantity doctor-shopped, expressed in defined daily doses (DDD), which measures the total quantity doctor-shopped by the study population for a given drug; and (ii) the proportion doctor-shopped, expressed as a percentage, which standardizes the quantity doctor-shopped according to the use level of the drug. FINDINGS The analyses included approximately 200 million dispensings to approximately 30 million patients each year. Opioids (e.g. buprenorphine, methadone, morphine, oxycodone and fentanyl), benzodiazepines and non-benzodiazepine hypnotics (Z-drugs) (e.g. diazepam, oxazepam, zolpidem and clonazepam) had the highest proportions doctor-shopped during the study period. In most cases, the proportion and the quantity doctor-shopped increased for opioids and decreased for benzodiazepines and Z-drugs. Pregabalin had the sharpest increase in the proportion doctor-shopped (from 0.28 to 1.40%), in parallel with a sharp increase in the quantity doctor-shopped (+843%, from 0.7 to 6.6 DDD/100 000 inhabitants/day). Oxycodone had the sharpest increase in the quantity doctor-shopped (+1000%, from 0.1 to 1.1 DDD/100 000 inhabitants/day), in parallel with a sharp increase in the proportion doctor-shopped (from 0.71 to 1.41%). Detailed results for all drugs during the study period can be explored interactively at: https://soeiro.gitlab.io/megadose/. CONCLUSIONS In France, doctor-shopping occurs for many drugs from many pharmacological classes, and mainly involves opioid maintenance drugs, some opioids analgesics, some benzodiazepines and Z-drugs and pregabalin.
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Affiliation(s)
- Thomas Soeiro
- Aix-Marseille Université, Inserm, Marseille, France
- Unité de pharmacoépidémiologie, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
| | - Vincent Pradel
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
| | - Maryse Lapeyre-Mestre
- Université de Toulouse, Inserm, Toulouse, France
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Centre hospitalier universitaire de Toulouse, Toulouse, France
| | - Joëlle Micallef
- Aix-Marseille Université, Inserm, Marseille, France
- Unité de pharmacoépidémiologie, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
- Centre d'évaluation et d'information sur la pharmacodépendance-Addictovigilance, Service de pharmacologie clinique, Hôpitaux universitaires de Marseille, Marseille, France
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Mercadante S, Cascio AL, Casuccio A. Switching to Intravenous Methadone in Advanced Cancer Patients: A Retrospective Analysis. J Pain Symptom Manage 2023; 66:287-292. [PMID: 37236430 DOI: 10.1016/j.jpainsymman.2023.04.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/17/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
CONTEXT Information about opioid switching to intravenous methadone is lacking. OBJECTIVES The aim of this study was to assess the outcome of opioid switching to intravenous methadone (IV-ME) in patients admitted to an acute supportive/palliative care unit (ASPCU). The secondary outcome was to assess the conversion ratio from IV-ME to oral methadone at time of hospital discharge. METHODS We retrieved from the pharmacy registry the list of patients who were prescribed IV-ME during their ASPCU admission for a period of 47 months. Poor analgesia with previous opioids and/or adverse effects were the main indications for opioid switching. IV-ME was titrated until acceptable analgesia was achieved. The effective dose was multiplied by three to establish the intravenous daily dose, given as a continuous infusion. Doses were then changed according to the clinical needs. Once the patient was stabilized, IV-ME dose was converted to oral methadone, by using an initial ratio of 1:1.2. Further dose changes were made according to clinical needs until stabilization, before patients' discharge. Information about patients' characteristics, pain scores on the Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire, previous opioids and their doses, expressed as oral morphine equivalents (OME), were recorded. The effective bolus of IV-ME, initial daily infusion rate, and oral methadone doses were assessed, and conversion ratios calculated. RESULTS Forty-one patients were taken into consideration for the study. The mean effective bolus of IV-ME titrated for achieving acceptable analgesia was 9 mg (range 5-15 mg). The mean daily continuous infusion rate of IV-ME was 27.6 mg/day (SD 21). The mean daily dose of oral methadone at time of discharge was 46.8 mg/day (SD 43). Discharge occurred within a median of seven days (range 6-9) after admission. Previous opioid (OME)/IV-ME, oral-IV-ME, and previous opioid (OME)/oral methadone were 6.25, 1.7, and 3.7, respectively. CONCLUSION IV-ME dose titration followed by intravenous infusion allowed a rapid pain control in few minutes in patients with severe pain intensity, not responsive to previous opioids. Conversion to oral route was successful and facilitated home discharge. Further studies should be performed to confirm these preliminary results.
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Affiliation(s)
- Sebastiano Mercadante
- Department of Health Promotion (S.M., A.L.C.), Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.
| | - Alessio Lo Cascio
- Department of Health Promotion (S.M., A.L.C.), Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Mean regional center for Pain relief and palliative care Unit (A.C.), La Maddalena Cancer Center, Palermo, Italy
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Sherbini AE, Liblik K, Lee J, Baranchuk A, Zhang S, El-Diasty M. Opioids-Induced Inhibition of HERG Ion Channels and Sudden Cardiac Death, A Systematic Review of Current Literature. Trends Cardiovasc Med 2023:S1050-1738(23)00040-3. [PMID: 37015297 DOI: 10.1016/j.tcm.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND It is estimated that over 60 million individuals regularly use opioids globally, with opioid use disorder increasing substantially in the past decade. Several reports have linked sudden cardiac death, QTc prolongation, and other adverse cardiovascular outcomes with opioid use through their inhibitory effect on the human ether-a-go-go-related gene (HERG) ion channel. Therefore, understanding this underlying mechanism may be critical for risk prevention and management in prescribing opioids and treating patients with opioid dependency. AIM The present systematic review summarizes the current literature on the impact of opioids-induced inhibition of HERG channel function and its relationship with sudden cardiac death, QTc prolongation, and other cardiovascular adverse effects. METHODS A systematic review was conducted of the databases PubMed, EMBASE, Cochrane, and ClinicalTrials.gov of primary studies that reported the effects of opioids on HERG channel function and associated cardiovascular outcomes. RESULTS The search identified 1,546 studies, of which 12 were finally included for data extraction. Based on the current literature, methadone, oliceridine, l-α-acetylmethadol (LAAM), and fentanyl were found to inhibit the HERG channel function and were associated with QTc prolongation. However, other opioids such as morphine, codeine, tramadol, and buprenorphine were not associated with inhibition of HERG channels or QTc prolongation. Additional cardiac outcomes associated with opioid related HERG channels dysfunction included sudden cardiac death and torsade de pointes. CONCLUSION Our findings suggest that certain opioid consumption may result in the inhibition of HERG channels, subsequently prolonging the QTc interval and increasing patient susceptibility to sudden cardiac death.
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Affiliation(s)
- Adham El Sherbini
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Kiera Liblik
- School of Medicine, Queen's University, Kingston, ON
| | - Junsu Lee
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Shetuan Zhang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mohammad El-Diasty
- Division of Cardiac Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada.
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Mehta A, Patel BM. Long-acting opioids and cardiovascular diseases: Help or hindrance! Vascul Pharmacol 2023; 149:107144. [PMID: 36740214 DOI: 10.1016/j.vph.2023.107144] [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: 12/02/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
Opioids are widely being used for chronic pain management, cough and diarrhea suppressants, anesthetic agents, and opioid de-addiction therapy. Opioid receptors, present in the central nervous system and peripheral tissues, are documented to regulate several cardiac functions through different signaling pathways. Long-acting opioids (LAO) have been successfully evaluated for their beneficial effects in various cardiovascular diseases viz. myocardial infarction, ischemic reperfusion injuries, atherosclerosis etc. However, on the other hand, several research studies pointed towards the harmful effects of LAOs which are mainly associated with QTc prolongation, torsade de pointes, ventricular arrhythmias, and cardiac arrest. This review shall familiarize readers with the benefits as well as the harmful effects of long-acting opioids in cardiovascular diseases. We have also provided an overview of cardiac opioid receptors, endogenous cardiac opioid peptides, and regulation of cardiovascular functions by central and cardiac opioid receptors.
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Affiliation(s)
- Ankita Mehta
- Labcorp Central Laboratory Services Limited Partnership, Bangalore, India
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Puccinelli C, Pelligra T, Briganti A, Citi S. Two-dimensional shear wave elastography of liver in healthy dogs: anaesthesia as a source of variability. Int J Vet Sci Med 2022; 10:46-51. [PMID: 35677323 PMCID: PMC9132446 DOI: 10.1080/23144599.2022.2073138] [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] [Indexed: 11/28/2022] Open
Abstract
Two-dimensional shear wave elastography (2D-SWE) is a non-invasive method to quantitatively evaluate the liver stiffness (LS), allowing the detection of hepatic pathological changes in both dogs and humans. In dogs, some factors such as patient movement and respiration can cause artefacts and potential errors of measurements. Therefore, anaesthesia has been suggested to reduce the effect of the movement on 2D-SWE in dogs. This study was performed to evaluate the influence of an anaesthetic protocol on 2D-SWE measurements for assessment of LS in healthy dogs. Forty-five dogs were included and subjected to anaesthesia: in 11 dogs, the 2D-SWE was performed both before and under anaesthesia, in 19 dogs, the 2D-SWE was performed only when they were awake and in 15 dogs, the examination was carried out only under anaesthesia. The anaesthetic protocol was composed of intramuscular injection of a combination of dexmedetomidine, methadone and ketamine and intravenous administration of propofol for induction and isoflurane for maintenance. The variability of 2D-SWE values according to anaesthesia was evaluated. Median 2D-SWE values were significantly higher in anesthetized dogs compared to awake dogs either by considering separately the dogs in which the examination was performed both awake and under anaesthesia and by considering all dogs included. According to our study, anaesthesia helped to avoid challenges related to patient movement and respiration; however, it was a source of variability on 2D-SWE values, and this factor should be considered before performing 2D-SWE under anaesthesia.
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Affiliation(s)
| | - Tina Pelligra
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - Angela Briganti
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - Simonetta Citi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
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Chang KC, Chen KW, Huang CL, Liao WL, Wu MY, Lin YK, Shiao YT, Chung WH, Lin YN, Lane HY. Association of a Common NOS1AP Variant with Attenuation of QTc Prolongation in Men with Heroin Dependence Undergoing Methadone Treatment. J Pers Med 2022; 12:jpm12050835. [PMID: 35629257 PMCID: PMC9143734 DOI: 10.3390/jpm12050835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/20/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The effects of methadone-induced severe prolongation of the corrected QT interval (QTc) and sudden cardiac death appear unpredictable and sex-dependent. Genetic polymorphisms in the nitric oxide synthase 1 adaptor protein (NOS1AP) have been implicated in QTc prolongation in general populations. We investigated whether common NOS1AP variants interact with methadone in relation to QTc prolongation in patients with heroin dependence. Methods: We genotyped 17 NOS1AP variants spanning the entire gene in heroin-dependent patients who received a 12-lead electrocardiography (ECG) examination both at baseline and during maintenance methadone treatment in Cohort 1 and only during maintenance methadone treatment in Cohort 2. The QT interval was measured automatically by the Marquette 12SL program, and was corrected for heart rate using Bazett’s formula. Results: Cohort 1 consisted of 122 patients (age: 37.65 ± 8.05 years, 84% male, methadone dosage: 42.54 ± 22.17 mg/day), and Cohort 2 comprised of 319 patients (age: 36.9 ± 7.86 years, 82% male, methadone dosage: 26.08 ± 15.84 mg/day), with complete genotyping data for analyses. Before methadone, the QTc intervals increased with increasing age (r = 0.3541, p < 0.001); the age-adjusted QTc showed dose-dependent prolongation in men (r = 0.6320, p < 0.001), but abbreviation in women (r = −0.5348, p = 0.018) in Cohort 1. The pooled genotype-specific analysis of the two cohorts revealed that the QTc interval was significantly shorter in male carriers of the rs164148 AA variant than in male carriers of the reference GG genotype (GG: n = 262, QTc = 423 ± 1.4 ms; AA: n = 10, QTc = 404.1 ± 7 ms, p = 0.009), according to univariate analysis. The QTc remained shorter in male carriers of the rs164148 AA variant compared to GG genotype (423 ± 1.4 ms vs. 405.9 ± 6.9 ms, p = 0.016) in multivariate analysis after adjusting for age and methadone dosage. A cut-off QTc interval of <410 ms identifies 100% of AA carriers compared to none of GG carriers when receiving a daily methadone dosage of 30.6 ± 19.3 mg. There was no significant gene-drug interaction in contributing to the adjusted QTc (p = 0.2164) in male carriers of the rs164148 variants. Conclusions: Carriers of a common NOS1AP rs164148 AA genotype variant were associated with a shorter QTc interval in men receiving maintenance methadone treatment. This genetic polymorphism attenuates the QTc-prolonging effect by methadone, and thus may explain at least in part the unpredictable and heterogeneous risks for severe QTc prolongation and sudden cardiac death in patients on methadone.
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Affiliation(s)
- Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 404332, Taiwan; (K.-W.C.); (Y.-K.L.); (W.-H.C.); (Y.-N.L.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan;
- Correspondence: ; Tel.: +886-4-22052121 (ext. 2626); Fax: +886-4-22065593
| | - Ke-Wei Chen
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 404332, Taiwan; (K.-W.C.); (Y.-K.L.); (W.-H.C.); (Y.-N.L.)
| | - Chieh-Liang Huang
- Department of Addiction Treatment, Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nan-Tou County 54249, Taiwan;
| | - Wen-Ling Liao
- Center for Personalized Medicine, China Medical University Hospital, Taichung 404332, Taiwan;
- Graduate Institute of Integrated Medicine, China Medical University, Taichung 404333, Taiwan
| | - Mei-Yao Wu
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung 40402, Taiwan;
- Department of Chinese Medicine, China Medical University Hospital, Taichung 404332, Taiwan
| | - Yu-Kai Lin
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 404332, Taiwan; (K.-W.C.); (Y.-K.L.); (W.-H.C.); (Y.-N.L.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan;
| | - Yi-Tzone Shiao
- Center of Institutional Research and Development, Asia University, Taichung 413305, Taiwan;
| | - Wei-Hsin Chung
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 404332, Taiwan; (K.-W.C.); (Y.-K.L.); (W.-H.C.); (Y.-N.L.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan;
| | - Yen-Nien Lin
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 404332, Taiwan; (K.-W.C.); (Y.-K.L.); (W.-H.C.); (Y.-N.L.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan;
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404333, Taiwan;
- Department of Psychiatry, China Medical University Hospital, Taichung 404332, Taiwan
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Palat G, Algotsson C, Rayala S, Gebre-Medhin M, Brun E, Segerlantz M. The Introduction and Experiences of Methadone for Treatment of Cancer Pain at a Low-resource Governmental Cancer Center in India. Indian J Palliat Care 2021; 27:382-404. [PMID: 34898933 PMCID: PMC8655673 DOI: 10.25259/ijpc_383_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/04/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives This study aimed to describe the clinical experience of the health-care professionals (HCPs) responsible for the introduction of methadone, for the treatment of complex cancer pain, at a low-resource hospital in India in a patient-group, burdened by illiteracy, and low socio-economic status. Materials and Methods Ten HCPs: Four medical doctors, four nurses, one pharmacist, and one hospital administrator were interviewed. The interviews are examined using a qualitative conventional content analysis. Results The interviews showed a confidence amongst the HCPs, responsible for the safe introduction of methadone in a stressful and low-resource surrounding, to patients with cancer pain and the different aspects of methadone, as initiation, titration, and maintenance of treatment. Conclusion Introduction of methadone for cancer pain management is safe and feasible although low resources in a challenging hospital setting and care environment.
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Affiliation(s)
- Gayatri Palat
- Department of Medical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India.,Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India.,Two-Worlds Cancer Collaboration-INCTR, Vancouver, British Columbia, Canada
| | | | - Spandana Rayala
- Department of Medical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India.,Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - Maria Gebre-Medhin
- Department of Clinical Sciences, Oncology, Lund University, Sweden.,Department of Radiotherapy and Radiophysics, Skane University Hospital, Lund, Sweden
| | - Eva Brun
- Department of Clinical Sciences, Oncology, Lund University, Sweden.,Department of Radiotherapy and Radiophysics, Skane University Hospital, Lund, Sweden
| | - Mikael Segerlantz
- Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skane, Region Skane, Lund, Sweden.,Department of Clinical Sciences, Oncology and Pathology, Institute for Palliative Care, Lund University, Lund, Sweden
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11
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Effects of opioid receptor agonist and antagonist medications on electrocardiogram changes and presentation of cardiac arrhythmia: review article. J Interv Card Electrophysiol 2021; 63:471-500. [PMID: 34674120 DOI: 10.1007/s10840-021-01072-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE Mortality associated with prescription opioids has significantly increased over the past few decades and is considered a global pandemic. Prescribed opioids can cause cardiac arrhythmias, leading to fatal outcomes and unexpected death, even in the absence of structural cardiac disease. Despite the extent of cardiac toxicity and death associated with these medications, there is limited data to suggest their influences on cardiac electrophysiology and arrhythmias, with the exception of methadone. The goal of our review is to describe the possible mechanisms and to review the different ECG changes and arrhythmias that have been reported. METHODS A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct to identify studies that demonstrated the use of prescription opioids leading to electrocardiogram (ECG) changes and cardiac arrhythmias. RESULTS Many of the commonly prescribed opioid medications can uniquely effect the ECG, and can lead to the development of various cardiac arrhythmias. One of the most significant side effects of these drugs is QTc interval prolongation, especially when administered to patients with a baseline risk for QTc prolongation. A prolonged QTc interval can cause lethal torsades de pointes and ventricular fibrillation. Obtaining an ECG at baseline, following a dosage increase, or after switching an opioid medication, is appropriate in patients taking certain prescribed opioids. Opioids are often used first line for the treatment of acute and chronic pain, procedural sedation, medication opioid use disorders, and maintenance therapy. CONCLUSIONS To reduce the risk of cardiac arrhythmias and to improve patient outcomes, consideration of accurate patient selection, concomitant medications, electrolyte monitoring, and vigilant ECG monitoring should be considered.
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Lobova VA, Roll JM, Roll MLC. Intraoperative Methadone Use in Cardiac Surgery: A Systematic Review. PAIN MEDICINE 2021; 22:2827-2834. [PMID: 34487175 DOI: 10.1093/pm/pnab269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/30/2021] [Accepted: 08/28/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate the effects of intraoperative methadone to standard of care opioids such as fentanyl and morphine on pain scores, opioid consumption, and adverse effects in adults undergoing cardiothoracic surgery. METHODS The literature was reviewed on PubMed, Embase, Cochrane Library, and Google Scholar, followed by a manual search using reference lists of the identified articles. Search terms included a combination of intraoperative methadone, methadone, and cardiac surgery. Our review includes four studies published between 2011 and 2020. Quality assessment of the studies was performed. RESULTS The initial search identified 715 articles with 461 duplicates removed, and 236 eliminated based on inclusion and exclusion criteria. Eighteen articles underwent full-text review. Four studies evaluating a total of 435 patients with various cardiothoracic procedures were included in this review. We found that intraoperative methadone decreases acute postoperative pain and reduces postoperative opioid consumption in the first 24 postoperative hours in patients who received 0.1-0.3 mg/kg intraoperative methadone in comparison to morphine and fentanyl. No difference was found in adverse effects between the groups. Quality assessment of the studies showed a low risk of bias in three of the randomized controlled trials and a high risk of bias in the retrospective review because of the baseline confounding bias in the study design. CONCLUSIONS Intraoperative methadone use reduces acute postoperative pain and lowers opioid consumption in comparison to morphine and fentanyl. Initial results suggest that methadone may be an equivalent opioid to be administered during cardiothoracic procedures to reduce acute post-surgical pain, though further research is warranted.
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Affiliation(s)
- Veronika A Lobova
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington
| | - John M Roll
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington.,Department of Community and Behavioral Health, Program of Excellence in the Addictions, Washington State University, Spokane, Washington
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13
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Palat G, Algotsson C, Rayala S, Haridass V, Nethagani J, Ahmed M, Rapelli V, Medhin MG, Brun E, Segerlantz M. The Use of Methadone in Adult Patients with Cancer Pain at a Governmental Cancer Center in India. Indian J Palliat Care 2021; 27:139-145. [PMID: 34035632 PMCID: PMC8121220 DOI: 10.4103/ijpc.ijpc_275_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/02/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Management of cancer-related pain relies on the access to opioids. When regular opioids as morphine are not tolerated or are insufficient, adjuvant opioids as methadone are an affordable and effective analgesic. Aim: The aim of the project was to describe the pattern of use and clinical experiences of methadone in patients with cancer-related pain at a low-resource hospital in Hyderabad, one of few Indian cancer centers with permission to prescribe methadone. Methods: Medical records of all patients who had been prescribed methadone, September 9, 2017 and November 19, 2019 were studied retrospectively. Data on analgesic treatment and opioid side effects were analyzed. Results: A total of 93 adult cancer patients were included in the study. A majority of patients (79%) were prescribed opioid analgesic, mainly morphine, before methadone introduction. The initial daily dose of methadone ranged between 5 and 22.5 years and in the vast majority of the patients 5 mg, divided in two daily administrations. A good analgesic effect, with decreased pain, was reported in 60% of the patients. No severe side effects were reported. Conclusions: In this study, methadone as a primary opioid was used with a good analgesic effect for cancer pain in a low-resource setting. Indication for methadone was mainly uncontrolled pain with a regular opioid treatment. No severe adverse effects were reported. Further research and prospective studies are needed on methadone treatment in low-resource settings to establish the robust guidelines to support prescribing physicians.
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Affiliation(s)
- Gayatri Palat
- Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Two Worlds Cancer Collaboration-INCTR, Vancouver, British Columbia, Canada
| | | | - Spandana Rayala
- Department of Pediatric Palliative Care, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Vikranth Haridass
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Jayalatha Nethagani
- Department of Radiology, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Mustafa Ahmed
- Department of Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Vineela Rapelli
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Maria Gebre Medhin
- Department of Clinical Sciences, Oncology and Pathology, Faculty of Medicine, Lund UniversitY, Lund, Sweden.,Department of Oncology, Skane University Hospital, Lund, Sweden
| | - Eva Brun
- Department of Clinical Sciences, Oncology and Pathology, Faculty of Medicine, Lund UniversitY, Lund, Sweden.,Department of Oncology, Skane University Hospital, Lund, Sweden
| | - Mikael Segerlantz
- Department of Clinical Sciences, Oncology and Pathology, Institute for Palliative Care, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skane, Region Skane, Lund, Sweden
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14
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Palat G, Algotsson C, Rayala S, Haridass V, Nethagani J, Rapelli V, Medhin MG, Brun E, Segerlantz M. The Use of Methadone in Pediatric Cancer Pain - A Retrospective Study from a Governmental Cancer Center in India. Indian J Palliat Care 2021; 27:133-138. [PMID: 34035631 PMCID: PMC8121219 DOI: 10.4103/ijpc.ijpc_109_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 01/07/2020] [Accepted: 02/10/2020] [Indexed: 01/22/2023] Open
Abstract
Background: The management of cancer-related pain relies on access to opioids. When regular opioids are not tolerated, or are insufficient, methadone is an affordable and effective analgesic. Aim: The aim of the project was to describe the pattern of use and clinical experience of methadone in pediatric cancer pain at a governmental cancer hospital in Hyderabad, one of the four Indian cancer centers with permission to prescribe methadone. Methods: This was a retrospective study of medical records of all children, under the age of 18, who had been prescribed methadone from September 9, 2017, to November 19, 2019. Data on analgesic effect, prior and concomitant analgesic treatment, opioid side effects, and the handling of methadone were analyzed. Results: A total of 11 children were identified and studied. Methadone was introduced mainly when pain was uncontrolled by regular opioids. Initial daily doses ranged from 1 to 15 mg. The duration of treatment ranged from 7 to 307, with a median of 50 days in the nine patients where treatment exceeded one single dosage. Good analgesic effect was reported in 5/9 children, unchanged from previous analgesic treatment in three patients and without any effect in one child. No severe side effects were reported. Conclusion: Low-dose methadone in the treatment of pediatric cancer pain at a low-resource cancer center was safe and well tolerated by the patients, with long treatment durations. It was safely managed, administered with single to double daily dosages, hence easy for patients and family to handle, and an affordable treatment option.
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Affiliation(s)
- Gayatri Palat
- Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | | | - Spandana Rayala
- Department of Pediatric Palliative Care, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Vikranth Haridass
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Jayalatha Nethagani
- Department of Radiology, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Vineela Rapelli
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Maria Gebre Medhin
- Department of Clinical Sciences, Oncology and Pathology, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Oncology, Skane University Hospital, Region Skane, Lund, Sweden
| | - Eva Brun
- Department of Clinical Sciences, Oncology and Pathology, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Oncology, Skane University Hospital, Region Skane, Lund, Sweden
| | - Mikael Segerlantz
- Department of Clinical Sciences, Oncology and Pathology, Institute for Palliative Care, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skane, Region Skane, Lund, Sweden
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15
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Niimi N, Yuki K, Zaleski K. Long QT Syndrome and Perioperative Torsades de Pointes: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2020; 36:286-302. [PMID: 33495078 DOI: 10.1053/j.jvca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Naoko Niimi
- Department of Anesthesiology, Juntendo University, Tokyo, Japan.
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Katherine Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
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16
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Kokubun H, Takigawa C, Chihara S, Hara S, Uezono Y. Population Pharmacokinetics of Methadone after Oral Administration in Japanese Patients with Cancer-Related Pain. J Pain Palliat Care Pharmacother 2020; 34:203-210. [PMID: 32870067 DOI: 10.1080/15360288.2020.1785070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Methadone tablets were approved for use in Japan in March 2013. The metabolism of methadone is complex and executed mainly by the cytochromes, CYP3A4 and CYP2B6. The aim of this study was to evaluate the pharmacokinetics of methadone upon oral administration in Japanese patients who experienced cancer-related pain. The concentration of the drug in blood samples was measured in 25 patients undergoing methadone therapy, and the factors leading to variations were investigated. A population pharmacokinetic analysis was evaluated using the Phoenix® NLMETM software. Based on this, the ALBI (albumin-bilirubin) score was identified as a significant factor that could be used to assess variations in the serum concentration of methadone, which was then incorporated into the following final model formula: clearance (L/h) = 5.38 × (ALBI score/-2.139)1.88. The results of these pharmacokinetic parameters suggested that, in clinical use, the dose of methadone should be reduced if liver function declined in patients with cancer-related pain.
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17
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Fenton C, Lyseng-Williamson KA. Methadone is an option to treat cancer pain in carefully selected patients. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00772-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Keating S, Fries R, Kling K, Graham L, Clark-Price S, Schaeffer DJ. Effect of Methadone or Hydromorphone on Cardiac Conductivity in Dogs Before and During Sevoflurane Anesthesia. Front Vet Sci 2020; 7:573706. [PMID: 33195568 PMCID: PMC7541965 DOI: 10.3389/fvets.2020.573706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/21/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate changes in electrocardiogram (ECG) variables in healthy dogs receiving either methadone or hydromorphone IV before and during sevoflurane anesthesia. Study Design: Prospective clinical study. Animals: Forty client-owned dogs. Methods: Dogs were randomized to receive methadone 0.5 mg/kg IV or hydromorphone 0.1 mg/kg IV in each part of a two-part study. In part one, dogs received the opioid prior to sevoflurane anesthesia (groups MS, n = 12 and HS, n = 12). Anesthesia was induced with propofol IV, maintained with sevoflurane, and dogs were mechanically ventilated. Standard 6-lead ECG recordings were obtained before opioid administration, 2, 5, and 10 min after opioid administration prior to anesthesia, and during anesthesia 15 min after end-tidal sevoflurane stabilized at 2.4%. In part two, conscious dogs received the same opioid treatments and ECGs were obtained at equivalent time points without undergoing anesthesia (groups M, n = 8 and H, n = 8). Values for ECG variables were determined by a blinded cardiologist and included: Heart rate (HR), PR interval, QT interval, and HR corrected QT interval (QTc) using the Bazett (QTcB), Fridericia (QTcF), and Van de Water (QTcV) formulas. Differences over time and between all four groups were evaluated using ANOVA for repeated measures with significance set at p ≤ 0.05. Results: Both methadone and hydromorphone administration reduced HR and prolonged PR and QT intervals, with greater changes observed during sevoflurane anesthesia. The greatest prolongation in QT interval was observed in dogs administered methadone during sevoflurane anesthesia. Conclusions and Clinical Relevance: Methadone and hydromorphone caused disturbances in myocardial electrical activity, and the addition of sevoflurane enhanced these disturbances. Both drugs caused considerable QT interval prolongation into the proarrhythmogenic range, with methadone causing greater prolongation.
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Affiliation(s)
- Stephanie Keating
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL, United States
| | - Ryan Fries
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL, United States
| | - Katherine Kling
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL, United States
| | - Lynelle Graham
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Stuart Clark-Price
- Department of Clinical Science, College of Veterinary Medicine, Auburn University, Auburn, AL, United States
| | - David J Schaeffer
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL, United States
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Vatter T, Klumpp L, Ganser K, Stransky N, Zips D, Eckert F, Huber SM. Against Repurposing Methadone for Glioblastoma Therapy. Biomolecules 2020; 10:biom10060917. [PMID: 32560384 PMCID: PMC7356722 DOI: 10.3390/biom10060917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/08/2020] [Accepted: 06/11/2020] [Indexed: 02/06/2023] Open
Abstract
Methadone, which is used as maintenance medication for outpatient treatment of opioid dependence or as an analgesic drug, has been suggested by preclinical in vitro and mouse studies to induce cell death and sensitivity to chemo- or radiotherapy in leukemia, glioblastoma, and carcinoma cells. These data together with episodical public reports on long-term surviving cancer patients who use methadone led to a hype of methadone as an anti-cancer drug in social and public media. However, clinical evidence for a tumoricidal effect of methadone is missing and prospective clinical trials, except in colorectal cancer, are not envisaged because of the limited preclinical data available. The present article reviews the pharmacokinetics, potential molecular targets, as well as the evidence for a tumoricidal effect of methadone in view of the therapeutically achievable doses in the brain. Moreover, it provides original in vitro data showing that methadone at clinically relevant concentrations fails to impair clonogenicity or radioresistance of glioblastoma cells.
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Affiliation(s)
- Tatjana Vatter
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
| | - Lukas Klumpp
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
| | - Katrin Ganser
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
| | - Nicolai Stransky
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
- Department of Pharmacology, Toxicology and Clinical Pharmacy, Institute of Pharmacy, University of Tübingen, 72076 Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Franziska Eckert
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
- German Cancer Consortium (DKTK), Partner Site Tübingen, Tübingen, Germany, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Stephan M. Huber
- Department of Radiation Oncology, University of Tübingen, 72076 Tübingen, Germany; (T.V.); (L.K.); (K.G.); (N.S.); (D.Z.); (F.E.)
- Correspondence: ; Tel.: +49-(0)7071-29-82183
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20
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QTc prolongation after haloperidol administration in critically ill patients post cardiovascular surgery: A cohort study and review of the literature. Palliat Support Care 2020; 18:447-459. [DOI: 10.1017/s1478951520000231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveFrom case reports, haloperidol administration has been associated with QTc prolongation, torsades de pointes, and sudden cardiac death. In a vulnerable population of critically ill patients after cardiac surgery, however, it is unclear whether haloperidol administration affects the QTc interval. Thus, the aim of this study is to explore the effect of haloperidol in low doses on this interval.MethodThis retrospective cohort study was performed on a cardio-surgical intensive care unit (ICU), screened 2,216 patients and eventually included 68 patients with delirium managed with oral and intravenous haloperidol. In this retrospective analysis, electrocardiograms were taken prior and within 24 h after haloperidol administration. The effect of haloperidol on QTc was determined with a Person correlation, and inter-group differences were measured with new long QT comparisons.ResultsIn total, 68 patients were included, the median age was 71 (64–79) years and predominantly male (77%). Haloperidol administration followed ICU admission by three days and the cumulative dose was 4 (2–9) mg. As a result, haloperidol administration did not affect the QTc (r = 0.144, p = 0.23). In total, 31% (21/68 patients) had a long QT before and 27.9% (19/68 patients) after haloperidol administration. Only 12% (8/68 patients) developed a newly onset long QT. These patients were not different in the route of administration, cumulative haloperidol doses, comorbidities, laboratory findings, or medications.Significance of resultsThese results indicated that low-dose intravenous haloperidol was safe and not clinically relevant for the development of a newly onset long QT syndrome or adverse outcomes and support recent findings inside and outside the ICU setting.
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The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials. Anesthesiol Res Pract 2020; 2020:6974321. [PMID: 32280341 PMCID: PMC7140144 DOI: 10.1155/2020/6974321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/06/2020] [Accepted: 02/26/2020] [Indexed: 12/28/2022] Open
Abstract
Methods We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases. Meta-analysis was performed using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals, and sample size. Methodological quality was evaluated using Cochrane Collaboration's tool. Results Seven randomized controlled trials evaluating 337 patients across different surgical procedures were included. The aggregated effect of intraoperative methadone on postoperative opioid consumption did not reveal a significant effect, WMD (95% CI) of −0.51 (−1.79 to 0.76), (P=0.43) IV morphine equivalents. In contrast, the effect of methadone on postoperative pain demonstrated a significant effect in the postanesthesia care unit, WMD (95% CI) of −1.11 (−1.88 to −0.33), P=0.005, and at 24 hours, WMD (95% CI) of −1.35 (−2.03 to −0.67), P < 0.001. Conclusions The use of intraoperative methadone reduces postoperative pain when compared to morphine. In addition, the beneficial effect of methadone on postoperative pain is not attributable to an increase in postsurgical opioid consumption. Our results suggest that intraoperative methadone may be a viable strategy to reduce acute pain in surgical patients.
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El Harchi A, Butler AS, Zhang Y, Dempsey CE, Hancox JC. The macrolide drug erythromycin does not protect the hERG channel from inhibition by thioridazine and terfenadine. Physiol Rep 2020; 8:e14385. [PMID: 32147975 PMCID: PMC7061092 DOI: 10.14814/phy2.14385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 12/25/2022] Open
Abstract
The macrolide antibiotic erythromycin has been associated with QT interval prolongation and inhibition of the hERG-encoded channels responsible for the rapid delayed rectifier K+ current I(Kr ). It has been suggested that low concentrations of erythromycin may have a protective effect against hERG block and associated drug-induced arrhythmia by reducing the affinity of the pore-binding site for high potency hERG inhibitors. This study aimed to explore further the notion of a potentially protective effect of erythromycin. Whole-cell patch-clamp experiments were performed in which hERG-expressing mammalian (Human Embryonic Kidney; HEK) cells were preincubated with low to moderate concentrations of erythromycin (3 or 30 µM) prior to whole-cell patch clamp recordings of hERG current (IhERG ) at 37°C. In contrast to a previous report, exposure to low concentrations of erythromycin did not reduce pharmacological sensitivity of hERG to the antipsychotic thioridazine and antihistamine terfenadine. The IC50 value for IhERG tail inhibition by terfenadine was decreased by ~32-fold in the presence of 3 µM erythromycin (p < .05 vs. no preincubation). Sensitivity to thioridazine remained unchanged (p > .05 vs. no preincubation). The effects of low concentrations of erythromycin were investigated for a series of pore blocking drugs, and the results obtained were consistent with additive and/or synergistic effects. Experiments with the externally acting blocker BeKm-1 on WT hERG and a pore mutant (F656V) were used to explore the location of the binding site for erythromycin. Our data are inconsistent with the use of erythromycin for the management of drug-induced QT prolongation.
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Affiliation(s)
- Aziza El Harchi
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Andrew S Butler
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Yihong Zhang
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Christopher E Dempsey
- School of Biochemistry, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Jules C Hancox
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
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Summary of Torsades de Pointes (TdP) Reports Associated with Intravenous Drug Formulations Containing the Preservative Chlorobutanol. Drug Saf 2020; 42:907-913. [PMID: 30888625 DOI: 10.1007/s40264-019-00804-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Drug-induced torsades de pointes (TdP) is a potentially lethal ventricular arrhythmia that is associated with drugs that prolong the QT interval on the electrocardiogram (ECG) due to their interference with the cardiac potassium current, IKR. Intravenous (IV) formulations of methadone have been associated with TdP and contain the preservative chlorobutanol, which, like methadone, blocks IKR. The combinations of chlorobutanol with methadone or terfenadine, another IKR blocker, produce synergistic IKR block. OBJECTIVE The aim of this study was to examine and summarize the evidence available to address the question: what other IV drug formulations contain chlorobutanol and are they associated with TdP? METHODS IV drug products containing the preservative chlorobutanol were identified by searching the websites DailyMed ( https://dailymed.nlm.nih.gov/dailymed/index.cfm ) and Drugs@FDA ( https://www.accessdata.fda.gov/scripts/cder/daf/ ). For each drug identified, PubMed and the FDA's Adverse Event Reporting System (FAERS) were searched for reports of TdP and/or QT prolongation and FAERS data were analyzed for disproportionality of reports. RESULTS The search found nine drugs (methadone, epinephrine, papaverine, oxytocin, vasopressin, testosterone, estradiol, isoniazid, and desmopressin) that contain chlorobutanol 2.5 (n = 1) or 5.0 mg/mL. All nine drugs had reports of QT prolongation or TdP reported in FAERS and all but estradiol, testosterone, desmopressin, and isoniazid had reports of QT prolongation or TdP in PubMed. Two of the nine drugs (epinephrine and methadone) had positive signals (by disproportionality analysis) for TdP in FAERS (EB05 2.88 and 23.81, respectively) and four (methadone, epinephrine, papaverine, and vasopressin) were reported in published articles as the suspect drugs in cases of TdP. CONCLUSION The pharmacologic profile of chlorobutanol (synergistic IKR block) and its association with reports of TdP and QT prolongation suggest the need for a full evaluation of its cardiac safety when used as a preservative in IV drug and vitamin formulations.
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Edmonds KP, Saunders IM, Willeford A, Ajayi TA, Atayee RS. Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations. Drugs 2019; 80:115-130. [PMID: 31820362 DOI: 10.1007/s40265-019-01234-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.
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Affiliation(s)
- Kyle P Edmonds
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Andrew Willeford
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Toluwalase A Ajayi
- Digital Medicine, Scripps Research Translational Institute, La Jolla, CA, 92037, USA
| | - Rabia S Atayee
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA.
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA.
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA.
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25
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Machado FC, Vieira JE, de Orange FA, Ashmawi HA. Intraoperative Methadone Reduces Pain and Opioid Consumption in Acute Postoperative Pain: A Systematic Review and Meta-analysis. Anesth Analg 2019; 129:1723-1732. [PMID: 31743194 DOI: 10.1213/ane.0000000000004404] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Methadone is a potent opioid exerting an analgesic effect through N-methyl-D-aspartate receptor antagonism and the inhibition of serotonin and noradrenaline reuptake. It has also been used in several procedures to reduce postoperative pain and opioid use. This meta-analysis aimed to determine whether the intraoperative use of methadone lowers postoperative pain scores and opioid consumption in comparison to other opioids. METHODS Double-blinded, controlled trials without language restrictions were included from MEDLINE, Embase, LILACS, The Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL via EBSCOhost. The included studies tracked total opioid consumption, postoperative pain scores, opioid-related side effects, and patient satisfaction until 72 hours postoperatively. Mean difference (MD) was used for effect size. RESULTS In total, 476 articles were identified and 13 were considered eligible for inclusion in the meta-analysis. In 486 patients (7 trials), pain at rest (MD, 1.09; 95% confidence interval (CI), 1.47-0.72; P < .00001) and at movement (MD, 2.48; 95% CI, 3.04-1.92; P = .00001) favored methadone 24 hours after surgery. In 374 patients (6 trials), pain at rest (MD, 1.47; 95% CI, 3.04-1.02; P < .00001) and at movement (MD, 2.03; 95% CI, 3.04-1.02; P < .00001) favored methadone 48 hours after surgery. In 320 patients (4 trials), pain at rest (MD, 1.02; 95% CI, 1.65-0.39; P = .001) and at movement (MD, 1.34; 95% CI, 1.82-0.87; P < .00001) favored methadone 72 hours after surgery. A Trial Sequential Analysis was performed and the Z-cumulative curve for methadone crossed the monitoring boundary at all evaluations, additionally crossing Required Information Size at 24 and 48 hours at rest. Methadone group also showed lower postoperative opioid consumption in morphine equivalent dosage (mg) at 24 hours (MD, 8.42; 95% CI, 12.99-3.84 lower; P < .00001), 24-48 hours (MD, 14.33; 95% CI, 26.96-1.91 lower; P < .00001), 48-72 hours (MD, 3.59; 95% CI, 6.18-1.0 lower; P = .007) postoperatively. CONCLUSIONS Intraoperative use of methadone reduced postoperative pain scores compared to other opioids, and Trial Sequential Analysis suggested that no more trials are required to confirm pain reduction at rest until 48 hours after surgery. Methadone also reduced postoperative opioid consumption and led to better patient satisfaction scores through 72 hours postoperatively compared to other opioids.
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Affiliation(s)
- Felipe C Machado
- From the Anesthesia Department, Universidade de Sao Paulo, São Paulo, Brazil
| | - Joaquim E Vieira
- From the Anesthesia Department, Universidade de Sao Paulo, São Paulo, Brazil
| | - Flávia A de Orange
- Anesthesia Department, Institute of Integral Medicine Prof. Fernando Figueira (IMIP), Recife, Brazil
| | - Hazem A Ashmawi
- From the Anesthesia Department, Universidade de Sao Paulo, São Paulo, Brazil
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Robinson JD, Caruso TJ, Wu M, Kleiman ZI, Kwiatkowski DM. Intraoperative Methadone Is Associated with Decreased Perioperative Opioid Use Without Adverse Events: A Case-Matched Cohort Study. J Cardiothorac Vasc Anesth 2019; 34:335-341. [PMID: 31699597 DOI: 10.1053/j.jvca.2019.09.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/21/2019] [Accepted: 09/25/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine if there is an association of intraoperative methadone use and total perioperative opioid exposure in patients undergoing congenital heart surgeries. DESIGN Retrospective, case-match cohort study. SETTING Single center quaternary care teaching hospital. PARTICIPANTS Seventy-four patients with congenital heart disease (CHD) undergoing surgical repair or palliative surgery. INTERVENTION Thirty-seven patients undergoing CHD surgeries receiving intraoperative methadone were matched to 37 patients based upon age and procedure who did not receive intraoperative methadone. The primary study outcome was to evaluate total opioid use in intravenous milligrams of morphine equivalents per kilogram (mg ME/kg) within the first 36-hours postoperatively. Mann-Whitney U test was used to compare total opioid exposure. MEASUREMENTS AND MAIN RESULTS The total opioid use was compared between groups. The methadone cohort required less opioids intraoperatively, in the first 12 hours postoperatively, and during the first 36 hours postoperatively (2.51 v 4.39 mg ME/kg, p < 0.001; 0.43 v 1.28 mg ME/kg, p = 0.001; and 0.83 v 1.91 mg ME/kg, p < 0.001) compared with the matched control cohort. There were no differences in clinical outcomes or adverse events. A dose-dependent reduction in opioid consumption in high- versus low-dose groups also was not observed. CONCLUSION Intraoperative methadone use was associated with a decrease in perioperative opioid exposure in patients undergoing congenital heart surgery and was not associated with adverse events or prolonged durations of mechanical ventilation or ICU stay.
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Affiliation(s)
- Joshua D Robinson
- Pharmacy Department, Lucile Packard Children's Hospital Stanford, Palo Alto, CA; Department of Pharmaceutical Services, University of California San Francisco Medical Center, San Francisco, CA.
| | - Thomas J Caruso
- Division of Pediatric Anesthesia, Department of Anesthesia Perioperative and Postoperative Pain, Stanford University School of Medicine, Palo Alto, CA
| | - May Wu
- Pharmacy Department, Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Zachary I Kleiman
- Division of Pediatric Anesthesia, Department of Anesthesia Perioperative and Postoperative Pain, Stanford University School of Medicine, Palo Alto, CA
| | - David M Kwiatkowski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Jungbauer CG, Maier LS. [Proarrhythmic adverse effects of nonarrhythmic drugs]. Herzschrittmacherther Elektrophysiol 2019; 30:262-267. [PMID: 31444571 DOI: 10.1007/s00399-019-00635-0] [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: 07/14/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
Acquired QT prolongation is almost exclusively the result of inhibition of the potassium channel Ikr. Especially hospitalized patients have a high risk to suffer from Torsade de points (TdP). Therefore, any prescription of drugs with the potential for QT prolongation should involve the consideration of the necessity of the agent and interaction with other QT prolonging drugs. The website www.crediblemed.com helps to identify the risk for TdP of each drug. During drug prescription, it is necessary to monitor QTc with regular ECGs; QTc prolongation >500 ms or QTc increase >60 ms should trigger end of drug administration followed by monitoring of the patient according to the individual risk for TdP.
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Affiliation(s)
- C G Jungbauer
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, 93053, Regensburg, Deutschland.
| | - L S Maier
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, 93053, Regensburg, Deutschland
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Swarm RA, Paice JA, Anghelescu DL, Are M, Bruce JY, Buga S, Chwistek M, Cleeland C, Craig D, Gafford E, Greenlee H, Hansen E, Kamal AH, Kamdar MM, LeGrand S, Mackey S, McDowell MR, Moryl N, Nabell LM, Nesbit S, O'Connor N, Rabow MW, Rickerson E, Shatsky R, Sindt J, Urba SG, Youngwerth JM, Hammond LJ, Gurski LA. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:977-1007. [PMID: 31390582 DOI: 10.6004/jnccn.2019.0038] [Citation(s) in RCA: 262] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.
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Affiliation(s)
- Robert A Swarm
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Judith A Paice
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Doralina L Anghelescu
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | | | - Ellin Gafford
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Heather Greenlee
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Susan LeGrand
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Nina O'Connor
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | - Jill Sindt
- Huntsman Cancer Institute at the University of Utah
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McPherson ML, Walker KA, Davis MP, Bruera E, Reddy A, Paice J, Malotte K, Lockman DK, Wellman C, Salpeter S, Bemben NM, Ray JB, Lapointe BJ, Chou R. Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper. J Pain Symptom Manage 2019; 57:635-645.e4. [PMID: 30578934 DOI: 10.1016/j.jpainsymman.2018.12.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/28/2018] [Accepted: 12/01/2018] [Indexed: 01/11/2023]
Abstract
Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.
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Affiliation(s)
| | - Kathryn A Walker
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA; MedStar Health, Baltimore, Maryland, USA
| | | | - Eduardo Bruera
- Palliative, Rehabilitation & Integrative Medicine Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA; F. T. McGraw Chair in the Treatment of Cancer, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Judith Paice
- Division of Hematology-Oncology, Northwestern University, Chicago, Illinois, USA; Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kasey Malotte
- Advanced Practice Pharmacist Supportive Care Medicine Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dawn Kashelle Lockman
- Hospice & Palliative Care, University of Iowa College of Pharmacy, Iowa City, Iowa, USA; Internal Medicine-Palliative Care Program, Iowa City, Iowa, USA
| | | | - Shelley Salpeter
- Stanford University School of Medicine, Stanford, California, USA; Mission Hospice and Home Care, San Mateo, California, USA
| | | | - James B Ray
- University of Iowa College of Pharmacy, Iowa City, Iowa, USA; Supportive and Palliative Care Consult Service, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Bernard J Lapointe
- Eric M. Flanders Chair in Palliative Medicine, McGill University, Montreal, Canada; Chief Supportive and Palliative Care Division, Jewish General Hospital, Montreal, Canada
| | - Roger Chou
- Division of General Internal Medicine and Geriatrics, OHSU, USA
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Tschirhart JN, Li W, Guo J, Zhang S. Blockade of the Human Ether A-Go-Go-Related Gene (hERG) Potassium Channel by Fentanyl. Mol Pharmacol 2019; 95:386-397. [PMID: 30665971 DOI: 10.1124/mol.118.114751] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/12/2019] [Indexed: 11/22/2022] Open
Abstract
The human ether-a-go-go-related gene (hERG) encodes the pore-forming subunit of the rapidly activating delayed rectifier potassium channel (IKr). Drug-mediated or medical condition-mediated disruption of hERG function is the primary cause of acquired long-QT syndrome, which predisposes affected individuals to ventricular arrhythmias and sudden death. Fentanyl abuse poses a serious health concern, with abuse and death rates rising over recent years. As fentanyl has a propensity to cause sudden death, we investigated its effects on the hERG channel. The effects of norfentanyl, the main metabolite, and naloxone, an antidote used in fentanyl overdose, were also examined. Currents of hERG channels stably expressed in HEK293 cells were recorded using the whole-cell voltage-clamp method. When hERG tail currents were analyzed upon -50 mV repolarization after a 50 mV depolarization, fentanyl and naloxone blocked hERG current (IhERG) with IC50 values of 0.9 and 74.3 μM, respectively, whereas norfentanyl did not block. However, fentanyl-mediated block of IhERG was voltage dependent. When a voltage protocol that mimics a human ventricular action potential (AP) was used, fentanyl blocked IhERG with an IC50 of 0.3 μM. Furthermore, fentanyl (0.5 μM) prolonged AP duration and blocked IKr in ventricular myocytes isolated from neonatal rats. The concentrations of fentanyl used in this study were higher than seen with clinical use but overlap with postmortem overdose concentrations. Although mechanisms of fentanyl-related sudden death need further investigation, blockade of hERG channels may contribute to the death of individuals with high-concentration overdose or compromised cardiac repolarization.
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Affiliation(s)
- Jared N Tschirhart
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Wentao Li
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jun Guo
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Shetuan Zhang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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Elsass K, Marks S, Malone N. Nonoral Routes of Methadone for Analgesia in Palliative Care #358. J Palliat Med 2018; 21:1357-1358. [DOI: 10.1089/jpm.2018.0346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Behzadi M, Joukar S, Beik A. Opioids and Cardiac Arrhythmia: A Literature Review. Med Princ Pract 2018; 27:401-414. [PMID: 30071529 PMCID: PMC6244110 DOI: 10.1159/000492616] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE One of the most important side effects of opioids is their influence on the electrical activity of the heart. This review focusses on the effects of opioids on QT interval prolongation and their arrhythmogenic liability. METHODS By using various keywords, papers published up to 2018 in different databases were searched and identified. The search terms were opioids names, corrected QT interval, human-ether-a-go-go gene, torsades de pointes (TdP), cardiac arrhythmias, opioid dependence and other relevant terms. It emphasized the effects of each opioid agent alone on electrocardiogram (ECG) and some interactions. RESULTS Available data indicate that some opioids such as methadone are high-risk even at low doses, and have potential for prolongation of the QT interval and development of TdP, a dangerous ventricular tachycardia. A number of opioids such as tramadol and oxycodone are intermediate risk drugs and may develop long QT interval and TdP in high doses. Some other opioids such as morphine and buprenorphine are low-risk drugs and do not produce QT interval prolongation and TdP at least in routine doses. Opium-consumers are at higher risk of supra-ventricular arrhythmias, sinus bradycardia, cardiac block and atrial fibrillation. CONCLUSION The cardiac arrhythmogenicity of various opioids is different. Methadone has a higher capability to induce long QT interval and dangerous arrhythmias in conventional doses than others. To reduce of arrhythmogenic risk, high doses of opioids must be used cautiously with periodic monitoring of ECG in high-risk consumers such as patients under opioid maintenance treatment.
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Affiliation(s)
- Mina Behzadi
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences and Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Siyavash Joukar
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences and Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Beik
- Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
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Mott C, Sarpal A, Moss K, Herbert A. Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children's Health Service. CHILDREN-BASEL 2018; 5:children5070086. [PMID: 29954057 PMCID: PMC6068960 DOI: 10.3390/children5070086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/20/2018] [Accepted: 06/20/2018] [Indexed: 01/08/2023]
Abstract
Methadone has the potential to assist in the management of pain in children with life-limiting illness, but its use is limited by its complex pharmacokinetic profile and limited research on its use in children. This is a retrospective review of the use of methadone as an analgesic in 16 children with life-limiting illness. Efficacy, dosing and side effect profile were analysed. Fifteen (94%) patients had improvements in their analgesia with minimal observed adverse effects. Patients were either rapidly converted from a prior opioid in one change or received methadone as an adjunct medication. Conversions were calculated using ratios frequently in the range of 10:1 to 20:1 from the oral morphine equivalent total daily dose (MEDD). Adjunct initial dosing was a low dose trial, often beginning with 1 mg at night. Only two patients required a dose adjustment due to side effects attributed to methadone. This was despite the cohort having significant underlying illnesses, extensive concurrent medications, and high methadone dosing where needed. Analysis of dosing and ratios indicates that an individualised approach is required. Based on this and on the infrequency of methadone use in this population, specialist assistance with dosing is recommended. Further research, including prospective and pharmacokinetic studies, is recommended.
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Affiliation(s)
- Christine Mott
- Lady Cilento Children's Hospital, Brisbane 4069, Australia.
| | - Amrita Sarpal
- Children's Hospital London Health Sciences Centre, London, ON N6A 5W9, Canada.
| | - Krista Moss
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK.
| | - Anthony Herbert
- Lady Cilento Children's Hospital, Brisbane 4069, Australia.
- Centre for Children's Health Research at Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane 4069, Australia.
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Giudicessi JR, Ackerman MJ, Camilleri M. Cardiovascular safety of prokinetic agents: A focus on drug-induced arrhythmias. Neurogastroenterol Motil 2018; 30:e13302. [PMID: 29441683 PMCID: PMC6364982 DOI: 10.1111/nmo.13302] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/08/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastrointestinal sensorimotor dysfunction underlies a wide range of esophageal, gastric, and intestinal motility and functional disorders that collectively constitute nearly half of all referrals to gastroenterologists. As a result, substantial effort has been dedicated toward the development of prokinetic agents intended to augment or restore normal gastrointestinal motility. However, the use of several clinically efficacious gastroprokinetic agents, such as cisapride, domperidone, erythromycin, and tegaserod, is associated with unfavorable cardiovascular safety profiles, leading to restrictions in their use. PURPOSE The purpose of this review is to detail the cellular and molecular mechanisms that lead commonly to drug-induced cardiac arrhythmias, specifically drug-induced long QT syndrome, torsades de pointes, and ventricular fibrillation, to examine the cardiovascular safety profiles of several classes of prokinetic agents currently in clinical use, and to explore potential strategies by which the risk of drug-induced cardiac arrhythmia associated with prokinetic agents and other QT interval prolonging medications can be mitigated successfully.
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Affiliation(s)
- J. R. Giudicessi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - M. J. Ackerman
- Departments of Cardiovascular Medicine, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - M. Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, MN, USA
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Mikkelsen CR, Jornil JR, Andersen LV, Hasselstrøm JB, Polak S. Utilizing postmortem drug concentrations in mechanistic modeling and simulation of cardiac effects: a proof of concept study with methadone. Toxicol Mech Methods 2018; 28:555-562. [PMID: 29747546 DOI: 10.1080/15376516.2018.1475537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Methadone-related poisoning has been found to be the leading and increasing cause of death among intoxication cases in several countries. Aside from respiratory depression, methadone is known to cause QT-prolongation, which may lead to sudden cardiac death. Concentrations in heart tissue should be more accurate for estimating cardiotoxic effects. The aim of this study was to investigate whether the effect of methadone on the QT-interval could be simulated and whether the concentrations in heart tissues allowed for better prediction of the Bazett corrected QT-interval (QTcB). A predictive performance study was conducted using the simulation platform Cardiac Safety Simulator to mimic five literature studies using their described study conditions. Both free and total plasma and heart concentrations were investigated using two different in silico models: the O'Hara-Rudy (ORD) model and the 10 Tusscher (TNNP) model. The results showed that the QTcB of methadone was best predicted either with total plasma using the TNNP model or with free plasma using the ORD model. The ORD model was highly sensitive to the total heart concentrations, resulting in overprediction of the QTcB. The TNNP model also overpredicted the QTcB, but to a lesser degree than the ORD model. Furthermore, due to a low baseline QTcB, the ORD model underpredicted the QTcB for both the free plasma and free heart concentrations. In conclusion, it is possible to simulate the cardiac effects of methadone, yet several elements influence the approach uncertainty including but not limited to biophysically details model of cardiac electrophysiology, exposure data, and input parameters.
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Affiliation(s)
- Christian Reuss Mikkelsen
- a Section of Forensic Chemistry, Department of Forensic Medicine , Aarhus University , Aarhus , Denmark
| | - Jakob Ross Jornil
- a Section of Forensic Chemistry, Department of Forensic Medicine , Aarhus University , Aarhus , Denmark
| | - Ljubica Vukelic Andersen
- a Section of Forensic Chemistry, Department of Forensic Medicine , Aarhus University , Aarhus , Denmark
| | - Jørgen Bo Hasselstrøm
- a Section of Forensic Chemistry, Department of Forensic Medicine , Aarhus University , Aarhus , Denmark
| | - Sebastian Polak
- b Department of Social Pharmacy, Faculty of Pharmacy , Jagiellonian University Medical College , Kraków , Poland.,c Simcyp Division , Certara UK , Sheffield , UK
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Kokubun H, Takigawa C, Miyano K, Uezono Y. A Novel Method for Determination of Methadone in the Serum by High-Performance Liquid Chromatography with Electrochemical Detection. Biol Pharm Bull 2018; 41:649-651. [PMID: 29607939 DOI: 10.1248/bpb.b17-00691] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In March 2013, the clinical use of oral methadone tablets was initiated in Japan. There are many factors responsible for the change in blood concentrations of methadone, and its pharmacokinetics is very complex. Therefore, a simple and accurate measurement method for methadone blood concentrations was developed using HPLC/electrochemical detector (ECD). An eluent of 10 mM Na2HPO4/CH3CN/CH3OH (20 : 19 : 3) was used as the mobile phase. The column was used the XTerra® RP18, and the voltage of the ECD was set at 400 to 800 mV. As a result, the calibration curve was linear in the ranges of 10 to 100 ng/mL (y=5012.7x+1041.1, r=0.999). The intra- and inter-day coefficients of variation were <5.2 and <5.8%, respectively. Therefore, this method was considered to be useful for the measurement of methadone blood levels in cancer patients. Also, using this method, blood methadone concentration was measured over time in a patient with cancer-associated pain who was treated with methadone. The estimated clearance (CL/F) and distribution volume (Vd/F) of methadone were 2.84 L/h and 502.8 L, respectively, and took about two weeks to reach steady state.
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Affiliation(s)
| | | | - Kanako Miyano
- Division of Cancer Pathophysiology, National Cancer Center Research Institute
| | - Yasuhito Uezono
- Division of Cancer Pathophysiology, National Cancer Center Research Institute.,Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital
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Heath TS, Greenberg RG, Hupp SR, Turner DA, Hornik CP, Zimmerman KO. Effects of Methadone on Corrected Q-T Interval Prolongation in Critically Ill Children. J Pediatr Pharmacol Ther 2018; 23:119-124. [PMID: 29720913 DOI: 10.5863/1551-6776-23.2.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to determine the association between methadone use and corrected Q-T interval (QTc) prolongation in critically ill children. METHODS A retrospective cohort study of critically ill children receiving methadone at a tertiary care pediatric hospital was conducted. Patients younger than 19 years who had been admitted to the intensive care unit between January 1, 2009, and June 21, 2013, who had received methadone while inpatients, and who had had electrocardiograms (ECGs) performed within 30 days before and after methadone initiation were included. The primary outcome was the net change in QTc interval between baseline and postmethadone ECGs. Secondary outcomes included percent change in QTc interval and the proportion of patients whose QTc intervals changed from normal to prolonged following methadone initiation. We also evaluated potential predictors of QTc interval prolongation, including age, sex, admission diagnosis category, exposure to other QTc-prolonging medications, presence of congenital heart disease or known arrhythmias, and methadone daily dose and route of administration. RESULTS Sixty-four patients met the inclusion criteria. The median (25th, 75th percentiles) change in QTc interval following methadone initiation was -8 msec (-34, 13.5 msec; p = 0.19). Five patients (8%) had a baseline normal QTc interval that became prolonged after methadone initiation. We identified no statistically significant predictors of QTc prolongation after methadone initiation. CONCLUSIONS In this dedicated pediatric safety study, methadone initiation did not result in prolongation of the QTc interval. Although these findings suggest methadone initiation may not have a substantial effect of QTc prolongation in critically ill children, a controlled, prospective evaluation in this population remains warranted.
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Woosley RL, Romero K, Heise CW, Gallo T, Tate J, Woosley RD, Ward S. Adverse Drug Event Causality Analysis (ADECA): A Process for Evaluating Evidence and Assigning Drugs to Risk Categories for Sudden Death. Drug Saf 2018; 40:465-474. [PMID: 28275963 DOI: 10.1007/s40264-017-0519-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Growing evidence indicates that many drugs have the ability to cause a potentially lethal cardiac arrhythmia, torsades de pointes (TdP). This necessitates the development of a compilation of drugs that have this potential toxicity. Such a list is helpful in identifying the etiology of TdP in patients taking multiple drugs and assists decision making by those caring for patients at high risk of TdP. The Arizona Center for Education and Research on Therapeutics (AZCERT) has developed a process to standardize the identification of drugs and place them in risk categories for their clinical ability to cause TdP and QT prolongation. AZCERT's Adverse Drug Event Causality Analysis (ADECA) utilizes 16 types of data drawn from four sources to compile an open-source knowledge base, QTdrugs, which is maintained on the CredibleMeds.org website. Because the evidence for most drugs is incomplete, the ADECA process is used to place drugs into one of three categories that represent different levels of certainty: known TdP risk, possible TdP risk, and conditional TdP risk. Each category has strict evidentiary requirements for clinical evidence of TdP and/or QT prolongation. These are described in this paper. Because evidence can evolve over time, the ADECA process includes the continuous gathering and analysis of newly emerging evidence to revise the lists. The QTdrugs lists have proven to be a valued, readily available, commercial influence-free resource for healthcare providers, patients, researchers, and authors of consensus guidelines for the safe use of medicines.
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Affiliation(s)
- Raymond L Woosley
- AZCERT, 1822 E. Innovation Park Drive, Oro Valley, AZ, 85755, USA. .,University of Arizona, College of Medicine-Phoenix, 550 E. Van Buren St., Phoenix, AZ, 85004, USA.
| | - Klaus Romero
- Critical Path Institute, 1730 E. River Road, Tucson, AZ, 85705, USA
| | - Craig W Heise
- University of Arizona, College of Medicine-Phoenix, 550 E. Van Buren St., Phoenix, AZ, 85004, USA
| | - Tyler Gallo
- University of Arizona, College of Medicine-Phoenix, 550 E. Van Buren St., Phoenix, AZ, 85004, USA
| | - Jared Tate
- University of Arizona, College of Pharmacy, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | - Raymond David Woosley
- Mel and Enid Zuckerman College of Public Heath, University of Arizona, 1295 N. Martin Ave, Tucson, AZ, 85721, USA
| | - Sophie Ward
- University of Arizona, College of Nursing, 1305 N. Martin Ave, Tucson, AZ, 85721, USA
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Atayee RS, Hur GH, Karimian P, Hollenbach KA, Edmonds KP. Methadone Inpatient and Discharge Prescribing Patterns for Pain at an Academic Health System. J Palliat Med 2018; 20:184-192. [PMID: 28085545 DOI: 10.1089/jpm.2016.0267] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Methadone is effective for the treatment of chronic pain, but its unique pharmacology requires additional considerations with dosing and monitoring. OBJECTIVE The study objective was to evaluate methadone prescribing for pain and subsequent monitoring. METHODS This retrospective chart review at a single center reviewed patients who received methadone over a two-year period. RESULTS Of the 100 patients, most were noncancer cases (60%) with unspecified pain (50%). The majority of methadone treatments were initiated by medicine service (37%), followed by burn service (27%), and trauma (10%). Forty-two percent of the patients were being followed by the palliative care team, primarily for the medicine patients (80%). Patients on the burn service had significantly higher oral morphine equivalent (χ2 = 10.6, p = 0.01) and longest length of stay (χ2 = 37.9, p = 0.0001). Patients on medicine service were significantly more likely to have an outpatient discharge plan for methadone starts in the hospital (odds ratio = 3.7, confidence interval: 1.4, 9.7). Only 45% of patients had an electrocardiogram (EKG) checked seven days before methadone start and 37% of those have a measured corrected QT (QTc) of greater than 450 milliseconds. Electrolytes (potassium and magnesium) were not consistently checked and, of those that were evaluated, 15-20% were abnormal. There was an average of 2.6 severe or major drug interactions per patient related to methadone, with the most common being related to concomitant sedatives and other medications that prolonged the QTc. CONCLUSIONS Prescribing guidelines for methadone would provide a consistent approach for all practitioners involved in using methadone safely and effectively for chronic pain.
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Affiliation(s)
- Rabia S Atayee
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences , La Jolla, California.,2 Doris A. Howell Palliative Medicine Program, UC San Diego Health Sciences , La Jolla, California
| | - Gene H Hur
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences , La Jolla, California
| | - Parisa Karimian
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences , La Jolla, California
| | - Kathy A Hollenbach
- 1 Skaggs School of Pharmacy and Pharmaceutical Sciences , La Jolla, California
| | - Kyle P Edmonds
- 2 Doris A. Howell Palliative Medicine Program, UC San Diego Health Sciences , La Jolla, California
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Madden K, Park M, Liu D, Bruera E. The frequency of QTc prolongation among pediatric and young adult patients receiving methadone for cancer pain. Pediatr Blood Cancer 2017; 64. [PMID: 28449209 DOI: 10.1002/pbc.26614] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 03/08/2017] [Accepted: 03/27/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION A prolonged corrected QT (QTc) interval in pediatric patients is defined as ≥470 msec. Methadone can cause a prolonged QTc interval that can lead to ventricular arrhythmias. The risk of methadone-induced prolongation of the QTc interval in children and young adults is unknown. The purpose of the study was to determine the frequency of QTc prolongation among pediatric and young adult patients with cancer pain on methadone treatment. METHODS We retrospectively reviewed data for all patients on methadone during the study period. Qualifying patient data were reviewed to determine whether these patients had an electrocardiogram (ECG) while on methadone. The QTc values for analysis were manually calculated using the standard formula described by Bazett. RESULTS Twenty-five patients were identified that met eligibility criteria. The median QTc decreased from baseline after initiation of methadone. QTc prolongation occurred in four of 25 (16%) patients and only one patient had a QTc greater than 500 msec. This patient had 17 normal QTc intervals on methadone prior to the prolongation. After resolution of electrolyte abnormalities, six subsequent ECGs on methadone had a normal QTc interval. CONCLUSIONS Prolongation of the QTc interval is infrequent. The only observed case was transient during multiple comorbid conditions. A prospective study is justified to better understand what role methadone plays as one of many risk factors for prolongation of the QTc interval in children and young adults.
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Affiliation(s)
- Kevin Madden
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- Department of Biostatistics, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
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Michalska M, Katzenwadel A, Wolf P. Methadone as a "Tumor Theralgesic" against Cancer. Front Pharmacol 2017; 8:733. [PMID: 29163148 PMCID: PMC5671505 DOI: 10.3389/fphar.2017.00733] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/28/2017] [Indexed: 12/24/2022] Open
Abstract
Methadone has beneficial characteristics as an analgesic against cancer pain, including high bioavailability, multiple receptor affinities, and lack of active metabolites that might induce adverse side effects. However, methadone has an own pharmacological profile that should be considered in the treatment of cancer patients. There is evidence from preclinical studies that methadone could also elicit antitumor activity by downregulating the threshold of apoptosis and to enhance the effects of different chemotherapeutic agents. This confirms the concept of using methadone as a chemosensitizer in the future treatment of cancer. Our article discusses major issues about the role of methadone as a possible “tumor theralgesic,” combining tumor therapeutic and analgesic activities.
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Affiliation(s)
- Marta Michalska
- Department of Urology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arndt Katzenwadel
- Department of Urology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Wolf
- Department of Urology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Predicting the Unpredictable: Drug-Induced QT Prolongation and Torsades de Pointes. J Am Coll Cardiol 2017; 67:1639-1650. [PMID: 27150690 DOI: 10.1016/j.jacc.2015.12.063] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/20/2015] [Accepted: 12/14/2015] [Indexed: 01/09/2023]
Abstract
Drug-induced long QT syndrome (diLQTS) and congenital LQTS (cLQTS) share many features, and both syndromes can result in life-threatening torsades de pointes (TdP). Our understanding of their mechanistic and genetic similarities has led to their improved clinical management. However, our inability to prevent diLQTS has resulted in removal of many medicines from the market and from development. Genetic and clinical risk factors for diLQTS and TdP are well known and raise the possibility of TdP prevention. Clinical decision support systems (CDSS) can scan the patient's electronic health records for clinical risk factors predictive of diLQTS and warn when a drug that can cause TdP is prescribed. CDSS have reduced prescriptions of QT-prolonging drugs, but these relatively small changes lack the power to reduce TdP. The growing genetic evidence linking diLQTS to cLQTS suggests that prevention of TdP in the future may require inclusion of both genetic and clinical predictors into CDSS.
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Relationship between Corrected-QT Intervals and Other ECG Characteristics with Methadone Dose in Methadone Maintenance Treatment (MMT) Patients and Healthy Subjects: A Case- Control Study. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2017. [DOI: 10.5812/rijm.13642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Juba KM, Khadem TM, Hutchinson DJ, Brown JE. Methadone and Corrected QT Prolongation in Pain and Palliative Care Patients: A Case-Control Study. J Palliat Med 2017; 20:722-728. [PMID: 28186837 DOI: 10.1089/jpm.2016.0411] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Methadone (ME) is commonly used in pain and palliative care (PPC) patients with refractory pain or intolerable opioid adverse effects (AEs). A unique ME AE is its corrected QT (QTc) interval prolongation risk, but most evidence exists in methadone maintenance therapy patients. OBJECTIVE Our goal was to identify QTc interval prolongation risk factors in PPC patients receiving ME and other medications known to prolong the QTc interval and develop a risk stratification tool. DESIGN We performed a case-control study of adult inpatients receiving ME for pain management. Settings/Subjects: Adult inpatients receiving ME with a QTc >470 msec (males) and >480 msec (females) were matched 1:2 according to age, history of QTc prolongation, and gender with ME patients who did not have a prolonged QTc interval. QTc prolongation risk factors were collected for both groups. Covariates were analyzed using conditional logistic regression. Classification and regression tree analysis was used to identify the ME dose associated with QTc prolongation. RESULTS Predictors of QTc prolongation included congestive heart failure (CHF) (OR: 11.9; 95% CI: 3.7-38.2; p < 0.00), peptic ulcer disease (PUD) (odds ratio [OR]: 8.3; 95% confidence interval [95% CI]: 2.4-28.9; p < 0.00), hypokalemia (OR: 6.5; 95% CI: 1.5-28.2; p < 0.01), rheumatologic diseases (OR: 4.7; 95% CI: 1.6-13.9; p < 0.00), taking medications with a known torsades de pointes (TdP) risk (OR: 4.4; 95% CI: 1.8-10.7; p < 0.01), malignancy (OR: 3.3; 95% CI: 1.2-9.3; p < 0.03), hypocalcemia (OR: 2.1; 95% CI: 0.9-4.8; p < 0.07), and ME doses >45 mg per day (OR: 1.9; 95% CI: 0.8-4.8; p < 0.16). Mild liver disease was protective against QTc prolongation (OR: 0.05; 95% CI: 0.0-0.46; p < 0.01). CONCLUSIONS Predictors of QTc prolongation in our multivariate conditional logistic regression model included CHF, PUD, hypokalemia, rheumatologic disorders, use of medications with a known TdP risk, malignancy, hypocalcemia, and ME doses >45 mg per day.
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Affiliation(s)
- Katherine M Juba
- 1 Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College , Rochester, New York
| | - Tina M Khadem
- 2 Department of Pharmacy, University of Rochester Medical Center-Strong Memorial Hospital , Rochester, New York
| | - David J Hutchinson
- 1 Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College , Rochester, New York
| | - Jack E Brown
- 1 Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College , Rochester, New York
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Gao L, Dimitropoulou P, Robertson JR, McTaggart S, Bennie M, Bird SM. Risk-factors for methadone-specific deaths in Scotland's methadone-prescription clients between 2009 and 2013. Drug Alcohol Depend 2016; 167:214-23. [PMID: 27593969 PMCID: PMC5047032 DOI: 10.1016/j.drugalcdep.2016.08.627] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/01/2016] [Accepted: 08/22/2016] [Indexed: 01/31/2023]
Abstract
AIM To quantify gender, age-group and quantity of methadone prescribed as risk factors for drugs-related deaths (DRDs), and for methadone-specific DRDs, in Scotland's methadone-prescription clients. DESIGN Linkage to death-records for Scotland's methadone-clients with one or more Community Health Index (CHI)-identified methadone prescriptions during July 2009 to June 2013. SETTING Scotland's Prescribing Information System and National Records of Scotland. MEASUREMENTS Covariates defined at first CHI-identified methadone prescription, and person-years at-risk (pys) thereafter until the earlier of death-date or 31 December 2013. Methadone-specific DRDs were defined as: methadone implicated but neither heroin nor buprenorphine. Hazard ratios (HRs) were assessed using proportional hazards regression. FINDINGS Scotland's CHI-identified methadone-prescription cohort comprised 33,128 clients, 121,254 pys, 1,171 non-DRDs and 760 DRDs (6.3 per 1,000 pys), of which 362 were methadone-specific. Irrespective of gender, methadone-specific DRD-rate, per 1,000 pys, was higher in the 35+ age-group (4.2; 95% CI: 3.6-4.7) than for younger clients (1.9; 95% CI: 1.5-2.2). For methadone-specific DRDs, age-related HRs (e.g., 2.9 at 45+ years; 95% CI: 2.1-3.9) were steeper than for all DRDs (1.9; 95% CI: 1.5-2.4); there was no hazard-reduction for females; no gender by age-group interaction; and, unlike for all DRDs, the highest quintile for quantity of prescribed methadone at cohort-entry (>1960mg) was associated with increased HR (1.8; 95% CI: 1.3-2.5). CONCLUSION Higher methadone-specific DRD rates in older clients, irrespective of gender, call for better understanding of methadone's pharmaco-dynamics in older, opioid-dependent clients, many with progressive physical or mental ill-health.
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Affiliation(s)
- Lu Gao
- MRC Biostatistics Unit, Cambridge CB2 0SR, United Kingdom
| | | | - J Roy Robertson
- Usher Institute of Population Health Sciences and Informatics, Edinburgh University, EDINBURGH EH16 4UX, United Kingdom
| | - Stuart McTaggart
- Information Services Division, NHS National Services Scotland, Edinburgh EH12 9EB, United Kingdom
| | - Marion Bennie
- Information Services Division, NHS National Services Scotland, Edinburgh EH12 9EB, United Kingdom; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, United Kingdom
| | - Sheila M Bird
- MRC Biostatistics Unit, Cambridge CB2 0SR, United Kingdom; Department of Mathematics and Statistics, Strathclyde University, Glasgow G1 1XH, United Kingdom.
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Abstract
The analgesic ladder guideline proposed by the World Health Organization has been shown to be effective in controlling cancer pain in about 80 percent of patients, but the remaining 20 percent still experience pain. Several strategies have been used to manage refractory cancer pain and opioid toxicity. Switching opioids, alternative routes of opioid administration, optimizing adjuvants, and invasive procedures are proposed treatments. Extensive medical literature corroborates each one of those treatments. Rotation from one opioid to another is a noninvasive strategy to overcome opioid side effects and refractory pain. Frequently, methadone is used during opioid rotation. However, there is a lack of consensus on how to proceed on rotation from morphine to methadone. In the current era of evidence-based medicine, the medical literature fails to answer some cancer pain-management issues. The purpose of this review is to clarify a process for transitioning from morphine to methadone.
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Wedam EF, Haigney MC. The Impact of Opioids on Cardiac Electrophysiology. Curr Cardiol Rev 2016; 12:27-36. [PMID: 26818485 PMCID: PMC4807715 DOI: 10.2174/1573403x1201160126122405] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 11/22/2022] Open
Abstract
Synthetic opioid agents have been used in modern medicine for over a century and for opioid addiction treatment for over a half-century. Liberal use of opioids in the United States has been attended by an extraordinary increase in opioid-related mortality, with over 16,000 deaths in 2012. As there have been advances in opioid agents for pain and addiction, so have there been advances in our understanding of the cardiac effects of these agents. In the last 10 years, significant data regarding electrophysiologic effects of these agents have been collected. We aim in this review to discuss the effects on cardiac electrophysiology of the various opioid agents currently in use and the evidence that these effects are contributing to the rise in opioid-related mortality.
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Affiliation(s)
| | - Mark C Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, A3060, USUHS, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Chowdhury M, Wong J, Cheng A, Khilkin M, Palma E. Methadone Therapy in Underserved Urban Community: QTc Prolongation and Life-Threatening Ventricular Arrhythmias. Cardiovasc Ther 2016; 33:127-33. [PMID: 25825202 DOI: 10.1111/1755-5922.12120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS Methadone has been associated with QTc prolongation and ventricular arrhythmias but the prevalence of QTc prolongation and association with ventricular arrhythmias remains unclear. We investigated this in our inner city urban community (Bronx, New York) that has a large number of patients on methadone. METHODS Telemetry records, nursing documentation and electronic charts of 291 patients spanning856 encounters were evaluated. QT was manually measured from ECG utilizing standardized QT measurement guidelines and was corrected for heart rate using Hodges formula. QTc >470 ms in males and >480 ms in females was considered to be prolonged. RESULTS Patients had prolonged QTc, QTc >500 ms and ventricular arrhythmias during 25.6%, 14.1% and 3.4% of encounters, respectively. There was a very weak dose dependent relationship between methadone dose and QTc (Spearman's rho = 0.09).In addition to methadone, patients were on at least one QT prolonging drugs during 39% of the encounters. Patients who were receiving two interacting drugs in addition to methadone had the highest prevalence (29%) of QTc prolongation. CONCLUSION Although the prevalence of QTc prolongation among patients on methadone therapy is high, the prevalence of ventricular arrhythmia is relatively low. Hospitalized patients on sustained methadone therapy are frequently on multiple additional QTc prolonging drugs. There is no significant dose dependent relationship between methadone dose and QTc. However, the concurrent use of methadone and interacting drugs lead to an increased prevalence of QTc prolongation.
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Affiliation(s)
- Mohsin Chowdhury
- Department of Internal Medicine, Yale School of Medicine/Yale-New Haven Hospital, New Haven, CT, USA
| | - Jason Wong
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA
| | - Angela Cheng
- Department of Pharmacy, Montefiore Medical Center, Bronx, NY, USA
| | - Michael Khilkin
- Department of Critical Care Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Eugen Palma
- Department of Cardiovascular Medicine, Montefiore Medical Center, Bronx, NY, USA
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Alinejad S, Kazemi T, Zamani N, Hoffman RS, Mehrpour O. A systematic review of the cardiotoxicity of methadone. EXCLI JOURNAL 2015; 14:577-600. [PMID: 26869865 PMCID: PMC4747000 DOI: 10.17179/excli2015-553] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 01/14/2015] [Indexed: 01/07/2023]
Abstract
UNLABELLED Methadone is one of the most popular synthetic opioids in the world with some favorable properties making it useful both in the treatment of moderate to severe pain and for opioid addiction. Increased use of methadone has resulted in an increased prevalence of its toxicity, one aspect of which is cardiotoxicity. In this paper, we review the effects of methadone on the heart as well as cardiac concerns in some special situations such as pregnancy and childhood. METHODS We searched for the terms methadone, toxicity, poisoning, cardiotoxicity, heart, dysrhythmia, arrhythmia, QT interval prolongation, torsade de pointes, and Electrocardiogram (ECG) in bibliographical databases including TUMS digital library, PubMed, Scopus, and Google Scholar. This review includes relevant articles published between 2000 and 2013. The main cardiac effects of methadone include prolongation of QT interval and torsade de pointes. Other effects include changes in QT dispersion, pathological U waves, Taku-Tsubo syndrome (stress cardiomyopathy), Brugada-like syndrome, and coronary artery diseases. The aim of this paper is to inform physicians and health care staff about these adverse effects. Effectiveness of methadone in the treatment of pain and addiction should be weighed against these adverse effects and physicians should consider the ways to lessen such undesirable effects. This article presents some recommendations to prevent heart toxicity in methadone users.
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Affiliation(s)
- Samira Alinejad
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences,Birjand, Iran
| | - Toba Kazemi
- Atherosclerosis and Coronary Artery Research Center, Birjand University of Medical Sciences,Birjand, Iran
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Pereleman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Pasdaran Avenue, Birjand, 9713643138 Iran
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