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Yue TM, Sun BJ, Xu N, Ohkuma R, Fowler C, Lee B. Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). Ann Surg Oncol 2024; 31:3769-3777. [PMID: 38466484 DOI: 10.1245/s10434-024-15120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/14/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center. METHODS A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs). RESULTS A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012). CONCLUSIONS ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.
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Affiliation(s)
- Tiffany M Yue
- Stanford University School of Medicine, Stanford, USA
| | - Beatrice J Sun
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - Nova Xu
- Stanford University School of Medicine, Stanford, USA
| | - Rika Ohkuma
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - Cedar Fowler
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, USA
| | - Byrne Lee
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Stanford, USA.
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Mehta P, Soliman A, Rodriguez-Vera L, Schmidt S, Muniz P, Rodriguez M, Forcadell M, Gonzalez-Perez E, Vozmediano V. Interspecies Brain PBPK Modeling Platform to Predict Passive Transport through the Blood-Brain Barrier and Assess Target Site Disposition. Pharmaceutics 2024; 16:226. [PMID: 38399280 PMCID: PMC10892872 DOI: 10.3390/pharmaceutics16020226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
The high failure rate of central nervous system (CNS) drugs is partly associated with an insufficient understanding of target site exposure. Blood-brain barrier (BBB) permeability evaluation tools are needed to explore drugs' ability to access the CNS. An outstanding aspect of physiologically based pharmacokinetic (PBPK) models is the integration of knowledge on drug-specific and system-specific characteristics, allowing the identification of the relevant factors involved in target site distribution. We aimed to qualify a PBPK platform model to be used as a tool to predict CNS concentrations when significant transporter activity is absent and human data are sparse or unavailable. Data from the literature on the plasma and CNS of rats and humans regarding acetaminophen, oxycodone, lacosamide, ibuprofen, and levetiracetam were collected. Human BBB permeability values were extrapolated from rats using inter-species differences in BBB surface area. The percentage of predicted AUC and Cmax within the 1.25-fold criterion was 85% and 100% for rats and humans, respectively, with an overall GMFE of <1.25 in all cases. This work demonstrated the successful application of the PBPK platform for predicting human CNS concentrations of drugs passively crossing the BBB. Future applications include the selection of promising CNS drug candidates and the evaluation of new posologies for existing drugs.
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Affiliation(s)
- Parsshava Mehta
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (P.M.); (A.S.); (S.S.)
| | - Amira Soliman
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (P.M.); (A.S.); (S.S.)
- Department of Pharmacy Practice, Faculty of Pharmacy, Helwan University, Helwan 11795, Egypt
| | - Leyanis Rodriguez-Vera
- Model Informed Development, CTI Laboratories, Covington, KY 41011, USA; (L.R.-V.); (P.M.); (M.R.)
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (P.M.); (A.S.); (S.S.)
| | - Paula Muniz
- Model Informed Development, CTI Laboratories, Covington, KY 41011, USA; (L.R.-V.); (P.M.); (M.R.)
| | - Monica Rodriguez
- Model Informed Development, CTI Laboratories, Covington, KY 41011, USA; (L.R.-V.); (P.M.); (M.R.)
| | - Marta Forcadell
- Neuraxpharm Pharmaceuticals SL, Clinical Research and Evidence-Generation Science, 08970 Barcelona, Spain; (M.F.); (E.G.-P.)
| | - Emili Gonzalez-Perez
- Neuraxpharm Pharmaceuticals SL, Clinical Research and Evidence-Generation Science, 08970 Barcelona, Spain; (M.F.); (E.G.-P.)
| | - Valvanera Vozmediano
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (P.M.); (A.S.); (S.S.)
- Model Informed Development, CTI Laboratories, Covington, KY 41011, USA; (L.R.-V.); (P.M.); (M.R.)
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Marie N, Noble F. Oxycodone, an opioid like the others? Front Psychiatry 2023; 14:1229439. [PMID: 38152360 PMCID: PMC10751306 DOI: 10.3389/fpsyt.2023.1229439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/28/2023] [Indexed: 12/29/2023] Open
Abstract
The over-prescription of opioid analgesics is a growing problem in the field of addiction, which has reached epidemic-like proportions in North America. Over the past decade, oxycodone has gained attention as the leading opioid responsible for the North America opioid crisis. Oxycodone is the most incriminated drug in the early years of the epidemic of opioid use disorder in USA (roughly 1999-2016). The number of preclinical articles on oxycodone is rapidly increasing. Several publications have already compared oxycodone with other opioids, focusing mainly on their analgesic properties. The aim of this review is to focus on the genomic and epigenetic regulatory features of oxycodone compared with other opioid agonists. Our aim is to initiate a discussion of perceptible differences in the pharmacological response observed with these various opioids, particularly after repeated administration in preclinical models commonly used to study drug dependence potential.
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Affiliation(s)
| | - Florence Noble
- Université Paris Cité, CNRS, Inserm, Pharmacologie et Thérapies des Addictions, Paris, France
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Bällgren F, Hammarlund-Udenaes M, Loryan I. Active Uptake of Oxycodone at Both the Blood-Cerebrospinal Fluid Barrier and The Blood-Brain Barrier without Sex Differences: A Rat Microdialysis Study. Pharm Res 2023; 40:2715-2730. [PMID: 37610619 PMCID: PMC10733202 DOI: 10.1007/s11095-023-03583-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Oxycodone active uptake across the blood-brain barrier (BBB) is associated with the putative proton-coupled organic cation (H+/OC) antiporter system. Yet, the activity of this system at the blood-cerebrospinal fluid barrier (BCSFB) is not fully understood. Additionally, sex differences in systemic pharmacokinetics and pharmacodynamics of oxycodone has been reported, but whether the previous observations involve sex differences in the function of the H+/OC antiporter system remain unknown. The objective of this study was, therefore, to investigate the extent of oxycodone transport across the BBB and the BCSFB in female and male Sprague-Dawley rats using microdialysis. METHODS Microdialysis probes were implanted in the blood and two of the following brain locations: striatum and lateral ventricle or cisterna magna. Oxycodone was administered as an intravenous infusion, and dialysate, blood and brain were collected. Unbound partition coefficients (Kp,uu) were calculated to understand the extent of oxycodone transport across the blood-brain barriers. Non-compartmental analysis was conducted using Phoenix 64 WinNonlin. GraphPad Prism version 9.0.0 was used to perform t-tests, one-way and two-way analysis of variance followed by Tukey's or Šídák's multiple comparison tests. Differences were considered significant at p < 0.05. RESULTS The extent of transport at the BBB measured in striatum was 4.44 ± 1.02 (Kp,uu,STR), in the lateral ventricle 3.41 ± 0.74 (Kp,uu,LV) and in cisterna magna 2.68 ± 1.01 (Kp,uu,CM). These Kp,uu values indicate that the extent of oxycodone transport is significantly lower at the BCSFB compared with that at the BBB, but still confirm the presence of active uptake at both blood-brain interfaces. No significant sex differences were observed in neither the extent of oxycodone delivery to the brain, nor in the systemic pharmacokinetics of oxycodone. CONCLUSIONS The findings clearly show that active uptake is present at both the BCSFB and the BBB. Despite some underestimation of the extent of oxycodone delivery to the brain, CSF may be an acceptable surrogate of brain ISF for oxycodone, and potentially also other drugs actively transported into the brain via the H+/OC antiporter system.
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Affiliation(s)
- Frida Bällgren
- Translational Pharmacokinetics/Pharmacodynamics group (tPKPD), Department of Pharmacy, Uppsala University, Box 580, 75123, Uppsala, Sweden.
| | - Margareta Hammarlund-Udenaes
- Translational Pharmacokinetics/Pharmacodynamics group (tPKPD), Department of Pharmacy, Uppsala University, Box 580, 75123, Uppsala, Sweden
| | - Irena Loryan
- Translational Pharmacokinetics/Pharmacodynamics group (tPKPD), Department of Pharmacy, Uppsala University, Box 580, 75123, Uppsala, Sweden.
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Piirainen P, Kokki H, Kokki M. Epidural Oxycodone for Acute Pain. Pharmaceuticals (Basel) 2022; 15:643. [PMID: 35631469 PMCID: PMC9144954 DOI: 10.3390/ph15050643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 02/01/2023] Open
Abstract
Epidural analgesia is commonly used in labour analgesia and in postoperative pain after major surgery. It is highly effective in severe acute pain, has minimal effects on foetus and newborn, may reduce postoperative complications, and enhance patient satisfaction. In epidural analgesia, low concentrations of local anaesthetics are combined with opioids. Two opioids, morphine and sufentanil, have been approved for epidural use, but there is an interest in evaluating other opioids as well. Oxycodone is one of the most commonly used opioids in acute pain management. However, data on its use in epidural analgesia are sparse. In this narrative review, we describe the preclinical and clinical data on epidural oxycodone. Early data from the 1990s suggested that the epidural administration of oxycodone may not offer any meaningful benefits over intravenous administration, but more recent clinical data show that oxycodone has advantageous pharmacokinetics after epidural administration and that epidural administration is more efficacious than intravenous administration. Further studies are needed on the safety and efficacy of continuous epidural oxycodone administration and its use in epidural admixture.
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Affiliation(s)
- Panu Piirainen
- Department of Anesthesiology, Surgery and Intensive Care, Oulu University Hospital, 90220 Oulu, Finland;
| | - Hannu Kokki
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, 70210 Kuopio, Finland;
| | - Merja Kokki
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, 70210 Kuopio, Finland
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Xie K, Wang YL, Teng WB, He R, Li YH, Huang SQ. The Median Effective Concentration (EC 50) of Epidural Ropivacaine With Different Doses of Oxycodone During Limb Surgery in Elderly Patients. Front Med (Lausanne) 2022; 8:808850. [PMID: 35127764 PMCID: PMC8814631 DOI: 10.3389/fmed.2021.808850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/23/2021] [Indexed: 01/03/2023] Open
Abstract
Background Oxycodone can be used both intravenously and epidurally in elderly patients because of its strong analgesic effect and more slight respiratory inhibition compared with other opioids at the same effect. In this study, we determined the median effective concentration (EC50) of epidural ropivacaine required for great saphenous vein surgery in elderly patients in order to describe its pharmacodynamic interaction with oxycodone. Methods One hundred forty-one elderly patients scheduled for high ligation and stripping of the great saphenous vein surgery were allocated into three groups in a randomized, double-blinded manner as follows: Q2.5 group (2.5 mg oxycodone), Q5.0 group (5.0 mg oxycodone), and C group (normal saline). Anesthesia, was achieved with epidural ropivacaine and oxycodone. The EC50 of ropivacaine for surgery with different doses of oxycodone was adjusted by using an up-and-down sequential methods with an adjacent concentration gradient at a factor of 0.9 to inhibit analgesia. Anesthesia associated adverse events and recovery, characteristics were also recorded. Results The EC50 of ropivacaine for the great saphenous vein surgery in elderly patients was 0.399% (95% CI, 0.371–0.430%) in the Q2.5 group, 0.396% (95% CI, 0.355–0.441%) in the Q5.0 group, and 0.487% (95% CI, 0.510–0.465%) in the C group, respectively (P < 0.05). Specially, the EC50 of ropivacaine in the Q2.5 and Q5.0 groups was lower than that in the C group (P < 0.01), But the difference between the Q2.5 group and the Q5.0 group was not significant (P > 0.05). There was no significant difference in the Bromage score from the motor block examination, heart rate (HR) or mean arterial pressure (MAP) at each observation time point after epidural administration among the three groups (P > 0.05). No serious adverse reactions occurred in any of the three groups. Conclusion Oxycodone combined with ropivacaine epidural anesthesia can reduce the EC50 of ropivacaine required for elderly patients undergoing the great saphenous vein surgery. There was no significant difference in anesthesia associated adverse events among the three groups. The recommended dose of oxycodone is 2.5 mg.
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Affiliation(s)
- Kai Xie
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, China
| | - Yu-Long Wang
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, China
| | - Wen-Bin Teng
- Department of Anesthesiology, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China
| | - Rui He
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, China
| | - Yu-Hong Li
- Department of Anesthesiology, Shulan (Hangzhou) Hospital, Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
| | - Su-Qin Huang
- Department of Anesthesiology, Shulan (Hangzhou) Hospital, Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
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Morse JD, Sundermann M, Hannam JA, Kokki H, Kokki M, Anderson BJ. Population pharmacokinetics of oxycodone: Premature neonates to adults. Paediatr Anaesth 2021; 31:1332-1339. [PMID: 34469607 DOI: 10.1111/pan.14283] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/18/2021] [Accepted: 08/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Oxycodone is used in children and adults for the control of acute postoperative pain. Covariate influences such as age, size, and fat mass on oxycodone pharmacokinetic parameters over the human lifespan are poorly quantified. METHODS Pooled oxycodone time-concentration profiles were available from preterm neonates to adults. Data from intravenous, intramuscular, buccal, and epidural formulations were analyzed using nonlinear mixed-effects models. Normal fat mass was used to determine the influence of fat on oxycodone pharmacokinetics. Theory-based allometry was used to scale pharmacokinetic parameters to a 70 kg individual. A maturation function described the increase in clearance in neonates and infants. RESULTS There were 237 subjects (24 weeks postmenstrual age to 75 years; 0.44-110 kg) providing 1317 plasma concentrations. A three-compartment model with first-order elimination best described oxycodone disposition. Population parameter estimates were clearance (CL) 48.6 L.h-1 .70 kg-1 (CV 71%); intercompartmental clearances (Q2) 220 L.h-1 .70 kg-1 (CV 64%); Q3 1.45 L.h-1 .70 kg-1 ; volume of distribution in the central compartment (V1) 98.2 L.70 kg-1 (CV 76%); rapidly equilibrating peripheral compartment (V2) 90.1 L. 70 kg-1 (CV 76%); slow equilibrating peripheral compartment (V3) 28.9 L.70 kg-1 . Total body weight was the best size descriptor for clearances and volumes. Absorption halftimes (TABS ) were: 1.1 minutes for intramuscular, 70 minutes for epidural, 82 minutes for nasogastric, and 159.6 minutes for buccal administration routes. The relative bioavailability after nasogastric administration was 0.673 with a lag time of 8.7 minutes. CONCLUSIONS Clearance matured with age; 8% of the typical adult value at 24 weeks postmenstrual age, 33% in a term neonate and reached 90% of the adult clearance value by the end of the first year of life. Allometric scaling using total body weight was the better size descriptor of oxycodone clearance than fat-free mass.
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Affiliation(s)
- James D Morse
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Milan Sundermann
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland, Auckland, New Zealand
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Merja Kokki
- Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - Brian J Anderson
- Department of Anaesthesiology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
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Differences in P-glycoprotein activity in human and rodent blood-brain barrier assessed by mechanistic modelling. Arch Toxicol 2021; 95:3015-3029. [PMID: 34268580 PMCID: PMC8380243 DOI: 10.1007/s00204-021-03115-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022]
Abstract
Variation in the efficacy and safety of central nervous system drugs between humans and rodents can be explained by physiological differences between species. An important factor could be P-glycoprotein (Pgp) activity in the blood–brain barrier (BBB), as BBB expression of this drug efflux transporter is reportedly lower in humans compared to mouse and rat and subject to an age-dependent increase. This might complicate animal to human extrapolation of brain drug disposition and toxicity, especially in children. In this study, the potential species-specific effect of BBB Pgp activity on brain drug exposure was investigated. An age-dependent brain PBPK model was used to predict cerebrospinal fluid and brain mass concentrations of Pgp substrate drugs. For digoxin, verapamil and quinidine, in vitro kinetic data on their transport by Pgp were derived from literature and used to scale to in vivo parameters. In addition, age-specific digoxin transport was simulated for children with a postnatal age between 25 and 81 days. BBB Pgp activity in the model was optimized using measured CSF data for the Pgp substrates ivermectin, indinavir, vincristine, docetaxel, paclitaxel, olanzapine and citalopram, as no useful in vitro data were available. Inclusion of Pgp activity in the model resulted in optimized predictions of their brain concentration. Total brain-to-plasma AUC values (Kp,brain) in the simulations without Pgp were divided by the Kp,brain values with Pgp. Kp ratios ranged from 1 to 45 for the substrates investigated. Comparison of human with rodent Kp,brain ratios indicated ≥ twofold lower values in human for digoxin, verapamil, indinavir, paclitaxel and citalopram and ≥ twofold higher values for vincristine. In conclusion, BBB Pgp activity appears species-specific. An age-dependent PBPK model-based approach could be useful to extrapolate animal data to human adult and paediatric predictions by taking into account species-specific and developmental BBB Pgp expression.
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Lu CW, Lin TY, Huang SK, Chiu KM, Lee MY, Huang JH, Wang SJ. Inhibition of glutamatergic transmission and neuronal excitability by oxycodone in the rat hippocampal CA3 neurons. Can J Physiol Pharmacol 2021; 99:737-743. [PMID: 33175564 DOI: 10.1139/cjpp-2020-0469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Oxycodone, a semisynthetic opioid analgesic with actions similar to morphine, is extensively prescribed for treatment of moderate to severe acute pain. Given that glutamate plays a crucial role in mediating pain transmission, the purpose of this study was to investigate the effect of oxycodone on glutamatergic synaptic transmission in rat hippocampal CA3 area, which is associated with the modulation of nociceptive perception. Whole-cell patch-clamp recordings revealed that oxycodone effectively reduced presynaptic glutamate release, as detected by decreased frequencies of spontaneous excitatory postsynaptic currents (sEPSCs) and miniature EPSCs (mEPSCs), without eliciting significant changes in the amplitudes of sEPSCs and mEPSCs and glutamate-evoked inward currents. The inhibitory effect of oxycodone on the frequency of sEPSCs was blocked by the nonselective opioid receptor antagonist naloxone. In addition, oxycodone suppressed burst firing induced by 4-aminopyridine and tonic repetitive firing evoked by the applied depolarizing current. These results suggest that oxycodone inhibits spontaneous presynaptic glutamate release possibly by activating opioid receptors and consequently suppressing the neuronal excitability of hippocampal CA3 neurons.
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Affiliation(s)
- Cheng-Wei Lu
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei 22060, Taiwan
- Department of Mechanical Engineering, Yuan Ze University, Taoyuan 32003, Taiwan
| | - Tzu-Yu Lin
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei 22060, Taiwan
- Department of Mechanical Engineering, Yuan Ze University, Taoyuan 32003, Taiwan
| | - Shu-Kuei Huang
- Department of Anesthesiology, Far-Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Kuan-Ming Chiu
- Division of Cardiovascular Surgery, Cardiovascular Center, Far-Eastern Memorial Hospital, New Taipei 22060, Taiwan
- Department of Nursing, Oriental Institute of Technology, New Taipei 22060, Taiwan
- Department of Photonics Engineering, Yuan Ze University, Taoyuan 32003, Taiwan
| | - Ming-Yi Lee
- Division of Cardiovascular Surgery, Cardiovascular Center, Far-Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Jih-Hsin Huang
- Division of Cardiovascular Surgery, Cardiovascular Center, Far-Eastern Memorial Hospital, New Taipei 22060, Taiwan
| | - Su-Jane Wang
- School of Medicine, Fu Jen Catholic University, New Taipei 24205, Taiwan
- Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33303, Taiwan
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Agema BC, Oosten AW, Sassen SD, Rietdijk WJ, van der Rijt CC, Koch BC, Mathijssen RH, Koolen SL. Population Pharmacokinetics of Oxycodone and Metabolites in Patients with Cancer-Related Pain. Cancers (Basel) 2021; 13:cancers13112768. [PMID: 34199534 PMCID: PMC8199682 DOI: 10.3390/cancers13112768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Patients with moderate to severe cancer-related pain are frequently treated with oxycodone, a strong-acting opioid. However, treatment with oxycodone does not always lead to sufficient analgesic action. In order to determine which factors affect treatment outcomes, we performed an observational study and developed a population pharmacokinetic model. The model described oxycodone, nor-oxycodone and nor-oxymorphone pharmacokinetics. The association between oxycodone or oxycodone metabolites’ exposure with pain scores and adverse events was not significant. The combined oxycodone, nor-oxycodone and nor-oxymorphone model is a good starting point for further unravelling the factors that affect the pharmacokinetic/pharmacodynamic relation of oxycodone and its metabolites. Abstract Oxycodone is frequently used for treating cancer-related pain, while not much is known about the factors that influence treatment outcomes in these patients. We aim to unravel these factors by developing a population-pharmacokinetic model to assess the pharmacokinetics of oxycodone and its metabolites in cancer patients, and to associate this with pain scores, and adverse events. Hospitalized patients with cancer-related pain, who were treated with oral oxycodone, could participate. Pharmacokinetic samples and patient-reported pain scores and occurrence and severity of nine adverse events were taken every 12 h. In 28 patients, 302 pharmacokinetic samples were collected. A one-compartment model for oxycodone and each metabolite best described oxycodone, nor-oxycodone, and nor-oxymorphone pharmacokinetics. Furthermore, oxycodone exposure was not associated with average and maximal pain scores, and oxycodone, nor-oxycodone, and nor-oxymorphone exposure were not associated with adverse events (all p > 0.05). This is the first model to describe the pharmacokinetics of oxycodone including the metabolites nor-oxycodone and nor-oxymorphone in hospitalized patients with cancer pain. Additional research, including more patients and a more timely collection of pharmacodynamic data, is needed to further elucidate oxycodone (metabolite) pharmacokinetic/pharmacodynamic relationships. This model is an important starting point for further studies to optimize oxycodone dosing regiments in patients with cancer-related pain.
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Affiliation(s)
- Bram C. Agema
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (A.W.O.); (C.C.D.v.d.R.); (R.H.J.M.); (S.L.W.K.)
- Department of Clinical Pharmacy, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (S.D.T.S.); (W.J.R.R.); (B.C.P.K.)
- Correspondence:
| | - Astrid W. Oosten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (A.W.O.); (C.C.D.v.d.R.); (R.H.J.M.); (S.L.W.K.)
| | - Sebastiaan D.T. Sassen
- Department of Clinical Pharmacy, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (S.D.T.S.); (W.J.R.R.); (B.C.P.K.)
| | - Wim J.R. Rietdijk
- Department of Clinical Pharmacy, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (S.D.T.S.); (W.J.R.R.); (B.C.P.K.)
| | - Carin C.D. van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (A.W.O.); (C.C.D.v.d.R.); (R.H.J.M.); (S.L.W.K.)
| | - Birgit C.P. Koch
- Department of Clinical Pharmacy, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (S.D.T.S.); (W.J.R.R.); (B.C.P.K.)
| | - Ron H.J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (A.W.O.); (C.C.D.v.d.R.); (R.H.J.M.); (S.L.W.K.)
| | - Stijn L.W. Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (A.W.O.); (C.C.D.v.d.R.); (R.H.J.M.); (S.L.W.K.)
- Department of Clinical Pharmacy, Erasmus University Medical Center, dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands; (S.D.T.S.); (W.J.R.R.); (B.C.P.K.)
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Intranasal Fentanyl for Intervention-Associated Breakthrough Pain After Cardiac Surgery. Clin Pharmacokinet 2021; 60:907-919. [PMID: 33686630 PMCID: PMC8249268 DOI: 10.1007/s40262-021-01002-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/29/2022]
Abstract
Background Cardiac bypass surgery patients have early postoperative interventions that elicit breakthrough pain. We evaluated the use of intranasal fentanyl for breakthrough pain management in these patients. Methods Multimodal analgesia (paracetamol 1 g three times a day, oxycodone 2–3 mg boluses with a patient-controlled intravenous pump) was used in 16 patients (age 49–70 years, weight 59–129 kg) after cardiac bypass surgery. Intranasal fentanyl 100 µg or 200 µg was used to manage breakthrough pain on the first and third postoperative mornings in a randomised order. Blood samples were collected for up to 3 h after fentanyl administration, pain was assessed with a numeric rating scale of 0–10. Plasma fentanyl concentration was assayed using liquid chromatography-mass spectrometry. Body composition was measured with a bioelectrical impedance device. Results Bioavailability of intranasal fentanyl was high (77%), absorption half-time short (< 2 min) and an analgesic plasma concentration ≥ 0.5 ng/mL was achieved in 31 of 32 administrations. Fentanyl exposure correlated inversely with skeletal muscle mass and total body water. Fentanyl analgesia was effective both on the first postoperative morning with chest pleural tube removal and during physiotherapy on the third postoperative morning. The median time of subsequent oxycodone administration was 1.1 h after intranasal fentanyl 100 µg and 2.1 h after intranasal fentanyl 200 µg, despite similar oxycodone concentrations (median 13.8, range 5.2–35 ng/mL) in both fentanyl dose groups. Conclusions Intranasal fentanyl 100 µg provided rapid-onset analgesia within 10 min and is an appropriate starting dose for incidental breakthrough pain in the first 3 postoperative days after cardiac bypass surgery. Clinical Trial Registration EudraCT Number: 2018-001280-22. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01002-4.
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12
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Oxycodone attenuates vascular leak and lung inflammation in a clinically relevant two-hit rat model of acute lung injury. Cytokine 2020; 138:155346. [PMID: 33187816 DOI: 10.1016/j.cyto.2020.155346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Oxycodone is a synthetic opioid receptor agonist that exerts antinociceptive activity via κ-, μ- and δ-opioid receptors (KOR, MOR and DOR, respectively). Activation of MOR has been reported to provide protection against acute lung injury (ALI). We hypothesized that pretreatment with oxycodone would attenuate lung injury at the level of alveolar tight junctions (TJs) and aquaporins (AQPs) and investigated this possibility in a two-hit model of ALI induced by lipopolysaccharide (LPS) and mechanical ventilation (MV). METHOD Male Sprague Dawley rats and A59 cells were divided into 6 groups: the control group, ALI group, oxycodone-pretreated group, and oxycodone/κ-, μ-, or δ-opioid receptor antagonist-pretreated groups. The rats were pretreated with oxycodone 30 min before intravenous injection of LPS and then allowed to recover for 24 h prior to MV, establishing a two-hit model of ALI. The cells were similarly treated with oxycodone (with or without antagonists) 30 min after exposure to lipopolysaccharide. The cells were cyclically stretched 24 h later to mirror the in vivo MV protocol. RESULTS Oxycodone alleviated the histological lung changes in the rats with ALI and decreased pulmonary microvascular permeability both in vivo and in vitro. Oxycodone upregulated the expression of claudin-5, ZO-1, AQP1, and AQP5 but downregulated the expression of TNF-α, IL-1β, TLR4, NF-κB, MMP9, and caspase-3 and suppressed endothelial apoptosis in vivo and in vitro. These protective effects of oxycodone were partly eliminated by KOR and MOR antagonists but not by DOR antagonists. CONCLUSION Oxycodone pretreatment appears to act via κ- and μ-opioid receptors to ameliorate LPS- and MV-induced lung injury by suppressing inflammation and apoptosis, and this protective effect might be mediated through the inhibition of the TLR4/NF-κB pathways.
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13
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Dang SJ, Li RL, Wang J, Zeng WB, He Y, Yue HY, Li SY, Han LC. Oxycodone vs Sufentanil in Patient-Controlled Intravenous Analgesia After Gynecological Tumor Operation: A Randomized Double-Blind Clinical Trial. J Pain Res 2020; 13:937-946. [PMID: 32440199 PMCID: PMC7211314 DOI: 10.2147/jpr.s236933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Abstract
Background This study aims to compare analgesic effect and side effects of oxycodone and sufentanil in transition analgesia and patient-controlled intravenous analgesia (PCIA) after gynecological tumor operation under general anesthesia. Patients and Methods A prospective, randomized, double-blind research was conducted. Patients undergoing elective gynecological tumor surgery were randomized into four groups: Group S (sufentanil transition analgesia and sufentanil PCIA), Group OS (oxycodone transition analgesia and sufentanil PCIA), Group SO (sufentanil transition analgesia and oxycodone PCIA) and Group O (oxycodone transition analgesia and oxycodone PCIA). The primary outcomes were Numerical Rating Scale (NRS) at rest and coughing, accumulated opioid consumption in PCIA and patients’ satisfaction. Results Patients in Group OS and Group O showed shorter time of consciousness recovery and extubation after surgery. Accumulated opioid consumption in PCIA (equal to morphine) in Group SO and Group O was significantly less than that in Group S and Group OS. Patients in Group O showed lower NRS at rest and coughing, but higher patients’ satisfaction 3, 24 and 48 hours after surgery. Patients in Group SO and Group O showed a shorter time of intestinal recovery, first feeding and first-time movement. Conclusion Both oxycodone and sufentanil provided adequate pain relief in transitional analgesia and PCIA treatment after surgery. Oxycodone without background infusion showed less analgesic drug consumption and faster recovery than sufentanil with background infusion in PCIA after gynecological tumor operation under general anesthesia.
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Affiliation(s)
- Sha-Jie Dang
- Department of Anesthesia, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, People's Republic of China.,The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Rui-Li Li
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Jun Wang
- Department of Anesthesia, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Wen-Bin Zeng
- Department of Anesthesia, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Yun He
- Department of Anesthesia, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Hui-Yu Yue
- Department of Anesthesia, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Si-Yuan Li
- Department of Anesthesia, The Second Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Li-Chun Han
- The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China.,Department of Anesthesia, Xi'an Daxing Hospital, Xi'an, Shaanxi, People's Republic of China
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14
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Kinnunen M, Kokki H, Hautajärvi H, Tuovinen K, Kokki M. Oxycodone for pain management in the latent phase of labour - A pragmatic trial. Acta Anaesthesiol Scand 2020; 64:685-690. [PMID: 31950485 DOI: 10.1111/aas.13550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/22/2019] [Accepted: 01/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Parenteral opioids are used for pain relief in labour but there are little data for oxycodone in this context. The aim of this study was to evaluate the efficacy, foetal exposure and safety of subcutaneous oxycodone in the latent phase of labour. METHODS This pragmatic trial included 76 parturients, who received subcutaneous oxycodone for pain relief in the latent phase of labour according to the hospital protocol: an initial dose 0.1 mg/kg, and a second dose, 0.05 mg/kg, could be administered four hours later. Pain intensity and pain relief were assessed using a numerical rating scale of 0-10. After delivery, blood samples from the maternal and umbilical veins were collected, and plasma concentrations of oxycodone and its main metabolites were quantified using UPLC-MS/MS. The Apgar scores and maternal and neonatal adverse effects were recorded. RESULTS The foetal exposure at birth was low, the median oxycodone and oxymorphone umbilical vein plasma concentrations were 1.2 ng/mL (range 0.21-7.8) and 0.14 ng/mL (0-0.26), respectively. Pain scores decreased substantially, from a median pain score of 7/10 before oxycodone to median scores of 5/10 at 30 minutes after administration, 5/10 at 60 minutes and 6/10 at 120 minutes. The median Apgar score was 9 (range 2-10) at 1 minute and 9 (6-10) at 5 minutes. Maternal adverse effects were mild, and there were no oxycodone-related neonatal adverse effects. CONCLUSION Subcutaneous oxycodone provided effective analgesia during the latent phase of labour. Newborn exposure at birth was low, and oxycodone was well-tolerated.
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Affiliation(s)
- Mari Kinnunen
- School of Medicine University of Eastern Finland Kuopio Finland
| | - Hannu Kokki
- School of Medicine University of Eastern Finland Kuopio Finland
| | | | - Kaisa Tuovinen
- School of Medicine University of Eastern Finland Kuopio Finland
| | - Merja Kokki
- Department of Anaesthesia and Intensive Care Kuopio University Hospital Kuopio Finland
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15
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Rytkönen J, Ranta VP, Kokki M, Kokki H, Hautajärvi H, Rinne V, Heikkinen AT. Physiologically based pharmacokinetic modelling of oxycodone drug-drug interactions. Biopharm Drug Dispos 2020; 41:72-88. [PMID: 31925778 DOI: 10.1002/bdd.2215] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/02/2020] [Accepted: 01/08/2020] [Indexed: 02/01/2023]
Abstract
Oxycodone is an opioid analgesic with several pharmacologically active metabolites and relatively narrow therapeutic index. Cytochrome P450 (CYP) 3A4 and CYP2D6 play major roles in the metabolism of oxycodone and its metabolites. Thus, inhibition and induction of these enzymes may result in substantial changes in the exposure of both oxycodone and its metabolites. In this study, a physiologically based pharmacokinetic (PBPK) model was built using GastroPlus™ software for oxycodone, two primary metabolites (noroxycodone, oxymorphone) and one secondary metabolite (noroxymorphone). The model was built based on literature and in house in vitro and in silico data. The model was refined and verified against literature clinical data after oxycodone administration in the absence of drug-drug interactions (DDI). The model was further challenged with simulations of oxycodone DDI with CYP3A4 inhibitors ketoconazole and itraconazole, CYP3A4 inducer rifampicin and CYP2D6 inhibitor quinidine. The magnitude of DDI (AUC ratio) was predicted within 1.5-fold error for oxycodone, within 1.8-fold and 1.3-4.5-fold error for the primary metabolites noroxycodone and oxymorphone, respectively, and within 1.4-4.5-fold error for the secondary metabolite noroxymorphone, when compared to the mean observed AUC ratios. This work demonstrated the capability of PBPK model to simulate DDI of the administered compounds and the formed metabolites of both DDI victim and perpetrator. However, the predictions for the formed metabolites tend to be associated with higher uncertainty than the predictions for the administered compound. The oxycodone model provides a tool for forecasting oxycodone DDI with other CYP3A4 and CYP2D6 DDI perpetrators that may be co-administered with oxycodone.
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Affiliation(s)
- Jaana Rytkönen
- Admescope Ltd, Oulu, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Merja Kokki
- Anesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
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16
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Luo Z, Miao J, Shu S, Wang Y, Zhu X, Hu C, Shen Y. Pharmacokinetics and Bioequivalence Evaluation of a New Oxycodone Tamper-Resistant Tablet Administered with an Opioid Antagonist in Patients with Chronic Pain. Clin Drug Investig 2019; 40:139-148. [PMID: 31679120 DOI: 10.1007/s40261-019-00870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Oxycodone tamper resistant (OTR) is a new extended-release abuse-deterrent formulation providing improvements in the tamper resistant characteristics. This study aimed to investigate the pharmacokinetic properties of the new OTR tablets and evaluate the bioequivalence of oxycodone from OTR and the original extended release (ER) formulation tablets administered with an opioid antagonist in patients with chronic pain. METHODS In this open-label, randomized, cross-over study, the enrolled patients were randomised to receive a single dose of 40 mg OTR or 40 mg OXYCONTIN® (OXY) tablet administered with naltrexone blockade under fasting conditions. Serial blood samples for pharmacokinetic analysis were collected. Plasma oxycodone was quantified by a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method. Tolerability was evaluated by monitoring adverse events, physical examinations, 12-lead ECG and laboratory tests. RESULTS A total of 38 patients were enrolled and 33 subjects completed the study. After a single dose of 40 mg tablets, pharmacokinetic results of the new OTR tablet were found to be similar to those of original extended-release oxycodone tablet. OTR 40 mg was bioequivalent to OXY 40 mg and was well tolerated in patients with chronic pain. CONCLUSIONS The new OTR formulation could provide a new choice in the treatment of chronic pain and reduce the potential for oxycodone abuse. Chictr.org identifier: ChiCTR1800017253.
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Affiliation(s)
- Zhu Luo
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jia Miao
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Shiqing Shu
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ying Wang
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xiaohong Zhu
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Chao Hu
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yali Shen
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Kinnunen M, Kokki H, Hautajärvi H, Lantto J, Räsänen J, Voipio HM, Kokki M. Oxycodone concentrations in the central nervous system and cerebrospinal fluid after epidural administration to the pregnant ewe. Basic Clin Pharmacol Toxicol 2019; 125:430-438. [PMID: 31222944 DOI: 10.1111/bcpt.13276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022]
Abstract
The main sites of the analgesic action of oxycodone are the brain and spinal cord. The present study describes the concentrations of oxycodone and its metabolites in the brain and spinal cord after epidural administration to the ewe. Twenty pregnant ewes undergoing laparotomy were randomized into two groups to receive epidural oxycodone: infusion group (n = 10, 0.1 mg·kg-1 bolus followed by continuous infusion of 0.05 mg·kg-1 ·h-1 for five days) or repeated boluses group (n = 10, 0.2 + 2x0.1 mg·kg-1 bolus followed by a 0.2 mg·kg-1 bolus every 12 hours for five days). After five days of oxycodone administration, arterial blood samples were collected, the sheep were killed, and a CSF sample and tissue samples from the cortex, thalamus, cerebellum and spinal cord were obtained for the quantification of oxycodone and its main metabolites. The median plasma and CSF concentrations of oxycodone were 9.0 and 14.2 ng·mL-1 after infusion and 0.4 and 1.1 ng·mL-1 after repeated boluses. In the infusion group, the cortex, thalamus and cerebellum oxycodone concentrations were 4-8 times higher and in the spinal cord 1310 times higher than in plasma. In the repeated boluses group, brain tissue concentrations were similar in the three areas, and in the spinal cord were 720 times higher than in plasma. Oxymorphone was the main metabolite detected, which accumulated in the brain and spinal cord tissue. In conclusion, first, accumulation of oxycodone and oxymorphone in the CNS was observed, and second, high spinal cord concentrations suggest that epidural oxycodone may provide segmental analgesia.
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Affiliation(s)
- Mari Kinnunen
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | | | - Juulia Lantto
- Department of Obstetrics and Gynaecology, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juha Räsänen
- Department of Obstetrics and Gynaecology, Oulu University Hospital and University of Oulu, Oulu, Finland.,Department of Obstetrics and Gynaecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna-Marja Voipio
- Laboratory Animal Centre, Department of Experimental Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Merja Kokki
- Department of Anaesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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18
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Piirainen P, Kokki H, Anderson B, Hannam J, Hautajärvi H, Ranta VP, Kokki M. Analgesic efficacy and pharmacokinetics of epidural oxycodone in pain management after gynaecological laparoscopy-A randomised, double blind, active control, double-dummy clinical comparison with intravenous administration. Br J Clin Pharmacol 2019; 85:1798-1807. [PMID: 31026086 DOI: 10.1111/bcp.13971] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 03/26/2019] [Accepted: 04/08/2019] [Indexed: 12/21/2022] Open
Abstract
AIMS Early pain after laparoscopy is often severe. Oxycodone is a feasible analgesic option after laparoscopy, but there are sparse data on epidural administration. The aim was to evaluate the analgesic efficacy and pharmacokinetics of a single dose of epidural oxycodone as a part of multimodal analgesia after gynaecological laparoscopy. METHODS Women (n = 60), aged 23-71 years, undergoing elective gynaecological laparoscopy, were administrated either epidural oxycodone 0.1 mg kg-1 and intravenous (i.v.) saline (EPI-group n = 31), or epidural saline and i.v. oxycodone 0.1 mg kg-1 (IV-group = 29) in a randomised, double blind, active control, double dummy clinical trial. A pharmacokinetic model was developed using population modelling of plasma and cerebrospinal fluid (CSF) concentrations obtained in these patients and data of 2 published studies. The primary outcome was the amount of i.v. fentanyl for rescue analgesia during the first 4 hours. RESULTS Twenty of the 31 patients in the EPI-group and 26 of the 29 patients in the IV-group needed i.v. fentanyl for rescue analgesia, P = .021. The median (interquartile range) number of fentanyl doses were 1.0 (1.0-3.0) in the EPI-group and 2.5 (1.0-4.0) doses in the IV-group, P = .008. Plasma concentrations were similar, but CSF concentrations were 100-fold higher in the EPI-group. The population model indicated that 60% of oxycodone injected into the epidural space enters into CSF and 40% is absorbed into the systemic circulation. CONCLUSIONS The data support superiority of epidural administration of oxycodone compared to i.v. administration during the first hours after laparoscopic surgery. This is likely to be based on enhanced permeation into the central nervous system after epidural administration.
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Affiliation(s)
- Panu Piirainen
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Brian Anderson
- Departments of Anaesthesiology, and Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Jacqueline Hannam
- Departments of Anaesthesiology, and Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | | | - Veli-Pekka Ranta
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Merja Kokki
- Department of Anaesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland
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19
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20
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Lamminsalo M, Piirainen P, Kokki H, Knibbe CAJ, Ranta VP, Välitalo P, Kokki M. Population pharmacokinetics of oxycodone in plasma and cerebrospinal fluid after epidural and intravenous administration. Expert Opin Drug Deliv 2019; 16:649-656. [PMID: 31092024 DOI: 10.1080/17425247.2019.1618267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives: To establish the first plasma and cerebrospinal fluid (CSF) oxycodone population pharmacokinetic (PopPK) model after epidural (EPI) and intravenous (IV) oxycodone administration. Methods: The study was conducted with 30 female subjects undergoing elective gynecological surgery with epidural analgesia. A parallel single dose of EPI oxycodone with IV placebo (EPI group; n = 18) or IV oxycodone with EPI placebo (IV group; n = 12) was administered. An epidural catheter for drug administration was placed at T12/L1 and a spinal catheter for CSF sampling at L3/4. Plasma and CSF for oxycodone analysis were frequently collected. A PopPK model was built using the NONMEM software package. Results: Plasma and CSF oxycodone concentrations were evaluated using separate central plasma and CSF compartments and separate peripheral plasma and CSF compartments. Epidural space served as a depot compartment with transfer to both the plasma and CSF central compartments. The population parameters for plasma clearance and apparent distribution volumes for central and peripheral compartments for plasma and CSF were 37.4 L/h, 90.2 L, 68.9 L, 0.035 L (fixed based on literature), and 0.039 L, respectively. Conclusion: A PopPK model was developed and found to precisely and accurately describe oxycodone time-concentration data in plasma and CSF.
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Affiliation(s)
- M Lamminsalo
- a School of Pharmacy , University of Eastern Finland , Kuopio , Finland
| | - P Piirainen
- b School of Medicine , University of Eastern Finland , Kuopio , Finland
| | - H Kokki
- b School of Medicine , University of Eastern Finland , Kuopio , Finland
| | - C A J Knibbe
- c Division of Pharmacology , Leiden University , Leiden , The Netherlands
| | - V-P Ranta
- a School of Pharmacy , University of Eastern Finland , Kuopio , Finland
| | - P Välitalo
- a School of Pharmacy , University of Eastern Finland , Kuopio , Finland.,d Finnish Medicines Agency, Assessment of Medicinal Products Department, Pharmacobiological Unit , Kuopio , Finland
| | - Merja Kokki
- b School of Medicine , University of Eastern Finland , Kuopio , Finland.,e Department of Anesthesiology and Intensive Care , Kuopio University Hospital , Kuopio , Finland
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Raff M, Belbachir A, El-Tallawy S, Ho KY, Nagtalon E, Salti A, Seo JH, Tantri AR, Wang H, Wang T, Buemio KC, Gutierrez C, Hadjiat Y. Intravenous Oxycodone Versus Other Intravenous Strong Opioids for Acute Postoperative Pain Control: A Systematic Review of Randomized Controlled Trials. Pain Ther 2019; 8:19-39. [PMID: 31004317 PMCID: PMC6514019 DOI: 10.1007/s40122-019-0122-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Optimal pain management is crucial to the postoperative recovery process. We aimed to evaluate the efficacy and safety of intravenous oxycodone with intravenous fentanyl, morphine, sufentanil, pethidine, and hydromorphone for acute postoperative pain. Methods A systematic literature search of PubMed, Cochrane Library, and EMBASE databases was performed for randomized controlled trials published from 2008 through 2017 (inclusive) that evaluated the acute postoperative analgesic efficacy of intravenous oxycodone against fentanyl, morphine, sufentanil, pethidine, and hydromorphone in adult patients (age ≥ 18 years). Outcomes examined included analgesic consumption, pain intensity levels, side effects, and patient satisfaction. Results Eleven studies were included in the review; six compared oxycodone with fentanyl, two compared oxycodone with morphine, and three compared oxycodone with sufentanil. There were no eligible studies comparing oxycodone with pethidine or hydromorphone. Overall, analgesic consumption was lower with oxycodone than with fentanyl or sufentanil. Oxycodone exhibited better analgesic efficacy than fentanyl and sufentanil, and comparable analgesic efficacy to morphine. In terms of safety, there was a tendency towards more side effects with oxycodone than with fentanyl, but the incidence of side effects with oxycodone was comparable to morphine and sufentanil. Where patient satisfaction was evaluated, higher satisfaction levels were observed with oxycodone than with sufentanil and comparable satisfaction was noted when comparing oxycodone with fentanyl. Patient satisfaction was not evaluated in the studies comparing oxycodone with morphine. Conclusions Our findings suggest that intravenous oxycodone provides better analgesic efficacy than fentanyl and sufentanil, and comparable efficacy to morphine with less adverse events such as sedation. No studies comparing intravenous oxycodone with pethidine or hydromorphone were identified in this review. Better alignment of study methodologies for future research in this area is recommended to provide the best evidence base for a meta-analysis. Funding Mundipharma Singapore Holding Pte Ltd, Singapore. Electronic supplementary material The online version of this article (10.1007/s40122-019-0122-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Milton Raff
- Pain Clinic, Christiaan Barnard Memorial Hospital, Cape Town, South Africa.
| | - Anissa Belbachir
- Faculté de médecine, Université Paris-Descartes, Pôle d'anesthésie-réanimation, Hôpital Cochin, Paris, France
| | - Salah El-Tallawy
- Department of Anesthesia and Pain Management, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Kok Yuen Ho
- The Pain Clinic, Mount Alvernia Medical Centre, Singapore, Singapore
| | - Eric Nagtalon
- Department of Anesthesia, University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines
| | - Amar Salti
- Anesthesiology Institute, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Aida Rosita Tantri
- Department of Anesthesiology and Intensive Care, Universitas Indonesia, Dr. Ciptomangunkusumo National General Hospital, Jakarta, Indonesia
| | - Hongwei Wang
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | | | | | - Yacine Hadjiat
- Mundipharma Singapore Holding Pte. Ltd., Singapore, Singapore
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Ryalino C, Agung Senapathi T, Gede Widnyana IM, Utara Hartawan IGAG, Arintha Devi C. Analgesic efficacy and safety of oxycodone as an adjuvant epidural analgesia for patients undergoing laparotomy gynecology. BALI JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.4103/bjoa.bjoa_13_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Solis E, Afzal A, Kiyatkin EA. Opposing mechanisms underlying differential changes in brain oxygen and temperature induced by intravenous morphine. J Neurophysiol 2018; 120:2513-2521. [PMID: 30183460 DOI: 10.1152/jn.00445.2018] [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: 01/19/2023] Open
Abstract
Morphine remains widely used in clinical settings due to its potent analgesic properties. However, one of the gravest risks of all opioids is their ability to induce respiratory depression and subsequent brain hypoxia that can lead to coma and death. Due to these life-threatening effects, our goal was to examine the effects of intravenous morphine at a wide range of doses (0.1-6.4 mg/kg) on changes in brain oxygen levels in freely moving rats. We used oxygen sensors coupled with high-speed amperometry and conducted measurements in the nucleus accumbens (NAc) and subcutaneous (SC) space, the latter serving as a proxy for blood oxygen levels that depend on respiratory activity. We also examined the effects of morphine on NAc, muscle, and skin temperature. Morphine induced dose-dependent decreases in SC oxygen levels, suggesting respiratory depression, but differential effects on NAc oxygen: increases at low and moderate doses (0.1-1.6 mg/kg) and decreases at the highest dose tested (6.4 mg/kg). Morphine also increased brain temperature at low and moderate doses but induced a biphasic, down-up change at high doses. The oxygen increases appear to result from a neurovascular coupling mechanism via local vasodilation and enhanced oxygen entry into brain tissue to compensate for blood oxygen drops caused by modest respiratory depression. At high morphine doses, this adaptive mechanism is unable to compensate for the enhanced respiratory depression, resulting in brain hypoxia. Hence, morphine appears to be safe when used as an analgesic at clinically relevant doses but poses great risks at high doses, likely to be abused by drug users. NEW & NOTEWORTHY With the use of oxygen sensors coupled with amperometry, we show that morphine induces differential effects on brain oxygen levels, slightly increasing them at low doses and strongly decreasing them at high doses. In contrast, morphine dose dependently decreases oxygen levels in the SC space. Therefore, morphine engages opposing mechanisms affecting brain oxygen levels, enhancing them through neurovascular coupling at low, clinically relevant doses and decreasing them due to dramatic respiratory depression at high doses, likely to be abused.
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Affiliation(s)
- Ernesto Solis
- Department of Health and Human Services, Behavioral Neuroscience Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, Maryland
| | - Anum Afzal
- Department of Health and Human Services, Behavioral Neuroscience Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, Maryland
| | - Eugene A Kiyatkin
- Department of Health and Human Services, Behavioral Neuroscience Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, Maryland
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Ye J, Yan H, Xia Z. Oxycodone ameliorates the inflammatory response induced by lipopolysaccharide in primary microglia. J Pain Res 2018; 11:1199-1207. [PMID: 29950892 PMCID: PMC6018850 DOI: 10.2147/jpr.s160659] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Activation of microglia participates in a wide range of pathophysiological processes in the central nervous system. Some studies reported that oxycodone (6-deoxy-7,8-dehydro-14-hydroxy-3-O-methyl-6oxomorphine) could inhibit the overactivation of glial cells in rats’ spinal cords. In the present study, we observed the effect of oxycodone on inflammatory molecules and pathway in lipopolysaccharide (LPS)-stimulated primary microglia in rats. Materials and methods Neonatal rats’ primary microglia were exposed to various concentrations (25, 50, 100 ng/mL) of oxycodone for 1 h after LPS stimulation for 24 h. The levels of pro-inflammatory mediators, IL-1β, TNF-α, and TGF-β1/smad2/3 signaling pathway were measured. The activation situation of microglia and the expression of TβR1 were observed by immunofluorescence. Results Oxycodone at 25 ng/mL did not change the levels of proinflammatory molecules and TGF-β1/smad2/3 signaling pathway in primary microglia, which was increased by LPS. Oxycodone at 50 and 100 ng/mL could significantly suppress LPS-induced production of TNF-α and IL-1β and the expression of TNF-αmRNA, IL-1βmRNA, and TGF-β1/smad2/3 signaling pathway. Conclusion These findings indicate that oxycodone, at relatively high clinically relevant concentration, can inhibit inflammatory response in LPS-induced primary microglia. The detailed mechanism needs to be investigated in future.
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Affiliation(s)
- Jishi Ye
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
| | - Hong Yan
- Department of Anesthesiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, People's Republic of China
| | - Zhongyuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, People's Republic of China
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Piirainen P, Kokki H, Hautajärvi H, Ranta VP, Kokki M. The analgesic efficacy and pharmacokinetics of epidural oxycodone after gynaecological laparotomy: a randomized, double-blind, double-dummy comparison with intravenous administration. Br J Clin Pharmacol 2018; 84:2088-2096. [PMID: 29782641 DOI: 10.1111/bcp.13643] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/01/2018] [Accepted: 05/05/2018] [Indexed: 12/20/2022] Open
Abstract
AIM The aim of the present study was to compare the analgesic efficacy of epidural and intravenous (i.v.) oxycodone at the same dose. METHODS In this randomized, double-blind, double-dummy clinical trial, 30 women, aged 24-67 years, undergoing elective gynaecological laparotomy, were administrated either i.v. saline and epidural oxycodone 0.1 mg·kg-1 (EPI group; n = 15) or i.v. oxycodone 0.1 mg·kg-1 and epidural saline (IV group; n = 15). For multimodal analgesia, patients received i.v. paracetamol and dexketoprofen, and a triple-mixture epidural infusion after the first 4 h postoperatively. The primary outcome was the total dose of i.v. fentanyl for rescue analgesia during the first 4 h postoperatively. RESULTS All patients required fentanyl during the first 4 h. The median number of fentanyl doses were three (quartiles 1, 8) in the EPI group and seven (6, 9) in the IV group (mean difference 3.1; 95% confidence interval 0.9, 5.2; P = 0.01). After the first 4 h, the two groups needed a similar total dose of epidural infusion. Patient satisfaction was similarly high in both groups, and both administration routes were well tolerated. CONCLUSIONS The data support the superiority of epidural oxycodone compared with that of i.v. administration in pain management after laparotomy.
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Affiliation(s)
- Panu Piirainen
- University of Eastern Finland, School of Medicine, Faculty of Health Sciences, Kuopio, Finland
| | - Hannu Kokki
- University of Eastern Finland, School of Medicine, Faculty of Health Sciences, Kuopio, Finland.,Kuopio University Hospital, Department of Anaesthesia and Operative Services, Kuopio, Finland
| | | | - Veli-Pekka Ranta
- University of Eastern Finland, School of Pharmacy, Faculty of Health Sciences, Kuopio, Finland
| | - Merja Kokki
- Kuopio University Hospital, Department of Anaesthesia and Operative Services, Kuopio, Finland
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Kinnunen M, Kokki H, Hautajärvi H, Huhta H, Ranta VP, Räsänen J, Voipio HM, Kokki M. Oxycodone pharmacokinetics and fetal exposure after intravenous or epidural administration to the ewe. Acta Obstet Gynecol Scand 2018; 97:1200-1205. [PMID: 29772054 DOI: 10.1111/aogs.13378] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/08/2018] [Indexed: 01/11/2023]
Abstract
INTRODUCTION There are limited data on oxycodone pharmacokinetics during pregnancy and on fetal exposure after maternal administration. The present study describes the pharmacokinetics of intravenous (i.v.) oxycodone in pregnant sheep and fetal exposure after intravenous and epidural administration. MATERIAL AND METHODS Ten pregnant sheep received 0.1 mg·kg-1 oxycodone intravenously, and blood samples were collected up to 24 hours. Seven days later, the ewes were randomized to receive 0.5 mg·kg-1 oxycodone intravenously (n = 5) or epidurally (n = 5) as a single bolus, before laparotomy for placement of catheters into the fetal superior vena cava and carotid artery. Paired maternal and fetal blood samples were taken when the fetal arterial catheter was in place and at the end of surgery. Maternal blood samples were taken up to 24 hours. RESULTS After 0.1 mg·kg-1 oxycodone intravenously, the median clearance was 5.2 L·h-1 ·kg-1 (range 4.6-6.2), but the volume of distribution varied between 1.5 and 4.7 L·kg-1 . The area under the curve was 17 h·ng·mL-1 (range 14-19) and the plasma concentration at 2 minutes 60 ng·mL-1 (range 50-74). Following administration of 0.5 mg·kg-1 intravenously or epidurally, oxycodone concentrations were similar in the maternal and the fetal plasma. Accumulation of oxymorphone in the fetus occurred; fetal-to-maternal ratios were 1.3-3.5 (median 2.1) in the i.v.-group and 0.9-3.0 (1.3) in the Epidural-group. CONCLUSIONS We determined the pharmacokinetics of oxycodone in pregnant sheep. We showed accumulation of oxymorphone, which an active metabolite of oxycodone, in the fetus. Further studies in human pregnancies are required to evaluate the safety of oxycodone.
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Affiliation(s)
- Mari Kinnunen
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | | | - Heikki Huhta
- Department of Surgery, University of Oulu, Oulu, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Juha Räsänen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland
| | - Hanna-Marja Voipio
- Laboratory Animal Center, Department of Experimental Surgery, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Merja Kokki
- Department of Anesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland
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Purdy M, Kinnunen M, Kokki M, Anttila M, Eskelinen M, Hautajärvi H, Lehtonen M, Kokki H. A prospective, randomized, open label, controlled study investigating the efficiency and safety of 3 different methods of rectus sheath block analgesia following midline laparotomy. Medicine (Baltimore) 2018; 97:e9968. [PMID: 29443788 PMCID: PMC5839819 DOI: 10.1097/md.0000000000009968] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND There is a controversy regarding the efficacy of rectus sheath block (RSB). The aim of the present study was to evaluate analgesic efficacy and safety of three different methods of RSB in postoperative pain management after midline laparotomy. METHODS A prospective, randomized, controlled, open-label clinical trial with 4 parallel groups was conducted in a tertiary care hospital in Finland. A total of 57 patients undergoing midline laparotomy were randomized to the control group (n = 12) or to 1 of the 3 active RSB analgesia groups: single-dose (n = 16), repeated-doses (n = 12), or continuous infusion (n = 17). Opioid consumption with iv-patient-controlled analgesia pump was recorded, and pain scores and patients' satisfaction were surveyed on an 11-point numeric rating scale for the first 48 postoperative h. Plasma concentrations of oxycodone and levobupivacaine were analyzed. All adverse events during the hospital stay were recorded. RESULTS Oxycodone consumption was less during the first 12 h in the repeated-doses and in the continuous infusion groups (P = .07) and in numerical values up to 48 h in the repeated-doses group. Plasma oxycodone concentrations were similar in all 4 groups. Pain scores were lower in the repeated-doses group when coughing during the first 4 h (P = .048 vs. control group), and at rest on the first postoperative morning (P = .034 vs. the other 3 groups) and at 24 h (P = .006 vs. the single-dose group). All plasma concentrations of levobupivacaine were safe. The patients' satisfaction was better in the repeated-doses group compared with the control group (P = .025). No serious or unexpected adverse events were reported. CONCLUSIONS RSB analgesia with repeated-doses seems to have opioid sparing efficacy, and it may enhance pain relief and patients' satisfaction after midline laparotomy.
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Affiliation(s)
- Martin Purdy
- Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna
- School of Medicine, University of Eastern Finland
| | | | - Merja Kokki
- School of Medicine, University of Eastern Finland
- Department of Anesthesia and Operative Services, Kuopio University Hospital
| | - Maarit Anttila
- Departments of Gynecology and Oncology, Kuopio University Hospital
| | - Matti Eskelinen
- School of Medicine, University of Eastern Finland
- Department of Surgery, Kuopio University Hospital, Kuopio
| | | | - Marko Lehtonen
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland
- Department of Anesthesia and Operative Services, Kuopio University Hospital
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Prediction of human CNS pharmacokinetics using a physiologically-based pharmacokinetic modeling approach. Eur J Pharm Sci 2018; 112:168-179. [DOI: 10.1016/j.ejps.2017.11.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/07/2017] [Accepted: 11/10/2017] [Indexed: 02/07/2023]
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Olczak B, Kowalski G, Leppert W, Bienert A, Teżyk A, Adamski M, Rzymski S, Wieczorowska-Tobis K. Analgesic efficacy and safety of epidural oxycodone in patients undergoing total hip arthroplasty: a pilot study. J Pain Res 2017; 10:2303-2309. [PMID: 29026333 PMCID: PMC5627752 DOI: 10.2147/jpr.s144799] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Oxycodone is poorly studied as an adjuvant to central blockades. The aim of this pilot study was to assess the efficacy and safety of oxycodone hydrochloride in epidural blockade among patients undergoing total hip arthroplasty (THA). PATIENTS AND METHODS In 11 patients (American Society of Anesthesiologists physical status classification system II/III, age range: 59-82 years), THA was conducted with an epidural blockade using 15 mL 0.25% bupivacaine (37.5 mg) with 5 mg oxycodone hydrochloride and sedation with propofol infusion at a dose of 3-5 mg/kg/h. After the surgery, patients received ketoprofen at a dose of 100 mg twice daily. In the first 24 hours postoperative period, pain was assessed by numerical rating scale at rest and on movement; adverse effects (AEs) were recorded; and plasma concentrations of oxycodone, noroxycodone, and bupivacaine were measured. RESULTS The administration of epidural oxycodone at a dose of 5 mg in patients undergoing THA provided analgesia for a mean time of 10.3±4.89 h. In one patient, mild pruritus was observed. Oxycodone did not evoke other AEs. Plasma concentrations of oxycodone while preserving analgesia were >2.9 ng/mL. Noroxycodone concentrations in plasma did not guarantee analgesic effect. CONCLUSION The administration of epidural oxycodone at a dose of 5 mg prolongs the analgesia period to ~10 hours in patients after THA. Oxycodone may evoke pruritus. A 5 mg dose of oxycodone hydrochloride used in an epidural blockade seems to be a safe drug in patients after THA.
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Affiliation(s)
- Bogumił Olczak
- Department of Anaesthesiology, Józef Struś Multiprofile Municipal Hospital, Poznań
| | - Grzegorz Kowalski
- Department of Anaesthesiology, Józef Struś Multiprofile Municipal Hospital, Poznań.,Department of Palliative Medicine
| | | | | | - Artur Teżyk
- Department of Forensic Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | - Michał Adamski
- Department of Anaesthesiology, Józef Struś Multiprofile Municipal Hospital, Poznań
| | - Stanisław Rzymski
- Department of Anaesthesiology, Józef Struś Multiprofile Municipal Hospital, Poznań
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Kokki M, Pesonen M, Vehviläinen P, Litmala O, Pasanen M, Kokki H. Cytotoxicity of Oxycodone and Morphine in Human Neuroblastoma and Mouse Motoneuronal Cells: A Comparative Approach. Drugs R D 2017; 16:155-63. [PMID: 26913723 PMCID: PMC4875920 DOI: 10.1007/s40268-016-0125-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives Oxycodone is the mo
st commonly used opioid for the treatment of moderate to severe pain. The peak cerebrospinal fluid concentration after epidural oxycodone was reported to be 300-fold greater (0.025 mM) than when administered intravenously after gynecologic surgery. Additionally, those patients administered epidural oxycodone had lower pain scores, needed less rescue analgesics and had fewer adverse effects compared with intravenous administration. However, oxycodone neurotoxicity requires evaluation before intrathecal implementation for routine clinical use. Methods We used two in vitro cell culture models to compare the cytotoxicity of oxycodone with that of morphine, and to study the mechanisms underlying toxicity. Human neuroblastoma cells and mouse motoneuronal cells were treated with increasing concentrations (0.0125–2 mM) of oxycodone or morphine, and were harvested at 24, 48 or 96 h. Cell cultures were evaluated with 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide and resazurin reduction assays. Results Both morphine and oxycodone decreased cell viability in a dose-dependent manner at concentrations between 0.5 and 2 mM. Morphine increased the number of apoptotic cells compared with oxycodone when assessed by flow cytometry, and transmission electron microscopy images revealed that exposure to both opioids evoked the appearance of numerous electron-dense, probable autophagic vacuoles in the cytoplasm of the cells. Conclusions Based on these results, it seems that the cytotoxicity of oxycodone in motoneuronal cells is similar to or less than that of morphine, and occurs only at concentrations above the peak clinical concentration in the cerebrospinal fluid after epidural administration.
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Affiliation(s)
- Merja Kokki
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029 KYS, Kuopio, Finland
| | - Maija Pesonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Piia Vehviläinen
- Department of Neurobiology, A.I. Virtanen Institute, University of Eastern Finland, Kuopio, Finland
| | - Outi Litmala
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029 KYS, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Markku Pasanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland. .,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029 KYS, Kuopio, Finland.
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Zhang C, Ding J, Wang B, Chen P. A Single Intravenous Injection of Oxycodone Hydrochloride In The Treatment of Acute Post-operative Pain after Laparoscopic Rectal Tumor Resection. BIO WEB OF CONFERENCES 2017. [DOI: 10.1051/bioconf/20170801055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kokki M, Heikkinen M, Välitalo P, Hautajärvi H, Hokkanen J, Pitkänen H, Sankilampi U, Ranta VP, Kokki H. Maturation of oxycodone pharmacokinetics in neonates and infants: Oxycodone and its metabolites in plasma and urine. Br J Clin Pharmacol 2016; 83:791-800. [PMID: 27780305 DOI: 10.1111/bcp.13164] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/12/2016] [Accepted: 10/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIMS This study aimed to characterize the pharmacokinetics of oxycodone and its major metabolites in infants and covered the age range between extremely preterm neonates and 2-year-old infants. METHODS Seventy-nine infants (gestational age 23-42 weeks; postnatal age 0-650 days) received intravenous oxycodone hydrochloride trihydrate at a dose of 0.1 mg kg-1 during or after surgery. Three to seven blood samples were taken from each infant, and plasma concentrations of oxycodone, noroxycodone, oxymorphone, and noroxymorphone were quantified. The unconjugated forms of these compounds were determined in urine collected after up to 24 or 48 h from 25 infants. Pharmacokinetics was determined using noncompartmental analysis and reported for six clinically relevant age groups based on postmenstrual age. RESULTS Oxycodone pharmacokinetics changed markedly with patient age. Preterm neonates were found to have the highest pharmacokinetic variability out of the study population. In extremely preterm neonates (n = 6) median of elimination half-life was 8.8 h (range 6.8-12.5), in preterm (n = 11) 7.4 h (4.2-11.6), and in older neonates (n = 22) 4.1 h (2.4-5.8), all of which were significantly longer than that in infants aged 6-24 months (n = 12) 2.0 h (1.7-2.6). Median renal clearance was fairly constant in all age groups, whereas non-renal clearance markedly increased with age. Noroxycodone was the major metabolite in plasma and urine. CONCLUSIONS Oxycodone elimination is slower and pharmacokinetic variability more pronounced in neonates when compared to older infants. These findings highlight the importance of careful dose titration for neonates.
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Affiliation(s)
- Merja Kokki
- Department of Anaesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marja Heikkinen
- Department of Paediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Pyry Välitalo
- Division of Pharmacology, Leiden University, Leiden, The Netherlands
| | | | | | - Hanna Pitkänen
- Department of Anaesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ulla Sankilampi
- School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- Department of Anaesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland.,School of Medicine, University of Eastern Finland, Kuopio, Finland
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Abstract
Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.
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Piirainen A, Kokki H, Immonen S, Eskelinen M, Häkkinen MR, Hautajärvi H, Kokki M. A Dose-Finding Study of Dexketoprofen in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Clinical Trial on Effects on the Analgesic Concentration of Oxycodone. Drugs R D 2016; 15:319-28. [PMID: 26364041 PMCID: PMC4662948 DOI: 10.1007/s40268-015-0107-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Dexketoprofen has been shown to provide efficient analgesia and an opioid-sparing effect after orthopedic surgery. In this dose-finding study, we evaluated the analgesic efficacy and opioid-sparing effect of dexketoprofen administered intravenously (i.v.) after laparoscopic cholecystectomy (LCC). Methods Twenty-four patients undergoing LCC were randomized to receive dexketoprofen 10 or 50 mg i.v. 15 min before the end of the surgery. Subjects were provided with 0.2 mg/kg of oxycodone at anesthesia induction. In the recovery room, pain was assessed with an 11-point numerical rating scale (NRS; score of 0 = no pain, score of 10 = most severe pain) every 10 min. When the NRS score was ≥3/10 at rest or ≥5/10 at wound compression, a plasma sample was taken for analysis of oxycodone [to determine the minimum effective concentration (MEC)], its metabolites, and dexketoprofen. After that, subjects were titrated with oxycodone 2 or 3 mg i.v. every 10 min until the NRS score was <3/10 at rest and <5/10 at wound compression. At this point, a second plasma sample was taken for analysis of oxycodone [minimum effective analgesic concentration (MEAC)], its metabolites, and dexketoprofen. Results At the onset of pain, the plasma oxycodone concentrations (MEC) were similar in the two groups: median 60 ng/mL (range 37–73) in the 10 mg group and median 52 ng/mL (range 24–79) in the 50 mg group. At the time of pain relief, the MEACs were 98 ng/mL (range 59–150) in the 10 mg group and 80 ng/mL (range 45–128) in the 50 mg group. The total doses of oxycodone needed to achieve pain relief were similar: 0.11 mg/kg (range 0–0.33) in the 10 mg group and 0.08 mg/kg (range 0–0.24) in the 50 mg group. Eleven subjects developed mild desaturation or a decreased respiratory rate after oxycodone titration. Conclusion In the present double-blinded, randomized clinical trial, the need for a rescue opioid analgesic, oxycodone, was similar with the two dose levels of dexketoprofen—10 and 50 mg i.v.—after LCC.
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Affiliation(s)
- Annika Piirainen
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029, Kuopio, Finland
| | - Hannu Kokki
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029, Kuopio, Finland
| | - Satu Immonen
- Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Matti Eskelinen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Merja R Häkkinen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Merja Kokki
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland. .,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029, Kuopio, Finland.
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Baba H, Petrenko AB, Fujiwara N. Clinically relevant concentration of pregabalin has no acute inhibitory effect on excitation of dorsal horn neurons under normal or neuropathic pain conditions: An intracellular calcium-imaging study in spinal cord slices from adult rats. Brain Res 2016; 1648:445-458. [PMID: 27543338 DOI: 10.1016/j.brainres.2016.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/11/2016] [Accepted: 08/13/2016] [Indexed: 01/10/2023]
Abstract
Pregabalin is thought to exert its therapeutic effect in neuropathic pain via binding to α2δ-1 subunits of voltage-gated calcium (Ca(2+)) channels. However, the exact analgesic mechanism after its binding to α2δ-1 subunits remains largely unknown. Whether a clinical concentration of pregabalin (≈10μM) can cause acute inhibition of dorsal horn neurons in the spinal cord is controversial. To address this issue, we undertook intracellular Ca(2+)-imaging studies using spinal cord slices with an intact attached L5 dorsal root, and examined if pregabalin acutely inhibits the primary afferent stimulation-evoked excitation of dorsal horn neurons in normal rats and in rats with streptozotocin-induced painful diabetic neuropathy. Under normal conditions, stimulation of a dorsal root evoked Ca(2+) signals predominantly in the superficial dorsal horn. Clinically relevant (10μM) and a very high concentration of pregabalin (100μM) did not affect the intensity or spread of dorsal root stimulation-evoked Ca(2+) signals, whereas an extremely high dose of pregabalin (300μM) slightly but significantly attenuated Ca(2+) signals in normal rats and in diabetic neuropathic (DN) rats. There was no difference between normal rats and DN rats with regard to the extent of signal attenuation at all concentrations tested. These results suggest that the activity of dorsal horn neurons in the spinal cord is not inhibited acutely by clinical doses of pregabalin under normal or DN conditions. It is very unlikely that an acute inhibitory action in the dorsal horn is the main analgesic mechanism of pregabalin in neuropathic pain states.
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Affiliation(s)
- Hiroshi Baba
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan.
| | - Andrey B Petrenko
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan
| | - Naoshi Fujiwara
- Division of Medical Technology, Niigata University Graduate School of Health Sciences, 2-746 Asahimachi-dori, Chuo-ku, Niigata 951-8518, Japan
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Sng BL, Kwok SC, Mathur D, Ithnin F, Newton-Dunn C, Assam PN, Sultana R, Sia ATH. Comparison of epidural oxycodone and epidural morphine for post-caesarean section analgesia: A randomised controlled trial. Indian J Anaesth 2016; 60:187-93. [PMID: 27053782 PMCID: PMC4800935 DOI: 10.4103/0019-5049.177877] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Epidural morphine after caesarean section may cause moderate to severe pruritus in women. Epidural oxycodone has been shown in non-obstetric trials to reduce pruritus when compared to morphine. We hypothesised that epidural oxycodone may reduce pruritus after caesarean section. Methods: A randomised controlled trial was conducted in pregnant women at term who underwent caesarean section with combined spinal-epidural technique initiated with intrathecal fentanyl 15 μg. Women received either epidural morphine 3 mg or epidural oxycodone 3 mg via the epidural catheter after delivery. The primary outcome was the incidence of pruritus at 24 h after caesarean section. The secondary outcomes were the pruritus scores, treatment for post-operative nausea and vomiting (PONV), pain scores and maternal satisfaction. Results: One hundred women were randomised (group oxycodone O = 50, morphine M = 50). There was no difference between Group O and M in the incidence of pruritus (n [%] 28 [56%] vs. 31 [62%], P = 0.68) and the worst pruritus scores (mean [standard deviation] 2.6 (2.8) vs. 3.3 [3.1], P = 0.23), respectively. Both groups had similar pain scores at rest (2.7 [2.3] vs. 2.0 [2.7], P = 0.16) and sitting up (5.0 [2.3] vs. 4.6 [2.4], P = 0.38) at 24 h. Pruritus scores were lower at 4–8, 8–12 and 12–24 h with oxycodone, but pain scores were higher. Both groups had a similar need for treatment of PONV and maternal satisfaction with analgesia. Conclusion: There was no difference in the incidence of pruritus at 24 h between epidural oxycodone and morphine. However, pruritus scores were lower with oxycodone between 4 and 24 h after surgery with higher pain scores in the same period.
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Affiliation(s)
- Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | - Sarah Carol Kwok
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | - Deepak Mathur
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | - Farida Ithnin
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | - Clare Newton-Dunn
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
| | | | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | - Alex Tiong Heng Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Bukit Timah, Singapore
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Li Y, Sun D, Palmisano M, Zhou S. Slow drug delivery decreased total body clearance and altered bioavailability of immediate- and controlled-release oxycodone formulations. Pharmacol Res Perspect 2016; 4:e00210. [PMID: 26977300 PMCID: PMC4777261 DOI: 10.1002/prp2.210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/01/2015] [Accepted: 12/09/2015] [Indexed: 11/15/2022] Open
Abstract
Oxycodone is a commonly used analgesic with a large body of pharmacokinetic data from various immediate-release or controlled-release formulations, under different administration routes, and in diverse populations. Longer terminal half-lives from extravascular administration as compared to IV administration have been attributed to flip-flop pharmacokinetics with the rate constant of absorption slower than elimination. However, PK parameters from the extravascular studies showed faster absorption than elimination. Sustained release formulations guided by the flip-flop concept produced mixed outcomes in formulation development and clinical studies. This research aims to develop a mechanistic knowledge of oxycodone ADME, and provide a consistent interpretation of diverging results and insight to guide further extended release development and optimize the clinical use of oxycodone. PK data of oxycodone in human studies were collected from literature and digitized. The PK data were analyzed using a new PK model with Weibull function to describe time-varying drug releases/ oral absorption, and elimination dependent upon drug input to the portal vein. The new and traditional PK models were coded in NONMEM. Sensitivity analyses were conducted to address the relationship between rates of drug release/absorption and PK profiles plus terminal half-lives. Traditional PK model could not be applied consistently to describe drug absorption and elimination of oxycodone. Errors were forced on absorption, elimination, or both parameters when IV and PO profiles were fitted separately. The new mechanistic PK model with Weibull function on absorption and slower total body clearance caused by slower absorption adequately describes the complex interplay between oxycodone absorption and elimination in vivo. Terminal phase of oxycodone PK profile was shown to reflect slower total body drug clearance due to slower drug release/absorption from oral formulations. Mechanistic PK models with Weibull absorption functions, and release rate-dependent saturable total body clearance well described the diverging oxycodone absorption and elimination kinetics in the literature. It showed no actual drug absorption during the terminal phase, but slower drug clearance caused by slower release/absorption producing the appearance of flip-flop and offered new insight for the development of modified release formulations and clinical use of oxycodone.
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Affiliation(s)
- Yan Li
- Translational Development and Clinical PharmacologyCelgene Corporation86 Morris AvenueSummit07920New Jersey
| | - Duxin Sun
- College of Pharmacythe University of MichiganAnn Arbor48109Michigan
| | - Maria Palmisano
- Translational Development and Clinical PharmacologyCelgene Corporation86 Morris AvenueSummit07920New Jersey
| | - Simon Zhou
- Translational Development and Clinical PharmacologyCelgene Corporation86 Morris AvenueSummit07920New Jersey
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Chana AS, Mahajan RP. BJA 2014; An overview. Br J Anaesth 2015; 114:ix-xvi. [PMID: 25500411 DOI: 10.1093/bja/aeu455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A S Chana
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
| | - R P Mahajan
- Anaesthesia and Critical Care, Division of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham NG7 2UK, UK
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Lomas JP, Jackson M, Martin A, Pasha T, Patvardhan C, Ramsaran R. Spinal catheter observer effect and surgical technique. Br J Anaesth 2014; 112:945-6. [DOI: 10.1093/bja/aeu124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mikus G, Klimas R. Contribution of oxycodone and its metabolites to the analgesic effect. Br J Anaesth 2014; 112:944-5. [DOI: 10.1093/bja/aeu123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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