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Thaulow CH, Helland A, Kongsgaard UE, Høiseth G. Oxycodone, Morphine, and Fentanyl in Patients With Chronic Pain: Proposal of Dose-Specific Concentration Ranges. Ther Drug Monit 2023; 45:777-785. [PMID: 37296504 DOI: 10.1097/ftd.0000000000001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 03/22/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Interpreting opioid concentrations is challenging because of the lack of reference ranges. Therefore, the authors aimed to propose dose-specific concentration ranges in serum for oxycodone, morphine, and fentanyl in patients with chronic pain, based on concentration measurements from a large number of patients and supported by theoretical pharmacokinetic calculations and previously published concentrations. METHODS The opioid concentrations in patients undergoing therapeutic drug monitoring (TDM) for various indications (TDM group) and patients with cancer (cancer group) were investigated. Patients were divided based on the daily opioid doses, and the 10th and 90th percentiles of the concentrations in each dose interval were evaluated. In addition, the expected average serum concentrations were calculated for each dose interval based on published pharmacokinetic data, and a targeted literature search for previously reported dose-specific concentrations was performed. RESULTS The opioid concentrations in 1054 patient samples were included: 1004 in the TDM group and 50 in the cancer group. In total, 607 oxycodone, 246 morphine, and 248 fentanyl samples were evaluated. The authors proposed dose-specific concentration ranges based mainly on 10th-90th percentiles of the concentrations measured in patient samples, whereas the calculated average concentrations and previously published concentrations were used to adjust the ranges. In general, results from calculations and concentrations retrieved from previous literature were within the 10th-90th percentiles of concentrations from patient samples. However, the lowest calculated average concentrations of fentanyl and morphine were below the 10th percentiles of patient samples in all dose groups. CONCLUSIONS The proposed dose-specific ranges may be useful for interpreting steady-state opioid serum concentrations in clinical and forensic settings.
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Affiliation(s)
- Cecilie Hasselø Thaulow
- Division of Laboratory Medicine, Department of Forensic Sciences, Oslo University Hospital, Oslo
| | - Arne Helland
- Department of Clinical Pharmacology, St. Olavs University Hospital
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim
| | - Ulf Erik Kongsgaard
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital
- Institute of Clinical Medicine, Medical Faculty, University of Oslo; and
| | - Gudrun Høiseth
- Division of Laboratory Medicine, Department of Forensic Sciences, Oslo University Hospital, Oslo
- Institute of Clinical Medicine, Medical Faculty, University of Oslo; and
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
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2
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Ghasemi A, Vaseghi G, Hojjatallah A, Haghjooy Javanmard S. The effects of morphine on vascular cell adhesion molecule 1(VCAM-1) concentration in lung cancer cells. Arch Physiol Biochem 2023; 129:484-488. [PMID: 33449821 DOI: 10.1080/13813455.2020.1838552] [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] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Vascular cell adhesion molecule 1 (VCAM-1) plays an important role in tumour cell adhesion to endothelial cells. Some tumour cells also show aberrant expression of VCAM-1. Toll-like receptor 4 (TLR4) agonists can increase VCAM-1 expression. Morphine, an opioid receptor agonist, is also a TLR4 agonist. In this study, we aimed to evaluate whether morphine increase VCAM-1 expression in a TLR4 dependent manner. METHODS A549 Lung cancer cells were treated with different doses of morphine and TLR4 antagonist for 24 and 48 h. TLR4 gene expression was evaluated by real-time PCR and VCAM-1 protein was measured by the enzyme-linked immunosorbent assay (ELISA). RESULTS Morphine enhanced mRNA expression of TLR4 and protein level of VCAM-1. TLR4 antagonist returned VCAM-1expression to the normal level. CONCLUSION Morphine effects VCAM-1expressions via TLR4 in lung cancer cell line.
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Affiliation(s)
- Ahmad Ghasemi
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Golnaz Vaseghi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alaei Hojjatallah
- Department of Physiology, School of medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shaghayegh Haghjooy Javanmard
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Noufal Y, Kringel D, Toennes SW, Dudziak R, Lötsch J. Pharmacological data science perspective on fatal incidents of morphine treatment. Pharmacol Ther 2023; 241:108312. [PMID: 36423714 DOI: 10.1016/j.pharmthera.2022.108312] [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: 09/16/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
Morphine prescribed for analgesia has caused drug-related deaths at an estimated incidence of 0.3% to 4%. Morphine has pharmacological properties that make it particularly difficult to assess the causality of morphine administration with a patient's death, such as its slow transfer between plasma and central nervous sites of action and the existence of the active metabolite morphine-6-glucuronide with opioid agonistic effects, Furthermore, there is no well-defined toxic dose or plasma/blood concentration for morphine. Dosing is often adjusted for adequate pain relief. Here, we summarize reported deaths associated with morphine therapy, including associated morphine exposure and modulating patient factors such as pharmacogenetics, concomitant medications, or comorbidities. In addition, we systematically analyzed published numerical information on the stability of concentrations of morphine and its relevant metabolites in biological samples collected postmortem. A medicolegal case is presented in which the causality of morphine administration with death was in dispute and pharmacokinetic modeling was applied to infer the administered dose. The results of this analytical review suggest that (i) inference from postmortem blood concentrations to the morphine dose administered has low validity and (ii) causality between a patient's death and the morphine dose administered remains a highly context-dependent and collaborative assessment among experts from different medical specialties.
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Affiliation(s)
- Yazan Noufal
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Dario Kringel
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan W Toennes
- Goethe-University, University Hospital Frankfurt, Institute of Legal Medicine, Kennedyallee 104, 60596 Frankfurt am Main, Germany
| | - Rafael Dudziak
- Goethe-University, University Hospital Frankfurt, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörn Lötsch
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany.
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4
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Wang K, Wang J, Liu T, Yu W, Dong N, Zhang C, Xia W, Wei F, Yang L, Ren X. Morphine-3-glucuronide upregulates PD-L1 expression via TLR4 and promotes the immune escape of non-small cell lung cancer. Cancer Biol Med 2021; 18:155-171. [PMID: 33628591 PMCID: PMC7877184 DOI: 10.20892/j.issn.2095-3941.2020.0442] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/25/2020] [Indexed: 12/31/2022] Open
Abstract
Objective Patients with cancer pain are highly dependent on morphine analgesia, but studies have shown a negative correlation between morphine demand and patient outcomes. The long-term use of morphine may result in abnormally elevated serum morphine-3-glucuronide (M3G) levels. Hence, the effects of M3G on tumor progression are worth studying. Methods The effects of M3G on PD-L1 expressions in human non-small cell lung cancer (NSCLC) cell lines were first evaluated. Activation of TLR4 downstream pathways after M3G treatment was then determined by Western blot. The effects of M3G on human cytotoxic T lymphocytes (CTL) cytotoxicity and INF-γ release was also detected. Finally, the LLC murine lung adenocarcinoma cell line were used to establish a murine lung cancer model, and the effects of M3G on tumor growth and metastasis were determined. Results M3G promoted the expressions of PD-L1 in the A549 and H1299 cell lines in a TLR4-dependent manner (P < 0.05). M3G activated the PI3K and the NFκB signaling pathways, and this effect was antagonized by a TLR4 pathway inhibitor. A PI3K pathway inhibitor reversed the M3G-mediated PD-L1 upregulation. M3G inhibited the cytotoxicity of CTL on A549 cells and decreased the level of INF-γ. Repeated M3G intraperitoneal injections promoted LLC tumor growth and lung metastasis through the upregulation of tumor expressed PD-L1 and the reduction of CTL in the tumor microenvironment. Conclusions M3G specifically activated TLR4 in NSCLC cells and upregulated PD-L1 expression through the PI3K signaling pathway, thereby inhibiting CTL cytotoxicity and finally promoting tumor immune escape.
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Affiliation(s)
- Kaiyuan Wang
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Jian Wang
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Ting Liu
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Wenwen Yu
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Nan Dong
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Chen Zhang
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Wenbin Xia
- Department of Cancer Biobank, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Feng Wei
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Lili Yang
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
| | - Xiubao Ren
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
- Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin’s Clinical Research Center for Cancer, Key Laboratory of Cancer Immunology and Biotherapy, Tianjin 300060, China
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Eiselt É, Otis V, Belleville K, Yang G, Larocque A, Régina A, Demeule M, Sarret P, Gendron L. Use of a Noninvasive Brain-Penetrating Peptide-Drug Conjugate Strategy to Improve the Delivery of Opioid Pain Relief Medications to the Brain. J Pharmacol Exp Ther 2020; 374:52-61. [DOI: 10.1124/jpet.119.263566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Indexed: 02/04/2023] Open
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Abstract
Background Oral and subcutaneous morphine is widely used for the treatment of cancer-related pain; however, solid pharmacokinetic data on this practice are lacking. Furthermore, it is largely unknown which factors contribute to the variability in clearances of morphine and its metabolites and whether morphine clearance is related to treatment outcome. Methods Blood samples from 49 cancer patients treated with oral and/or subcutaneous morphine were prospectively collected and were used to develop a population pharmacokinetic model for morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). The influence of age, gender, renal function and several polymorphisms possibly related to the pharmacokinetics of the three compounds was investigated. In addition, the relation between treatment failure and morphine and metabolite clearances was explored. Results A one-compartment model including an extensive first-pass effect adequately described the data of morphine and its metabolites. Estimated mean area under the plasma concentration–time curve (AUC) ratios following oral versus subcutaneous administration were: M3G/morphine 29.7:1 vs. 11.1:1; M6G/morphine 5.26:1 vs. 1.95:1; and M3G/M6G 5.65:1 vs. 5.70:1. Renal function was significantly correlated with clearance of the metabolites, which increased 0.602 L/h per every 10 mL/min/1.73 m2 increase of estimated glomerular filtration rate (eGFR), reaching a plateau for eGFR >90 mL/min/1.73 m2. The clearance of morphine or its metabolites was not found to be correlated with treatment failure. Conclusion The influence of age-, gender- and pharmacokinetic-related polymorphisms was not identified on the pharmacokinetics of morphine. Clearance of morphine or its metabolites was not found to explain treatment outcome; however, large variations in plasma concentrations of morphine, M3G and M6G support further studies on the relation between plasma concentrations and treatment outcome. Dutch Trial Register ID: NTR4369. Electronic supplementary material The online version of this article (doi:10.1007/s40262-016-0471-7) contains supplementary material, which is available to authorized users.
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7
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Gordon E, Stang BV, Heidel J, Poulsen KP, Cebra CK, Schlipf JW. Pharmacokinetic evaluation and safety of topical 1% morphine sulfate application on the healthy equine eye. Vet Ophthalmol 2018; 21:516-523. [PMID: 29350477 DOI: 10.1111/vop.12541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine if corneal epithelial cell integrity is detrimentally affected by short-term administration of 1.0% morphine sulfate. Additionally, we sought to determine if topical 1.0% morphine applied to the equine cornea would result in ocular or systemic absorption. ANIMAL STUDIED Six healthy horses. PROCEDURE Morphine sulfate (1.0%) was applied topically to one eye every four hours for 72 h before horses were euthanized. Serum samples were collected at varying time points during the study and aqueous and vitreous humor were collected immediately after euthanasia. Morphine quantification in serum, aqueous, and vitreous humor was performed by ELISA. Treated and control corneas were submitted for histopathology. Horses were monitored for adverse ocular and systemic effects throughout the study period. RESULTS All horses developed mild mucoid ocular discharge in the treated eye. One horse developed a fever during treatment. Morphine was detected in the aqueous humor of the treated eye for all horses with mean ± standard deviation of 165.18 ng/mL ± 87.69 ng/mL. Morphine was detected in vitreous humor of the treated eye of 5 of 6 horses with mean ± standard deviation of 4.87 ± 4.46 ng/mL. Morphine was detected in the serum of 5 of 6 horses at varying time points. Maximum systemic concentration reached in a single horse was 6.98 ng/mL. Corneal histopathology revealed no difference in microscopic appearance between morphine-treated and control corneas. CONCLUSIONS Topical administration of 1.0% morphine sulfate did not appear to cause any significant ocular or systemic adverse effects. Topical ophthalmic morphine application resulted in both ocular and systemic absorption.
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Affiliation(s)
- Emma Gordon
- Department of Clinical Sciences, College of Veterinary Medicine, Oregon State University, Corvallis, OR, USA
| | - Bernadette V Stang
- Department of Clinical Sciences, College of Veterinary Medicine, Oregon State University, Corvallis, OR, USA
| | - Jerry Heidel
- Department of Biomedical Sciences, College of Veterinary Medicine, Oregon State University, Corvallis, OR, USA
| | - Keith P Poulsen
- Department of Medical Sciences, School of Veterinary Medicine and Wisconsin Veterinary Diagnostic Laboratory, University of Wisconsin-Madison, Madison, WI, USA
| | - Christopher K Cebra
- Department of Clinical Sciences, College of Veterinary Medicine, Oregon State University, Corvallis, OR, USA
| | - John W Schlipf
- Department of Clinical Sciences, College of Veterinary Medicine, Oregon State University, Corvallis, OR, USA
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8
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Franken LG, de Winter BCM, van Esch HJ, van Zuylen L, Baar FPM, Tibboel D, Mathôt RAA, van Gelder T, Koch BCP. Pharmacokinetic considerations and recommendations in palliative care, with focus on morphine, midazolam and haloperidol. Expert Opin Drug Metab Toxicol 2016; 12:669-80. [PMID: 27081769 DOI: 10.1080/17425255.2016.1179281] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION A variety of medications are used for symptom control in palliative care, such as morphine, midazolam and haloperidol. The pharmacokinetics of these drugs may be altered in these patients as a result of physiological changes that occur at the end stage of life. AREAS COVERED This review gives an overview of how the pharmacokinetics in terminally ill patients may differ from the average population and discusses the effect of terminal illness on each of the four pharmacokinetic processes absorption, distribution, metabolism, and elimination. Specific considerations are also given for three commonly prescribed drugs in palliative care: morphine, midazolam and haloperidol). EXPERT OPINION The pharmacokinetics of drugs in terminally ill patients can be complex and limited evidence exists on guided drug use in this population. To improve the quality of life of these patients, more knowledge and more pharmacokinetic/pharmacodynamics studies in terminally ill patients are needed to develop individualised dosing guidelines. Until then knowledge of pharmacokinetics and the physiological changes that occur in the final days of life can provide a base for dosing adjustments that will improve the quality of life of terminally ill patients. As the interaction of drugs with the physiology of dying is complex, pharmacological treatment is probably best assessed in a multi-disciplinary setting and the advice of a pharmacist, or clinical pharmacologist, is highly recommended.
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Affiliation(s)
- L G Franken
- a Department of Hospital Pharmacy , Erasmus Medical Centre , Rotterdam , the Netherlands
| | - B C M de Winter
- a Department of Hospital Pharmacy , Erasmus Medical Centre , Rotterdam , the Netherlands
| | - H J van Esch
- b Palliative Care Centre , Laurens Cadenza , Rotterdam , the Netherlands
| | - L van Zuylen
- c Department of Medical Oncology , Erasmus MC Cancer Institute , Rotterdam , the Netherlands
| | - F P M Baar
- b Palliative Care Centre , Laurens Cadenza , Rotterdam , the Netherlands
| | - D Tibboel
- d Intensive Care, Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,e Pain Expertise Centre , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - R A A Mathôt
- f Hospital Pharmacy - Clinical Pharmacology , Academic Medical Centre , Amsterdam , the Netherlands
| | - T van Gelder
- a Department of Hospital Pharmacy , Erasmus Medical Centre , Rotterdam , the Netherlands
| | - B C P Koch
- a Department of Hospital Pharmacy , Erasmus Medical Centre , Rotterdam , the Netherlands
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Chidambaran V, Venkatasubramanian R, Zhang X, Martin LJ, Niu J, Mizuno T, Fukuda T, Meller J, Vinks AA, Sadhasivam S. ABCC3 genetic variants are associated with postoperative morphine-induced respiratory depression and morphine pharmacokinetics in children. THE PHARMACOGENOMICS JOURNAL 2016; 17:162-169. [PMID: 26810133 PMCID: PMC4959996 DOI: 10.1038/tpj.2015.98] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 11/04/2015] [Accepted: 11/13/2015] [Indexed: 02/07/2023]
Abstract
Respiratory depression (RD) is a serious side effect of morphine and detrimental to effective analgesia. We reported that variants of the ATP binding cassette gene ABCC3 (facilitates hepatic morphine metabolite efflux) affect morphine metabolite clearance. In this study of 316 children undergoing tonsillectomy, we found significant association between ABCC3 variants and RD leading to prolonged postoperative care unit stay (prolonged RD). Allele A at rs4148412 and allele G at rs729923 caused a 2.36 (95% CI=1.28-4.37, P=0.0061) and 3.7 (95% CI 1.47-9.09, P=0.0050) times increase in odds of prolonged RD, respectively. These clinical associations were supported by increased formation clearance of morphine glucuronides in children with rs4148412 AA and rs4973665 CC genotypes in this cohort, as well as an independent spine surgical cohort of 67 adolescents. This is the first study to report association of ABCC3 variants with opioid-related RD, and morphine metabolite formation (in two independent surgical cohorts).
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Affiliation(s)
- V Chidambaran
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - R Venkatasubramanian
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - X Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - L J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Niu
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - T Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - T Fukuda
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Meller
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Bioinformatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A A Vinks
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Sadhasivam
- Department of Anesthesia, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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King MT, Costa DSJ, Aaronson NK, Brazier JE, Cella DF, Fayers PM, Grimison P, Janda M, Kemmler G, Norman R, Pickard AS, Rowen D, Velikova G, Young TA, Viney R. QLU-C10D: a health state classification system for a multi-attribute utility measure based on the EORTC QLQ-C30. Qual Life Res 2016; 25:625-36. [PMID: 26790428 DOI: 10.1007/s11136-015-1217-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To derive a health state classification system (HSCS) from the cancer-specific quality of life questionnaire, the EORTC QLQ-C30, as the basis for a multi-attribute utility instrument. METHODS The conceptual model for the HSCS was based on the established domain structure of the QLQ-C30. Several criteria were considered to select a subset of dimensions and items for the HSCS. Expert opinion and patient input informed a priori selection of key dimensions. Psychometric criteria were assessed via secondary analysis of a pooled dataset comprising HRQOL and clinical data from 2616 patients from eight countries and a range of primary cancer sites, disease stages, and treatments. We used confirmatory factor analysis (CFA) to assess the conceptual model's robustness and generalisability. We assessed item floor effects (>75 % observations at lowest score), disordered item response thresholds, coverage of the latent variable and differential item function using Rasch analysis. We calculated effect sizes for known group comparisons based on disease stage and responsiveness to change. Seventy-nine cancer patients assessed the relative importance of items within dimensions. RESULTS CFA supported the conceptual model and its generalisability across primary cancer sites. After considering all criteria, 12 items were selected representing 10 dimensions: physical functioning (mobility), role functioning, social functioning, emotional functioning, pain, fatigue, sleep, appetite, nausea, bowel problems. CONCLUSIONS The HSCS created from QLQ-C30 items is known as the EORTC Quality of Life Utility Measure-Core 10 dimensions (QLU-C10D). The next phase of the QLU-C10D's development involves valuation studies, currently planned or being conducted across the globe.
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Affiliation(s)
- M T King
- Psycho-Oncology Cooperative Research Group (PoCoG), School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia.
- Central Clinical School, Sydney Medical School, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia.
| | - D S J Costa
- Psycho-Oncology Cooperative Research Group (PoCoG), School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia
| | - N K Aaronson
- Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J E Brazier
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, South Yorkshire, UK
| | - D F Cella
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - P M Fayers
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - P Grimison
- Chris O'Brien Lifehouse, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - M Janda
- School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - G Kemmler
- Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Innsbruck, Austria
| | - R Norman
- School of Public Health, Curtin University, Perth, WA, Australia
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - A S Pickard
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - D Rowen
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, South Yorkshire, UK
| | - G Velikova
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
| | - T A Young
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, South Yorkshire, UK
| | - R Viney
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney (UTS), Sydney, NSW, Australia
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11
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Lee YJ, Suh SY, Song J, Lee SS, Seo AR, Ahn HY, Lee MA, Kim CM, Klepstad P. Serum and urine concentrations of morphine and morphine metabolites in patients with advanced cancer receiving continuous intravenous morphine: an observational study. BMC Palliat Care 2015; 14:53. [PMID: 26507979 PMCID: PMC4624671 DOI: 10.1186/s12904-015-0052-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 10/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The feasibility and clinical implication of drug monitoring of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) need further investigation. This study aimed to determine what predicts serum concentrations of morphine in cancer patients receiving continuously intravenous morphine, the relationships between serum concentration of morphine/its metabolites and urinary concentrations, and the relation between morphine concentrations and with clinical outcomes. METHODS We collected serum and urine samples from 24 patients with advanced cancer undergoing continuously intravenous morphine therapy. Serum samples were obtained at day one. Spot urine samples were collected once daily on three consecutive days. Pain and adverse drug events were assessed using the Korean version of MD Anderson Symptom Inventory. RESULTS A total of 96 samples (72 urine and 24 serum samples) were collected. Median dose of morphine was 82.0 mg/24 h. In a multivariate analysis, total daily morphine dose was the most significant predictors of both serum and urine concentration of morphine. Morphine, M6G, and M3G in serum and urine were statistical significantly correlated (correlation coefficient = 0.81, 0.44, 0.56; p values < 0.01, 0.03, 0.01, respectively). CONCLUSION Spot urine concentrations of morphine and its metabolites were highly correlated to those of serum. Total dose of daily morphine was related to both serum and urine concentration of morphine and its metabolites.
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Affiliation(s)
- Yong Joo Lee
- Department of Palliative Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University School of Medicine, 30 Pildong-ro 1-gil, Jung-gu, Seoul, 100-715, South Korea.
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| | | | - Ah-Ram Seo
- Department of Statistics, Dongguk University, Seoul, South Korea.
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University, Seoul, South Korea.
| | - Myung Ah Lee
- Division of Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Chul-Min Kim
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Pål Klepstad
- Departments of Anaesthesiology and Intensive Care Medicine, St. Olvas University Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Medical Faculty, Norwegian University of Technology and Science, Trondheim, Norway.
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12
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Opioid needs of terminally ill patients with gynecologic malignancies. Int J Clin Oncol 2014; 20:405-10. [DOI: 10.1007/s10147-014-0708-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
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13
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Devine EP, KuKanich B, Beard WL. Pharmacokinetics of intramuscularly administered morphine in horses. J Am Vet Med Assoc 2014; 243:105-12. [PMID: 23786198 DOI: 10.2460/javma.243.1.105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the pharmacokinetics of morphine after IM administration in a clinical population of horses. DESIGN Prospective clinical study. ANIMALS 77 horses. PROCEDURES Morphine sulfate (0.1 mg/kg [0.045 mg/lb], IM) was administered to horses, and blood samples were obtained at predetermined time points. Plasma morphine concentrations were measured via liquid chromatography and mass spectrometry. In preliminary investigations, samples were obtained from 2 healthy horses at 12 time points (up to 12 hours after drug administration) and analyzed via 2-stage pharmacokinetic analysis. In the clinical phase, blood samples were obtained from 75 hospitalized horses at various times (total, 2 to 3 samples/horse) up to 9 hours after drug administration, and data were analyzed via a naïve pooled pharmacokinetic model. RESULTS In the clinical phase, the apparent terminal half-life (t(½)) of morphine was approximately 1.5 hours, volume of distribution per bioavailability was approximately 4.5 L/kg, and clearance per bioavailability was approximately 35 mL/kg/min. Peak plasma concentration in naïve pooled analysis was 21.6 ng/mL and occurred approximately 4 minutes after administration. Morphine concentrations were below the limit of quantification ≤ 7 hours after administration in 74 horses. Adverse effects attributed to morphine administration were uncommon and considered mild. CONCLUSIONS AND CLINICAL RELEVANCE The short t(½) of morphine in horses suggested frequent administration may be needed to maintain targeted plasma concentrations. Variations in plasma concentrations suggested optimal dosages may differ among horses. The drug was well tolerated at the described dose, but patients receiving morphine should be monitored carefully.
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Affiliation(s)
- Elizabeth P Devine
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66502, USA.
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Giannopoulos P, Papatheodoropoulos C. Effects of μ-opioid receptor modulation on the hippocampal network activity of sharp wave and ripples. Br J Pharmacol 2013; 168:1146-64. [PMID: 23043226 DOI: 10.1111/j.1476-5381.2012.02240.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 08/30/2012] [Accepted: 09/17/2012] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Hippocampus-dependent memory involves the activity of sharp wave ripples (SWRs), which are thought to participate in the process of memory consolidation. The hippocampus contains high levels of endogenous opioids and of μ-opioid receptors (MORs). Here, we have assessed the role of MOR agonists in the modulation of SWRs. EXPERIMENTAL APPROACH Using recordings of extracellular potentials from the CA1 field of rat hippocampal slices, we examined the pharmacological actions of morphine, DAMGO and fentanyl on SWRs and on network excitability and paired-pulse inhibition. KEY RESULTS All three MOR agonists (1 nM-10 μM) significantly increased the amplitude of sharp waves and the occurrence of SWR sequences, but reduced the initiation of episodes of SWRs. Fentanyl was most potent in producing these effects and morphine the least. Interestingly, although SWRs were reduced by relatively high concentrations (≥100 nM) of all agonists, they were significantly enhanced by very low concentrations of morphine (5-10 nM). Morphine and DAMGO at moderate-to-high concentrations increased network excitability and reduced inhibition. Furthermore, DAMGO suppressed inhibition more readily than it increased excitation, whereas morphine suppressed inhibition only at high concentrations. These drug effects were reversed by the MOR antagonists naloxone and CTOP. CONCLUSIONS AND IMPLICATIONS We found that the SWRs were significantly modulated by three MOR agonists and that the SWRs were very sensitive to subtle changes in the excitation/inhibition balance induced by MOR agonists. Such modulation might underlie the effects of these agonists on hippocampus-dependent memory.
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Affiliation(s)
- Panagiotis Giannopoulos
- Specialist Community Addictions Service, Unit 5, The Valley Centre, Gordon Road High Wycombe, Buckinghamshire, HP13 6EQ, UK.
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15
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Variability in UDP-glucuronosyltransferase genes and morphine metabolism: observations from a cross-sectional multicenter study in advanced cancer patients with pain. Pharmacogenet Genomics 2013; 23:117-26. [PMID: 23277092 DOI: 10.1097/fpc.0b013e32835ce485] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of the present study was to determine whether genetic variability in UDP-glucuronosyltransferase (UGT) genes, together with clinical factors, contribute to variability in morphine glucuronide (M6G and M3G) to morphine serum concentration ratios in patients with advanced cancer receiving chronic morphine therapy. MATERIALS AND METHODS A total of 41 polymorphisms and predicted haplotypes in the UGT2B7, UGT1A1, and UGT1A8 genes were analyzed in 759 patients who were recruited from the European Pharmacogenetic Opioid Study and received chronic morphine therapy by the oral route (n=635) or parenterally (n=124). The administration groups were analyzed separately by multiple linear regression analyses. RESULTS Two haplotypes in UGT1A1/UGT1A8 were weak predictors of reduced M6G/morphine and M3G/morphine serum ratios after oral administration (false discovery rate-corrected P-values<0.1). No effect of genotype was seen in the parenteral group. Of the clinical variables (age, sex, BMI, renal function, Karnofsky performance status, and presence of liver metastases), renal function was the major contributor to variation in serum concentration ratios. Concomitant administration of paracetamol predicted significantly higher morphine metabolic ratios after oral administration of morphine (false discovery rate-corrected P-values<2.1E-12). The regression models explained about 35% of the total variability in the data. CONCLUSION Genetic variation in the UGT genes together with clinical factors influence morphine metabolic ratios in patients with advanced cancer disease and who are scheduled with oral morphine. This information may be included in future research that develop and test new classification systems for opioid treatment in patients with advanced cancer.
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Using group-based trajectory modeling to examine heterogeneity of symptom burden in patients with head and neck cancer undergoing aggressive non-surgical therapy. Qual Life Res 2013; 22:2331-9. [PMID: 23475689 DOI: 10.1007/s11136-013-0380-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2013] [Indexed: 11/12/2022]
Abstract
PURPOSE Treatment-related symptom burden varies significantly among patients undergoing radiotherapy or chemoradiotherapy, yet such variation is typically not reflected in the results from single-group studies. We applied group-based trajectory modeling (GBTM) to describe the heterogeneity of symptom burden among patients with head and neck cancer and to identify subgroups with distinct symptom-development trajectories. METHODS Patients (n = 130) were recruited pretherapy and rated multiple symptoms weekly for 10 weeks via the M. D. Anderson Symptom Inventory. With the mean of five most severe symptoms over time as an outcome measure, GBTM was used to identify patient subgroups with distinct symptom trajectories. Linear mixed-effects modeling (LMM) was applied to compare with GBTM's ability to describe the longitudinal symptom data. RESULTS The five most severe symptoms were problems with taste, difficulty swallowing or chewing, problems with mucus, fatigue, and dry mouth. A two-group GBTM model identified 68 % of patients as having high symptom burden, associated with older age, worse baseline performance status, and chemoradiotherapy treatment. A four-group GBTM model generated one stable group (4 % of patients) and three groups varying in symptom severity with both linear and quadratic functions over time. LMM revealed symptom-change patterns similar to that produced by GBTM but was inferior in identifying risk factors for high symptom burden. CONCLUSIONS For cancer patients undergoing aggressive therapy, GBTM is capable of identifying various symptom-burden trajectories and provides severity groupings that will aid research and may be of clinical utility. These results may be generalizable to other cancer types and treatments.
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Andersen G, Sjøgren P, Hansen SH, Jensen NH, Christrup L. Pharmacological consequences of long-term morphine treatment in patients with cancer and chronic non-malignant pain. Eur J Pain 2012; 8:263-71. [PMID: 15109977 DOI: 10.1016/j.ejpain.2003.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2003] [Accepted: 09/22/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with pain of malignant origin morphine may be administered in high and often increasing doses during extended periods of time. In patients with chronic pain of non-malignant origin morphine may be an important remedy, and in these cases the goal is to keep the morphine dose stable. The pharmacokinetic as well as the pharmacodynamic consequences of long-term morphine treatment with special reference to the two most important metabolites of morphine morphine-6-glucuronide (M-6-G) and morphine-3-glucuronide (M-3-G) remain to be settled. METHODS Assessments for pain, sedation and other morphine induced side effects were made several times for 19 cancer patients treated with changing doses of oral sustained release (SR) morphine and twice for 17 non-cancer patients treated with stable doses of SR morphine. Blood samples were obtained simultaneously and analysed for contents of morphine, M-3-G and M-6-G by high-performance liquid chromatography (HPLC). RESULTS Significant correlations were found between the daily dose of SR morphine and plasma morphine (r = 0.469, p < 0.01), plasma M-6-G (r = 0.677, p < 0.01), and plasma M-3-G ((r = 0.827, p < 0.01), in the cancer patient group, but only between the daily dose of SR morphine and plasma M-3-G (0.662, p < 0.01) and plasma M-6-G (0.571, p < 0.01) in the non-cancer patient group. Normalised M-3-G/M and M-6-G/M ratios for the cancer patient group were independent of duration of treatment and daily dose of SR morphine. Likewise in the non-cancer patient group duration of treatment did not influence the metabolite ratios. Correlations between pain score and plasma morphine, M-6-G and M-6-G/M were weak in the cancer patient as well as in the non-cancer patient group making it impossible to draw any conclusion regarding the potential contributory analgesic effect of M-6-G. Dryness of the mouth was the most frequent adverse effect reported in the non-cancer as well as the cancer patient group. In the latter group patients complaining of dryness of the mouth had significantly higher plasma morphine and M-6-G concentrations than patients who did not suffer from this side effect. This difference persisted (or was close to significance) when excluding patients receiving antidepressants. CONCLUSION In the cancer patient group neither dose nor treatment period seems to influence morphine glucuronidation. Likewise in the non-cancer patient group receiving stable doses of morphine duration of treatment does not seem to influence morphine glucuronidation. Dryness of the mouth was positively correlated to high plasma concentrations of morphine and M-6-G.
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Affiliation(s)
- Gertrud Andersen
- Multidisciplinary Pain Centre, Herlev University Hospital, Herlev 2730, Denmark.
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18
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King S, Forbes K, Hanks GW, Ferro CJ, Chambers EJ. A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project. Palliat Med 2011; 25:525-52. [PMID: 21708859 DOI: 10.1177/0269216311406313] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative's opioid guidelines project. OBJECTIVE The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines. SEARCH STRATEGY The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. SELECTION CRITERIA Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded. DATA COLLECTION AND ANALYSIS This is a narrative systematic review and no meta-analysis was performed. The Grading of RECOMMENDATIONS Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines. MAIN RESULTS Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil. CONCLUSIONS All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids. RECOMMENDATIONS RECOMMENDATIONS regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.
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Affiliation(s)
- S King
- Department of Palliative Medicine, University of Bristol, Bristol Oncology and Haematology Centre, Bristol BS2 8ED, UK.
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19
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Abstract
In patients with active cancer, the management of chronic pain is an essential element in a comprehensive strategy for palliative care. This strategy emphasises multidimensional assessment and the coordinated use of treatments that together mitigate suffering and provide support to the patient and family. This review describes this framework, an approach to pain assessment, and widely accepted techniques to optimise the safety and effectiveness of opioid drugs and other treatments. The advances of recent decades suggest a future that includes increased evidence-based targeting of specific analgesic interventions within an individualised plan of care that is appropriate throughout the course of illness.
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Affiliation(s)
- Russell K Portenoy
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY 10003, USA.
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20
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Abstract
Opioids are the most potent drugs for treatment of acute and chronic pain. However, accumulating evidence suggests that opioids may paradoxically also enhance pain, often referred to as opioid-induced hyperalgesia. Opioid-induced hyperalgesia is defined as an increased sensitivity to pain or a decreased pain threshold in response to opioid therapy. Several mechanisms have been proposed to support opioid-induced hyperalgesia. However, it remains unclear whether opioid-induced hyperalgesia develops during continuous chronic application of opioids or on their withdrawal. This review provides a comprehensive summary of clinical research concerning opioid-induced hyperalgesia and the molecular mechanisms of opioid withdrawal and opioid tolerance and other potential mechanisms which might induce hyperalgesia during opioid therapy will be discussed. The status quo of our knowledge will be summarized and the clinical relevance of opioid-induced hyperalgesia will be discussed.
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Affiliation(s)
- C Zöllner
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg Eppendorf, Martinistr. 52, 20246 Hamburg, Deutschland.
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Andreassen TN, Klepstad P, Davies A, Bjordal K, Lundström S, Kaasa S, Dale O. Influences on the pharmacokinetics of oxycodone: a multicentre cross-sectional study in 439 adult cancer patients. Eur J Clin Pharmacol 2010; 67:493-506. [PMID: 21140139 PMCID: PMC3076582 DOI: 10.1007/s00228-010-0948-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 10/27/2010] [Indexed: 12/16/2022]
Abstract
Objective Oxycodone is widely used for the treatment of cancer pain, but little is known of its pharmacokinetics in cancer pain patients. The aim of this study was to explore the relationships between ordinary patient characteristics and serum concentrations of oxycodone and the ratios noroxycodone or oxymorphone/oxycodone in cancer patients. Methods Four hundred and thirty-nine patients using oral oxycodone for cancer pain were included. The patients’ characteristics (sex, age, body mass index [BMI], Karnofsky performance status, “time since starting opioids”, “oxycodone total daily dose”, “time from last oxycodone dose”, use of CYP3A4 inducer/inhibitor, “use of systemic steroids”, “number of medications taken in the last 24 h”, glomerular filtration rate (GFR) and albumin serum concentrations) influence on oxycodone serum concentrations or metabolite/oxycodone ratios were explored by multiple regression analyses. Results Sex, CYP3A4 inducers/inhibitors, total daily dose, and “time from last oxycodone dose” predicted oxycodone concentrations. CYP3A4 inducers, total daily dose, and “number of medications taken in the last 24 h” predicted the oxymorphone/oxycodone ratio. Total daily dose, “time from last dose to blood sample”, albumin, sex, CYP3A4 inducers/inhibitors, steroids, BMI and GFR predicted the noroxycodone/oxycodone ratio. Conclusion Women had lower oxycodone serum concentrations than men. CYP3A4 inducers/inhibitors should be used with caution as these are predicted to have a significant impact on oxycodone pharmacokinetics. Other characteristics explained only minor parts of the variability of the outcomes.
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Affiliation(s)
- Trine Naalsund Andreassen
- Pain and Palliation Research Group, Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Shi Q, Cleeland CS, Klepstad P, Miaskowski C, Pedersen NL. Biological pathways and genetic variables involved in pain. Qual Life Res 2010; 19:1407-17. [PMID: 20842532 DOI: 10.1007/s11136-010-9738-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE This paper summarizes current knowledge of pain-related and analgesic-related pathways as well as genetic variations involved in pain perception and management. METHODS The pain group of the GENEQOL Consortium was given the task of summarizing the current status of research on genetic variations in pain and analgesic efficacy. This review is neither exhaustive nor comprehensive; we focus primarily on single-nucleotide polymorphisms. RESULTS Two categories of potential genetic pain-perception pathways were identified: neurotransmission modulators and mechanisms that affect inflammation. Four categories were identified for analgesic efficacy: genes related to receptor interaction, modulation of opioid effects, metabolism, and transport. Various genetic variations involved in these pathways are proposed as candidate genetic markers for pain perception and for individual sensitivity to analgesics. CONCLUSIONS Candidate gene association studies have been used to provide evidence for the genetic modulation of pain perception and response to analgesics. However, the nature and range of genetic modulation of pain is not well addressed due to the limited number of patients and the limited number of genes and genetic variants investigated in studies to date. Moreover, personalized analgesic treatments will require a more complete understanding of the effects of genetic variants and gene-gene interactions in response to analgesics.
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Affiliation(s)
- Qiuling Shi
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1450, Houston, TX 77030, USA.
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Ridgway D, Sopata M, Burneckis A, Jespersen L, Andersen C. Clinical efficacy and safety of once-daily dosing of a novel, prolonged-release oral morphine tablet compared with twice-daily dosing of a standard controlled-release morphine tablet in patients with cancer pain: a randomized, double-blind, exploratory crossover study. J Pain Symptom Manage 2010; 39:712-20. [PMID: 20413058 DOI: 10.1016/j.jpainsymman.2009.08.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 08/04/2009] [Accepted: 08/11/2009] [Indexed: 11/23/2022]
Abstract
CONTEXT Recently, a new oral prolonged-release formulation of morphine sulfate for once-daily dosing has been developed based on an injection-molded matrix (abuse-deterrent, prolonged-release erodible matrix [ADPREM]). OBJECTIVES The objective of this double-blind, randomized, exploratory crossover study was to assess the efficacy and safety of once-daily ADPREM compared with twice-daily controlled-release morphine (CRM; MST ContinusNapp Pharmaceuticals, Cambridge, UK). METHODS Thirty-eight adult cancer pain patients participated in the study, which consisted of a run-in period for stabilization and two consecutive fixed-dose treatment periods of two weeks' duration each. Rescue medication, immediate-release morphine sulfate, was available during the entire study for treatment of breakthrough pain (BTP). RESULTS There was no difference between the treatments in use of rescue medication. The medians of the average number of rescue doses per day were 1.0 and 0.7 during the ADPREM and CRM treatment periods, respectively, with an estimated median difference of 0.07 dose/day (95% confidence interval: -0.21, 0.29). Likewise, no differences between treatments were found for the number of BTP episodes per day or morning and evening ratings of pain intensity (current, average, minimum, and maximum). Median assessment of the drugs was "good" for both treatments, and neither of the treatments was preferred. Steady-state trough concentrations of morphine and its metabolites in plasma before morning dosing were similar after either treatment period. The adverse events were as expected in an opioid-treated cancer population and showed no differences between ADPREM and CRM. CONCLUSION In this study, dosing with ADPREM at intervals of 24 hours was therapeutically equivalent to CRM dosed at intervals of 12 hours.
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Benítez-Rosario MA, Salinas-Martín A, Aguirre-Jaime A, Pérez-Méndez L, Feria M. Morphine-methadone opioid rotation in cancer patients: analysis of dose ratio predicting factors. J Pain Symptom Manage 2009; 37:1061-8. [PMID: 19171458 DOI: 10.1016/j.jpainsymman.2008.05.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 05/13/2008] [Accepted: 06/16/2008] [Indexed: 11/20/2022]
Abstract
The dose ratio that is effective when switching opioid therapy from morphine to methadone in cancer patients varies widely. There are no conclusive data explaining the source of this variability. We analyzed 54 cancer patients undergoing opioid rotation to clarify those factors that influenced the morphine/methadone dose ratio (MMEDR) at Day 10 after the switch. Reasons for switching were uncontrolled pain (10 patients) or side effects (with or without pain, 44 patients). Initial MMEDR was 5:1 or 10:1 (82% or 18% of patients, respectively). Multivariate regression analysis was used to identify the demographic, cancer-related, and treatment-related variables that were potential predictors of MMEDR. Median previous morphine dose for the entire sample was 220 mg/day (range: 30-1000 mg/day). The stable MMEDR median was 5:1 (range: 2:1-15:1). In the univariate analysis, reasons for opioid rotation, age, and previous morphine doses were associated with MMEDR. Multiple linear regression analysis showed that only the reason for switching (pain vs. side effects; P<0.001) and previous morphine doses (lower vs. upper to 300 mg/day; P<0.001) were associated with MMEDR. From this analysis, the MMEDRs for patients rotated for side effects at 300 mg/day or more or less than 300 mg/day of morphine were 9.1:1 or 5.6:1, respectively, and the MMEDRs for those switched for pain at 300 mg/day or more or less than 300 mg/day of morphine were 4.9:1 or 3:1, respectively. Both the reasons for opioid rotation and previous morphine doses are predictive factors and should be used to select the MMEDR more accurately.
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Affiliation(s)
- Miguel Angel Benítez-Rosario
- Palliative Care Unit, NS Candelaria University Hospital, Canary Health Service, Department of Pharmacology, University of La Laguna, 38271 La Laguna, Tenerife, Spain.
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25
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Four nonfatal and six fatal cases of opiate use: utility of morphine, its metabolites, and their ratios in blood specimens. Forensic Toxicol 2008. [DOI: 10.1007/s11419-008-0056-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ohno S, Kawana K, Nakajin S. Contribution of UDP-glucuronosyltransferase 1A1 and 1A8 to morphine-6-glucuronidation and its kinetic properties. Drug Metab Dispos 2008; 36:688-94. [PMID: 18187562 DOI: 10.1124/dmd.107.019281] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The metabolic conversion of morphine to morphine-6-glucuronide (M6G) seems to play a significant role in mediation of the clinical effect of morphine because of the superior analgesic effect of M6G. Therefore, it would be of great interest to clarify the specificity of morphine-6-glucuronidation by UDP glucuronosyltransferase (UGT) isozymes. We investigated the specificity of morphine-6-glucuronidation catalyzed by recombinant human UGT isozymes in microsomes from baculovirus-infected insect cells. The morphine glucuronidation activity of recombinant human UGT isozymes incubated with morphine and UDP-glucuronic acid was determined by high-performance liquid chromatography with a fluorescence detector. Not only UGT2B7, which is well known to catalyze morphine-6-glucuronidation, but also UGT1A1 and 1A8 effectively catalyzed morphine-6-glucuronidation at relatively low morphine concentrations (<100 muM). The kinetics of both isozymes at the low substrate concentrations showed hyperbolic Michaelis-Menten kinetics. However, as the morphine concentration approached 100 muM, morphine-6-glucuronidation activity gradually decreased, and the kinetics closely resembled substrate inhibition Michaelis-Menten kinetic behavior. The K(m) values were 67.9 and 68.1 muM and the K(si) values were 218.9 and 88.0 muM for UGT1A1 and 1A8, respectively. These kinetics are basically different from that of morphine-6-glucuronidation by UGT2B7, which suggested biphasic Michaelis-Menten kinetic behavior. Furthermore, to estimate the contribution of these UGT isozymes in M6G formation in vivo, the expression levels of UGT1A1 and 1A8 mRNA in human liver and intestine were determined by reverse transcription real-time polymerase chain reaction. The results strongly suggest that UGT1A1 and UGT1A8 are isozymes involved in morphine-6-glucuronidation in vivo, as is UGT2B7 in humans.
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Affiliation(s)
- Shuji Ohno
- Department of Biochemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, Ebara 2-4-41, Shinagawa, Tokyo 142-8501, Japan.
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Hewitt M, Goldman A, Collins GS, Childs M, Hain R. Opioid use in palliative care of children and young people with cancer. J Pediatr 2008; 152:39-44. [PMID: 18154896 DOI: 10.1016/j.jpeds.2007.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Revised: 04/03/2007] [Accepted: 07/03/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Identify opioids prescribed, preferred routes, and doses among children with incurable cancer. STUDY DESIGN Prospective survey with monthly questionnaires regarding patients 0 to 19 years old from oncology centers. Data were collected by professionals on each patient for 6 months or until death, and analyzed from patients who died. Impact of tumor was analyzed with Kruskal-Wallis and Mann-Whitney tests. Major opioid dosages are expressed as oral morphine equivalents. RESULTS Of 185 children recruited, 164 (88 boys, 76 girls) died. Mean palliative care duration was 67 days. One hundred forty-seven (89.6%) received major opioids. Morphine, diamorphine, and fentanyl were prescribed in 75%, 57.9%, and 11.6%, respectively. Seventy-three (44.5%) received >1 major opioid. Median monthly maximum doses prescribed rose from 2.1 mg/kg/24 h (study entry) to 4.4 mg/kg/24 h (death) (P < .001); overall variable (0.09-1500 mg/kg/24 h, median 3.7 mg/kg/24 h). Opioids were given by the oral (117/164, 71.3%), intravenous (68/164, 41.5%), subcutaneous (40, 28%), rectal (20, 12.2%), and transdermal (18, 11%) routes. There was a shift to intravenous use as death approached. Numbers within each tumor group were too small to show significance. Children with solid tumors outside the central nervous system were likely to receive more opioids, be given multiple different opioids, and receive opioids in the last month. CONCLUSIONS The study shows the United Kingdom practice of opioid use and provides comparator data for practice in children's palliative medicine.
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Affiliation(s)
- Martin Hewitt
- Queen's Medical Centre, University Hospital, Nottingham, United Kingdom
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28
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Candidate gene polymorphisms predicting individual sensitivity to opioids. Naunyn Schmiedebergs Arch Pharmacol 2007; 377:269-81. [DOI: 10.1007/s00210-007-0205-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 10/18/2007] [Indexed: 11/26/2022]
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29
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Rudin A, Lundberg JF, Hammarlund-Udenaes M, Flisberg P, Werner MU. Morphine metabolism after major liver surgery. Anesth Analg 2007; 104:1409-14, table of contents. [PMID: 17513633 DOI: 10.1213/01.ane.0000261847.26044.1d] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Impaired metabolism of morphine may lead to an increase in sedation and respiratory depression. METHODS In the present study we investigated morphine pharmacokinetics in patients who had undergone liver resection (n = 15) compared to a control group undergoing colon resection (n = 15). Morphine was administered IV by patient-controlled analgesia. Plasma concentrations of morphine, morphine-6-glucuronide, and morphine-3-glucuronide were measured 2-3 times daily for the first two postoperative days. Pain intensity scores were assessed three times daily and respiratory rate and sedation scores every third hour. RESULTS There were no differences in morphine requirements 1.1 (0.8-2.5 [median, interquartile range]) mg/h (liver resection) and 1.5 (1.1-1.7) mg/h (colon resection) [P = 0.84]) or in pain intensity scores (P > 0.3) between the groups. Plasma morphine concentrations were higher in patients undergoing liver resection than in the control group (P < 0.01) reflecting a lower rate of morphine metabolism. Plasma morphine concentrations were correlated with the volume of liver resection (P < 0.02). However, plasma concentrations of morphine-6-glucuronide and morphine-3-glucuronide did not differ between the groups (P = 0.62 and P = 0.48, respectively). There was a higher incidence of sedation (P = 0.02), but not respiratory depression (P = 0.48), after liver resection. CONCLUSION The study demonstrates that plasma concentrations of morphine are higher in patients undergoing liver resection compared with patients undergoing colon resection. Sedation scores were higher in patients undergoing liver resection. Caution is therefore recommended when administering morphine to this patient group.
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Affiliation(s)
- Asa Rudin
- Department of Anesthesiology and Intensive Care, Lund University Hospital, Lund, Sweden.
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30
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Yamashita K, Nabeshima A, Hara Y, Okochi J. [Influence of body weight, age, and primary tumor site on opioid dose in advanced cancer pain patients]. Nihon Ronen Igakkai Zasshi 2007; 44:345-50. [PMID: 17575439 DOI: 10.3143/geriatrics.44.345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
AIM The aim of this study was to evaluate the relationship between maximum opioid dose and body weight, age, and primary site in terminal cancer patients in a palliative care unit. METHODS Medical records of 152 terminal cancer patients were reviewed retrospectively. Body weight, primary tumor site, age, and analgesic state were used as independent variables, and the maximum opioid dose was used as a dependent variable. RESULTS There was no correlation between body weight and maximum opioid requirement. Selected independent variables were age and location of the primary lesion in the lower gastrointestinal tract. Maximum opioid dose was negatively correlated with age (P < or =0.0001). Opioid needs of age <65 was 344.2 mg/day oral morphine equivalent, but age 65-74 was 168.5, and age > or =75 was 116.9 mg/day. CONCLUSION Elderly cancer patients required a lower amount of opioid analgesia than younger adults. The ratio for age <65, 65-74, and > or =75 was about 1:1/2:1/3.
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31
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Shipkova M, Wieland E. Glucuronidation in therapeutic drug monitoring. Clin Chim Acta 2005; 358:2-23. [PMID: 15893300 DOI: 10.1016/j.cccn.2005.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Revised: 02/21/2005] [Accepted: 02/22/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Glucuronidation is a major drug-metabolizing reaction in humans. A pharmacological effect of glucuronide metabolites is frequently neglected and the value of therapeutic drug monitoring has been questioned. However, this may not always be true. METHODS In this review the impact of glucuronidation on therapeutic drug monitoring has been evaluated on the basis of a literature search and experience from the own laboratory. RESULTS The potential role of monitoring glucuronide metabolite concentrations to optimize therapeutic outcome is addressed on the basis of selected examples of drugs which are metabolized to biologically active/reactive glucuronides. Furthermore indirect effects of glucuronide metabolites on parent drug pharmacokinetics are presented. In addition, factors that may modulate the disposition of these metabolites (e.g. genetic polymorphisms, disease processes, age, and drug-drug interactions) are briefly mentioned and their relevance for the clinical situation is critically discussed. CONCLUSION Glucuronide metabolites can have indirect as well as direct pharmacological or toxicological effects. Although convincing evidence to support the introduction of glucuronide monitoring into clinical practice is currently missing, measurement of glucuronide concentrations may be advantageous in specific situations. If the glucuronide metabolite has an indirect effect on the pharmacokinetics of the parent compound, monitoring of the parent drug may be considered. Furthermore pharmacogenetic approaches considering uridine diphosphate (UDP) glucuronosyltransferases polymorphisms may become useful in the future to optimize therapy with drugs subject to glucuronidation.
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Affiliation(s)
- Maria Shipkova
- Department of Clinical Chemistry and Laboratory Medicine, Klinikum Stuttgart, Stuttgart, Germany.
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Zelcer N, van de Wetering K, Hillebrand M, Sarton E, Kuil A, Wielinga PR, Tephly T, Dahan A, Beijnen JH, Borst P. Mice lacking multidrug resistance protein 3 show altered morphine pharmacokinetics and morphine-6-glucuronide antinociception. Proc Natl Acad Sci U S A 2005; 102:7274-9. [PMID: 15886284 PMCID: PMC1091780 DOI: 10.1073/pnas.0502530102] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Glucuronidation is a major detoxification pathway for endogenous and exogenous compounds in mammals that results in the intracellular formation of polar metabolites, requiring specialized transporters to cross biological membranes. By using morphine as a model aglycone, we demonstrate that multidrug resistance protein 3 (MRP3/ABCC3), a protein present in the basolateral membrane of polarized cells, transports morphine-3-glucuronide (M3G) and morphine-6-glucuronide in vitro. Mrp3(-/-) mice are unable to excrete M3G from the liver into the bloodstream, the major hepatic elimination route for this drug. This results in increased levels of M3G in liver and bile, a 50-fold reduction in the plasma levels of M3G, and in a major shift in the main disposition route for morphine and M3G, predominantly via the urine in WT mice but via the feces in Mrp3(-/-) mice. The pharamacokinetics of injected morphine-glucuronides are altered as well in the absence of Mrp3, and this results in a decreased antinociceptive potency of injected morphine-6-glucuronide.
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Affiliation(s)
- Noam Zelcer
- Division of Molecular Biology and Center of Biomedical Genetics, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Abstract
This paper is the 26th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2003 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology, Doctoral Sub-Program, Queens College, City University of New York, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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Klepstad P, Rakvåg TT, Kaasa S, Holthe M, Dale O, Borchgrevink PC, Baar C, Vikan T, Krokan HE, Skorpen F. The 118 A > G polymorphism in the human mu-opioid receptor gene may increase morphine requirements in patients with pain caused by malignant disease. Acta Anaesthesiol Scand 2004; 48:1232-9. [PMID: 15504181 DOI: 10.1111/j.1399-6576.2004.00517.x] [Citation(s) in RCA: 269] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dispositions for genes encoding opioid receptors may explain some variability in morphine efficacy. Experimental studies show that morphine and morphine-6-glucuronide are less effective in individuals carrying variant alleles caused by the 118 A > G polymorphism in the mu-opioid receptor gene (OPRM1). The purpose of the study was to investigate whether this and other genetic polymorphisms in OPRM1 influence the efficacy of morphine in cancer pain patients. METHODS We screened 207 cancer pain patients on oral morphine treatment for four frequent OPRM1 gene polymorphisms. The polymorphisms were the -172 G > T polymorphism in the 5'untranslated region of exon 1, the 118 A > G polymorphism in exon 1, and the IVS2 + 31 G > A and IVS2 + 691 G > C polymorphisms, both in intron 2. Ninety-nine patients with adequately controlled pain were included in an analysis comparing morphine doses and serum concentrations of morphine and morphine metabolites in the different genotypes for the OPRM1 polymorphisms. RESULTS No differences related to the -172 G > T, the IVS2 + 31 G > A and the IVS2 + 691 G > C polymorphisms were observed. Patients homozygous for the variant G allele of the 118 A > G polymorphism (n = 4) needed more morphine to achieve pain control, compared to heterozygous (n = 17) and homozygous wild-type (n = 78) individuals. This difference was not explained by other factors such as duration of morphine treatment, performance status, time since diagnosis, time until death, or adverse symptoms. CONCLUSION Patients homozygous for the 118 G allele of the mu-opioid receptor need higher morphine doses to achieve pain control. Thus, genetic variation at the gene encoding the mu-opioid receptor contributes to variability in patients' responses to morphine.
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MESH Headings
- Aged
- Alleles
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Dose-Response Relationship, Drug
- Female
- Genetic Testing
- Genotype
- Humans
- Male
- Middle Aged
- Morphine/administration & dosage
- Morphine/adverse effects
- Morphine/therapeutic use
- Morphine Derivatives/blood
- Neoplasms/complications
- Neoplasms/genetics
- Neoplasms/pathology
- Pain Measurement/drug effects
- Pain, Intractable/drug therapy
- Pain, Intractable/genetics
- Polymorphism, Genetic
- Quality of Life
- Receptors, Opioid, mu/genetics
- Receptors, Opioid, mu/physiology
- Reverse Transcriptase Polymerase Chain Reaction
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Affiliation(s)
- P Klepstad
- Institute of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
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Klepstad P, Hilton P, Moen J, Kaasa S, Borchgrevink PC, Zahlsen K, Dale O. Day-to-day variations during clinical drug monitoring of morphine, morphine-3-glucuronide and morphine-6-glucuronide serum concentrations in cancer patients. A prospective observational study. BMC CLINICAL PHARMACOLOGY 2004; 4:7. [PMID: 15461818 PMCID: PMC526195 DOI: 10.1186/1472-6904-4-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Accepted: 10/04/2004] [Indexed: 11/23/2022]
Abstract
Background The feasibility of drug monitoring of serum concentrations of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) during chronic morphine therapy is not established. One important factor relevant to drug monitoring is to what extent morphine, M6G and M3G serum concentrations fluctuate during stable morphine treatment. Methods We included twenty-nine patients admitted to a palliative care unit receiving oral morphine (n = 19) or continuous subcutaneous (sc) morphine infusions (n = 10). Serum concentrations of morphine, M6G and M3G were obtained at the same time on four consecutive days. If readmitted, the patients were followed for another trial period. Day-to-day variations in serum concentrations and ratios were determined by estimating the percent coefficient of variation (CV = (mean/SD) ×100). Results The patients' median morphine doses were 90 (range; 20–1460) mg/24 h and 135 (range; 30–440) mg/24 h during oral and sc administration, respectively. Intraindividual fluctuations of serum concentrations estimated by median coefficients of day-to-day variation were in the oral group for morphine 46%, for M6G 25% and for M3G 18%. The median coefficients of variation were lower in patients receiving continuous sc morphine infusions (morphine 10%, M6G 13%, M3G 9%). Conclusion These findings indicate that serum concentrations of morphine and morphine metabolites fluctuate. The fluctuations found in our study are not explained by changes in morphine doses, administration of other drugs or by time for collection of blood samples. As expected the day-to-day variation was lower in patients receiving continuous sc morphine infusions compared with patients receiving oral morphine.
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Affiliation(s)
- Pål Klepstad
- Department of Circulation and Imaging, Faculty of Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway
| | - Priscilla Hilton
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jorunn Moen
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Petter C Borchgrevink
- Department of Circulation and Imaging, Faculty of Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway
| | - Kolbjørn Zahlsen
- Department of Clinical Pharmacology, St. Olavs University Hospital, Trondheim, Norway
| | - Ola Dale
- Department of Circulation and Imaging, Faculty of Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway
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Klepstad P, Borchgrevink PC, Dale O, Zahlsen K, Aamo T, Fayers P, Fougner B, Kaasa S. Routine drug monitoring of serum concentrations of morphine, morphine-3-glucuronide and morphine-6-glucuronide do not predict clinical observations in cancer patients. Palliat Med 2003; 17:679-87. [PMID: 14694919 DOI: 10.1191/0269216303pm835oa] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The clinical importance of routine drug monitoring of serum concentrations of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) during chronic morphine therapy is not established. We measured morphine, M6G and M3G serum concentrations in cancer pain patients receiving oral (n = 263, median dose 80 mg/24 hours) or subcutaneous (sc) (n = 35, median dose 110 mg/24 hours) morphine. Regression analyses were performed to investigate if serum concentrations of morphine, M3G and M6G predicted pain intensity (Brief Pain Inventory), health-related quality-of-life variables (EORTC QLQ-C30) and cognitive function (Mini-Mental Score). Serum concentrations were also compared in patients categorized as morphine 'treatment successes' and 'treatment failures'. We observed that serum concentrations of morphine, M6G or M3G did not predict pain intensity, cognitive function, nausea or tiredness. 'Treatment failures' caused by nausea, tiredness, cognitive failure or constipation did not have statistically significant different morphine, M6G and M3G serum concentrations than patients classified as 'treatment successes'. In conclusion, this study did not observe any concentration-effect relationships of morphine, M3G or M6G with pain intensity, nausea, constipation, tiredness or cognitive failure in blood samples obtained during routine clinical drug monitoring in cancer patients. This result suggests that therapeutic drug monitoring as a routine tool during chronic morphine treatment has limited value for clinical decision making.
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Affiliation(s)
- Pål Klepstad
- Department of Anaesthesia and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
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