1
|
Simão AY, Antunes M, Cabral E, Oliveira P, Rosendo LM, Brinca AT, Alves E, Marques H, Rosado T, Passarinha LA, Andraus M, Barroso M, Gallardo E. An Update on the Implications of New Psychoactive Substances in Public Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084869. [PMID: 35457736 PMCID: PMC9028227 DOI: 10.3390/ijerph19084869] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023]
Abstract
The emergence of new psychoactive substances has earned a great deal of attention, and several reports of acute poisoning and deaths have been issued involving, for instance, synthetic opiates. In recent years, there have been profound alterations in the legislation concerning consumption, marketing, and synthesis of these compounds; rapid alert systems have also been subject to changes, and new substances and new markets, mainly through the internet, have appeared. Their effects and how they originate in consumers are still mostly unknown, primarily in what concerns chronic toxicity. This review intends to provide a detailed description of these substances from the point of view of consumption, toxicokinetics, and health consequences, including case reports on intoxications in order to help researchers and public health agents working daily in this area.
Collapse
Affiliation(s)
- Ana Y. Simão
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
| | - Mónica Antunes
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Serviço de Química e Toxicologia Forenses, Instituto Nacional de Medicina Legal e Ciências Forenses, Delegação do Sul, 1150-219 Lisboa, Portugal
| | - Emanuel Cabral
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Patrik Oliveira
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Luana M. Rosendo
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Ana Teresa Brinca
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Estefânia Alves
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
| | - Hernâni Marques
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
| | - Tiago Rosado
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
| | - Luís A. Passarinha
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- UCIBIO—Applied Molecular Biosciences Unit, Departamento de Química, NOVA School of Science and Technology, Universidade NOVA, 2829-516 Caparica, Portugal
- Associate Laboratory i4HB-Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA, 2819-516 Caparica, Portugal
- Correspondence: (L.A.P.); (M.A.); (M.B.); (E.G.); Tel.: +351-275-329-001 (L.A.P. & E.G.); +55-800-042-0384 (M.A.); +351-21-881-1800 (M.B.)
| | - Maristela Andraus
- Chromatox/Dasa Laboratory Ltda. Sumaré, São Paulo 01259-000, Brazil
- Correspondence: (L.A.P.); (M.A.); (M.B.); (E.G.); Tel.: +351-275-329-001 (L.A.P. & E.G.); +55-800-042-0384 (M.A.); +351-21-881-1800 (M.B.)
| | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto Nacional de Medicina Legal e Ciências Forenses, Delegação do Sul, 1150-219 Lisboa, Portugal
- Correspondence: (L.A.P.); (M.A.); (M.B.); (E.G.); Tel.: +351-275-329-001 (L.A.P. & E.G.); +55-800-042-0384 (M.A.); +351-21-881-1800 (M.B.)
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, 6200-506 Covilha, Portugal; (A.Y.S.); (M.A.); (E.C.); (P.O.); (L.M.R.); (A.T.B.); (E.A.); (H.M.); (T.R.)
- Laboratório de Fármaco-Toxicologia, UBIMedical, Universidade da Beira Interior, 6200-284 Covilha, Portugal
- Correspondence: (L.A.P.); (M.A.); (M.B.); (E.G.); Tel.: +351-275-329-001 (L.A.P. & E.G.); +55-800-042-0384 (M.A.); +351-21-881-1800 (M.B.)
| |
Collapse
|
2
|
Wang G, Xiao B, Deng J, Gong L, Li Y, Li J, Zhong Y. The Role of Cytochrome P450 Enzymes in COVID-19 Pathogenesis and Therapy. Front Pharmacol 2022; 13:791922. [PMID: 35185562 PMCID: PMC8847594 DOI: 10.3389/fphar.2022.791922] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has become a new public health crisis threatening the world. Dysregulated immune responses are the most striking pathophysiological features of patients with severe COVID-19, which can result in multiple-organ failure and death. The cytochrome P450 (CYP) system is the most important drug metabolizing enzyme family, which plays a significant role in the metabolism of endogenous or exogenous substances. Endogenous CYPs participate in the biosynthesis or catabolism of endogenous substances, including steroids, vitamins, eicosanoids, and fatty acids, whilst xenobiotic CYPs are associated with the metabolism of environmental toxins, drugs, and carcinogens. CYP expression and activity are greatly affected by immune response. However, changes in CYP expression and/or function in COVID-19 and their impact on COVID-19 pathophysiology and the metabolism of therapeutic agents in COVID-19, remain unclear. In this analysis, we review current evidence predominantly in the following areas: firstly, the possible changes in CYP expression and/or function in COVID-19; secondly, the effects of CYPs on the metabolism of arachidonic acid, vitamins, and steroid hormones in COVID-19; and thirdly, the effects of CYPs on the metabolism of therapeutic COVID-19 drugs.
Collapse
Affiliation(s)
- Guyi Wang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bing Xiao
- Department of Emergency, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jiayi Deng
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Linmei Gong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jinxiu Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yanjun Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
3
|
Cooman T, Hoover B, Sauvé B, Bergeron SA, Quinete N, Gardinali P, Arroyo LE. The metabolism of valerylfentanyl using human liver microsomes and zebrafish larvae. Drug Test Anal 2022; 14:1116-1129. [PMID: 35128825 DOI: 10.1002/dta.3233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/22/2022] [Accepted: 01/28/2022] [Indexed: 11/09/2022]
Abstract
Valerylfentanyl, a novel synthetic opioid less potent than fentanyl, has been reported in biological samples, but there are limited studies on its pharmacokinetic properties. The goal of this study was to elucidate the metabolism of valerylfentanyl using an in vitro human liver microsome (HLM) model compared with an in vivo zebrafish model. Nineteen metabolites were detected with N-dealkylation-valeryl norfentanyl and hydroxylation as the major metabolic pathways. The major metabolites in HLMs were also detected in 30 day postfertilization zebrafish. An authentic liver specimen that tested positive for valerylfentanyl, among other opioids and stimulants, revealed the presence of a metabolite that shared transitions and retention time as the hydroxylated metabolite of valerylfentanyl but could not be confirmed without an authentic standard. 4-Anilino-N-phenethylpiperidine (4-ANPP), a common metabolite to other fentanyl analogs, was also detected. In this study, we elucidated the metabolic pathway of valerylfentanyl, confirmed two metabolites using standards, and demonstrated that the zebrafish model produced similar metabolites to the HLM model for opioids.
Collapse
Affiliation(s)
- Travon Cooman
- Department of Forensic and Investigative Science, West Virginia University, Morgantown, West Virginia, USA
| | - Brianna Hoover
- Department of Forensic and Investigative Science, West Virginia University, Morgantown, West Virginia, USA
| | - Brianna Sauvé
- Department of Forensic and Investigative Science, West Virginia University, Morgantown, West Virginia, USA
| | - Sadie A Bergeron
- Department of Biology, West Virginia University, Morgantown, West Virginia, USA
| | - Natalia Quinete
- Institute of Environment and Department of Chemistry and Biochemistry, Florida International University, Miami, Florida, USA
| | - Piero Gardinali
- Institute of Environment and Department of Chemistry and Biochemistry, Florida International University, Miami, Florida, USA
| | - Luis E Arroyo
- Department of Forensic and Investigative Science, West Virginia University, Morgantown, West Virginia, USA
| |
Collapse
|
4
|
Flynn SM, France CP. Characterization of the discriminative stimulus effects of binary mixtures of mu opioid receptor agonists in rats discriminating fentanyl. J Pharmacol Exp Ther 2021; 380:171-179. [PMID: 34903563 DOI: 10.1124/jpet.121.000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022] Open
Abstract
Drug overdose deaths involving synthetic opioids, primarily fentanyl, have risen dramatically over the past decade and are currently the driving force of the opioid epidemic in the United States. Fentanyl analogs with greater potency than fentanyl (e.g., carfentanil) pose serious risk to public health. While fentanyl analogs are primarily encountered by humans as constituents of a mixture of drugs, research has primarily evaluated the effects of these drugs alone. The present study characterized interactions between mu opioid receptor agonists in seven male Sprague-Dawley rats trained to discriminate 10 µg/kg fentanyl from saline while responding under a fixed-ratio 10 schedule of food presentation. Dose-effect curves were determined for each drug alone and in binary mixtures (fentanyl:heroin, fentanyl:carfentanil, and heroin:carfentanil) at fixed-dose ratios of 3:1, 1:1, and 1:3 relative to the ED50 for each drug when given alone. Dose addition analyses were used to determine the nature of the drug-drug interaction for each mixture. Additive interactions were observed for all binary mixtures at each fixed dose ratio, except the 1:3 fentanyl:carfentanil mixture which exhibited supra-additive effects at the 80% effect level. These results suggest a lack of a significant interaction between the discriminative stimulus effects of these mu opioid receptor agonists at the doses tested in this study. Future studies expanding these findings to the respiratory depressant effects of these drugs are of significant importance to rule out possible interactions directly relevant to opioid overdose that occur at doses much larger than those tested in this study. Significance Statement In the United States, drug overdose deaths involving synthetic opioids, primarily fentanyls including superpotent fentanyl analogs (e.g., carfentanil), have increased 12-fold over the past decade. While previous studies have evaluated the effects of carfentanil alone, fentanyl analogs are encountered by humans as a mixture with other drugs; this study determined the effects of mixtures of carfentanil and other opioids (fentanyl and heroin) to characterize interactions between these drugs that might contribute to their apparent increased lethality in humans.
Collapse
Affiliation(s)
- Shawn M Flynn
- University of Texas Health Science Center, United States
| | - Charles P France
- Department of Pharmacology, University of Texas Health Science Center, United States
| |
Collapse
|
5
|
Pharmacokinetic Characterisation and Comparison of Bioavailability of Intranasal Fentanyl, Transmucosal, and Intravenous Administration through a Three-Way Crossover Study in 24 Healthy Volunteers. Pain Res Manag 2021; 2021:2887773. [PMID: 34880961 PMCID: PMC8648480 DOI: 10.1155/2021/2887773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/25/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022]
Abstract
Background For more than 60 years, the synthetic opioid fentanyl has been widely used in anaesthesia and analgesia. While the intravenous formulation is primarily used for general anaesthesia and intensive care settings, the drug's high lipophilic properties also allow various noninvasive routes of administration. Published data suggest that intranasal administration is also attractive for use as intranasal patient-controlled analgesia (PCA). A newly developed intranasal fentanyl formulation containing 47 μg fentanyl, intravenous fentanyl, and oral transmucosal fentanyl citrate were characterised, and bioavailability was compared to assess the suitability of the intranasal formulation for an intranasal PCA product. Methods 27 healthy volunteers were enrolled in a single-centre, open-label, randomised (order of treatments), single-dose study in a three-period crossover design. The pharmacokinetics of one intranasal puff of fentanyl formulation (47 μg, 140 mL per puff), one short intravenous infusion of 50 μg fentanyl, and one lozenge with an integrated applicator (200 μg fentanyl) were studied, and bioavailability was calculated. Blood samples were collected over 12 hours, and plasma concentrations of fentanyl were determined by HPLC with MS/MS detection. Results 24 volunteers completed the study. The geometric mean of AUC0-tlast was the highest with oral transmucosal administration (1106 h ∗ pg/ml, CV% = 32.86), followed by intravenous (672 h ∗ pg/ml, CV% = 32.18) and intranasal administration (515 h ∗ pg/ml, CV% = 30.10). C max was 886 pg/ml (CV% = 59.38) for intravenous, 338 pg/ml (CV% = 45.61) for intranasal, and 310 pg/ml (CV% = 29.58) for oral transmucosal administration. t max was shortest for intravenous administration (0.06 h, SD = 0.056), followed by intranasal (0.21 h, SD = 0.078) and oral transmucosal administration (1.20 h, SD = 0.763). Dose-adjusted absolute bioavailability was determined to be 74.70% for the intranasal formulation and 41.25% for the oral transmucosal product. In total, 38 adverse events (AEs) occurred. Fourteen AEs were potentially related to the investigational items. No serious AE occurred. Conclusion Pharmacokinetic parameters and bioavailability of the investigated intranasal fentanyl indicated suitability for its intended use as an intranasal PCA option.
Collapse
|
6
|
The use of heat to deliver fentanyl via pulmonary drug delivery. Int J Pharm X 2021; 3:100096. [PMID: 34704012 PMCID: PMC8521112 DOI: 10.1016/j.ijpx.2021.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/22/2021] [Accepted: 08/31/2021] [Indexed: 11/21/2022] Open
Abstract
The golden standard to treat acute pain is by intravenous drug delivery of opioids such as fentanyl or morphine. Intravenous drug delivery requires the placement of an intravenous (IV) port, which can cause infections, dislodgments, and distress to the patients, and therefore a non-invasive method is desirable. Pulmonary drug delivery is a non-invasive method that has been shown to be a good alternative to intravenous administration. New devices have been investigated for treating acute pain by delivering fentanyl by heat. The pure drug, fentanyl, is applied onto a surface which is then heated up to 350 °C and inhaled, resulting in no formation of degradation products. Furthermore, forced degradation of fentanyl has been studied which showed that longer heating time and higher temperatures will result in the formation of degradation products. The evidence indicates that heat can be used to deliver drugs to the lungs where fast onset reaction can be obtained giving fast and non-invasive pain relief.
Collapse
|
7
|
Mulder TAM, van Eerden RAG, de With M, Elens L, Hesselink DA, Matic M, Bins S, Mathijssen RHJ, van Schaik RHN. CYP3A4∗22 Genotyping in Clinical Practice: Ready for Implementation? Front Genet 2021; 12:711943. [PMID: 34306041 PMCID: PMC8296839 DOI: 10.3389/fgene.2021.711943] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 12/26/2022] Open
Abstract
Cytochrome P450 3A4 (CYP3A4) is the most important drug metabolizing enzyme in the liver, responsible for the oxidative metabolism of ∼50% of clinically prescribed drugs. Therefore, genetic variation in CYP3A4 could potentially affect the pharmacokinetics, toxicity and clinical outcome of drug treatment. Thus far, pharmacogenetics for CYP3A4 has not received much attention. However, the recent discovery of the intron 6 single-nucleotide polymorphism (SNP) rs35599367C > T, encoding the CYP3A4∗22 allele, led to several studies into the pharmacogenetic effect of CYP3A4∗22 on different drugs. This allele has a relatively minor allele frequency of 3-5% and an effect on CYP3A4 enzymatic activity. Thus far, no review summarizing the data published on several drugs is available yet. This article therefore addresses the current knowledge on CYP3A4∗22. This information may help in deciding if, and for which drugs, CYP3A4∗22 genotype-based dosing could be helpful in improving drug therapy. CYP3A4∗22 was shown to significantly influence the pharmacokinetics of several drugs, with currently being most thoroughly investigated tacrolimus, cyclosporine, and statins. Additional studies, focusing on toxicity and clinical outcome, are warranted to demonstrate clinical utility of CYP3A4∗22 genotype-based dosing.
Collapse
Affiliation(s)
- Tessa A M Mulder
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ruben A G van Eerden
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Mirjam de With
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Laure Elens
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sander Bins
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
8
|
Shah SB, Hariharan U, Chawla R. Common anti-COVID-19 drugs and their anticipated interaction with anesthetic agents. J Anaesthesiol Clin Pharmacol 2021; 37:160-170. [PMID: 34349362 PMCID: PMC8289657 DOI: 10.4103/joacp.joacp_461_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/21/2020] [Accepted: 11/29/2020] [Indexed: 12/24/2022] Open
Abstract
The corona virus disease 2019 (COVID-19) pandemic has till date (26/7/20) affected 1crore 62 lac 73 thousand 638 people globally with almost 6.5 lakh mortalities. COVID-19 has invaded the operation theatre and intensive care unit (ICU) in a short span of 6 months. It appears inevitable that all of us, as anesthesiologists, have to treat COVID-positive patients, either in the ICU or the operation theatre. Many asymptomatic, presumably noninfected people including frontline health care workers are also consuming potential anticorona viral drugs (such as hydroxychloroquine) prophylactically and may present for surgery. Detailed knowledge of which anesthetic and perioperative care drugs can interact with anti-COVID drugs would be very valuable for pre, intra-, and postoperative management of such patients and COVID-19 positive patients requiring intubation, mechanical ventilation, and ICU-sedation. Powered with this knowledge, anesthesiologists and intensivists can minimize the adverse effects of drug interactions. An extensive literature search using different search engines including Cochrane, Embase, Google Scholar, Scopus, and PubMed for all indexed review articles, original articles, case reports, and referenced webpages was performed to extract the most current and relevant literature on drug-drug interactions for clinicians.
Collapse
Affiliation(s)
- Shagun B. Shah
- Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, India
| | - Uma Hariharan
- Dr. Ram Manohar Lohia Hospital and PGIMER, CHS, New Delhi, India
| | - Rajiv Chawla
- Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, India
| |
Collapse
|
9
|
Wang CH, Terracciano AC, Masunov AE, Xu M, Vasu SS. Accurate prediction of terahertz spectra of molecular crystals of fentanyl and its analogs. Sci Rep 2021; 11:4062. [PMID: 33603077 PMCID: PMC7892882 DOI: 10.1038/s41598-021-83536-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/04/2021] [Indexed: 11/09/2022] Open
Abstract
Fentanyl is a potent synthetic opioid pain reliever with a high bioavailability that can be used as prescription anesthetic. Rapid identification via non-contact methods of both known and emerging opioid substances in the fentanyl family help identify the substances and enable rapid medical attention. We apply PBEh-3c method to identify vibrational normal modes from 0.01 to 3 THz in solid fentanyl and its selected analogs. The molecular structure of each fentanyl analog and unique arrangement of H-bonds and dispersion interactions significantly change crystal packing and is subsequently reflected in the THz spectrum. Further, the study of THz spectra of a series of stereoisomers shows that small changes in molecular structure results in distinct crystal packing and significantly alters THz spectra as well. We discuss spectral features of synthetic opioids with higher potency than conventional fentanyl such as ohmefentanyl and sufentanil and discover the pattern of THz spectra of fentanyl analogs.
Collapse
Affiliation(s)
- Chun-Hung Wang
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Orlando, FL, 32826, USA
| | - Anthony C Terracciano
- Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA.,Center for Advanced Turbomachinery and Energy Research, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA
| | - Artёm E Masunov
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Orlando, FL, 32826, USA. .,South Ural State University, Lenin Pr. 76, Chelyabinsk, Russia, 454080. .,National Research Nuclear University MEPhI, Kashirskoye Shosse 31, Moscow, Russia, 115409.
| | - Mengyu Xu
- Center for Advanced Turbomachinery and Energy Research, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA.,Department of Statistics and Data Science, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA
| | - Subith S Vasu
- Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA.,Center for Advanced Turbomachinery and Energy Research, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA
| |
Collapse
|
10
|
Factors Contributing to Fentanyl Pharmacokinetic Variability Among Diagnostically Diverse Critically Ill Children. Clin Pharmacokinet 2020; 58:1567-1576. [PMID: 31168770 DOI: 10.1007/s40262-019-00773-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The objective of this study was to characterize the population pharmacokinetics of fentanyl and identify factors that contribute to exposure variability in critically ill pediatric patients. METHODS We conducted a single-center, retrospective cohort study using electronic record data and remnant blood samples in the setting of a mixed medical/surgical intensive care unit (ICU) at a quaternary children's hospital. Children with a predicted ICU length of stay of at least 3 days and presence of an indwelling central venous or arterial line were included. Serum fentanyl measurements were performed for 278 unique remnant samples from 66 patients. Both one- and two-compartment models were evaluated to describe fentanyl disposition. Covariates were introduced into the model in a forward/backward, stepwise approach and included age, sex, race, weight, cytochrome P450 (CYP) 3A5 genotype, and the presence of CYP3A4 or CYP3A5 inducers or inhibitors. Simulations were performed using the successful model to depict the influence of inducers on fentanyl concentrations. RESULTS A two-compartment base model best described the data. There was good agreement between observed and predicted concentrations in the final model. The typical fentanyl clearance for 70 kg (reference weight) and 20.1 kg (median weight) patients were 34.6 and 13.6 L/h, respectively. The magnitude of the unexplained random inter-individual variability was high for both clearance (60.7%) and apparent volume of the central compartment (V1) (107.2%). Coadministration of the known CYP3A4/5 inducers fosphenytoin and/or phenobarbital was associated with significantly increased fentanyl clearance. Simulations demonstrate that the effect of inducer administration was most pronounced following discontinuation of a fentanyl infusion. CONCLUSIONS In this study we show the feasibility and utility of using electronic record data and remnant blood samples to successfully construct population pharmacokinetic models for a heterogeneous cohort of critically ill children. A clinically relevant effect of concomitant CYP3A4/5 inducers was identified. Scaling this population pharmacokinetic approach is necessary to craft precision approaches to fentanyl administration for critically ill children.
Collapse
|
11
|
Xu M, Wang CH, Terracciano AC, Masunov AE, Vasu SS. High accuracy machine learning identification of fentanyl-relevant molecular compound classification via constituent functional group analysis. Sci Rep 2020; 10:13569. [PMID: 32782338 PMCID: PMC7419312 DOI: 10.1038/s41598-020-70471-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/28/2020] [Indexed: 11/14/2022] Open
Abstract
Fentanyl is an anesthetic with a high bioavailability and is the leading cause of drug overdose death in the U.S. Fentanyl and its derivatives have a low lethal dose and street drugs which contain such compounds may lead to death of the user and simultaneously pose hazards for first responders. Rapid identification methods of both known and emerging opioid fentanyl substances is crucial. In this effort, machine learning (ML) is applied in a systematic manner to identify fentanyl-related functional groups in such compounds based on their observed spectral properties. In our study, accurate infrared (IR) spectra of common organic molecules which contain functional groups that are constituents of fentanyl is determined by investigating the structure–property relationship. The average accuracy rate of correctly identifying the functional groups of interest is 92.5% on our testing data. All the IR spectra of 632 organic molecules are from National Institute of Standards and Technology (NIST) database as the training set and are assessed. Results from this work will provide Artificial Intelligence (AI) based tools and algorithms increased confidence, which serves as a basis to detect fentanyl and its derivatives.
Collapse
Affiliation(s)
- Mengyu Xu
- Statistics and Data Science, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA.,Center for Advanced Turbomachinery and Energy Research, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA
| | - Chun-Hung Wang
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Orlando, FL, 32826, USA
| | - Anthony C Terracciano
- Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA.,Center for Advanced Turbomachinery and Energy Research, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA
| | - Artem E Masunov
- NanoScience Technology Center, University of Central Florida, 12424 Research Parkway, Orlando, FL, 32826, USA.,School of Modeling, Simulation, and Training, University of Central Florida, 3100 Technology Parkway, Orlando, FL, 32816, USA.,Department of Chemistry, University of Central Florida, 4111 Libra Dr., Orlando, FL, 32816, USA.,South Ural State University, Lenin pr. 76, Chelyabinsk, 454080, Russia.,National Research Nuclear University MEPhI, Kashirskoye shosse 31, Moscow, 115409, Russia
| | - Subith S Vasu
- Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA. .,Center for Advanced Turbomachinery and Energy Research, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL, 32816, USA.
| |
Collapse
|
12
|
Affiliation(s)
- Samuel A. Krug
- Forensic Science Arcadia University Glenside Pennsylvania USA
| | - Karen S. Scott
- Forensic Science Arcadia University Glenside Pennsylvania USA
| |
Collapse
|
13
|
Gundersen POM, Åstrand A, Gréen H, Josefsson M, Spigset O, Vikingsson S. Metabolite Profiling of Ortho-, Meta- and Para-Fluorofentanyl by Hepatocytes and High-Resolution Mass Spectrometry. J Anal Toxicol 2020; 44:140-148. [PMID: 31788682 PMCID: PMC7238673 DOI: 10.1093/jat/bkz081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/12/2019] [Accepted: 07/28/2019] [Indexed: 11/17/2022] Open
Abstract
New psychoactive substances are emerging on the illegal drug market. Synthetic opioids including fentanyl analogues are of special concern due to their high potency. This indicates the possibility of low drug concentrations in vivo and calls for sensitive analytical methods and identification of the most appropriate analytical targets. In this study the in vitro metabolism of ortho-, meta- and para-fluorofentanyl, three fluorinated derivatives of fentanyl, has been investigated using human hepatocytes and compared to the results from an authentic human urine sample. Based on knowledge on the metabolism of similar fentanyl analogues N-dealkylation and hydroxylation was hypothesized to be the most central pathways. The three fluorofentanyl isomers were incubated with pooled human hepatocytes at 1, 3 and 5 h. Liquid chromatography quadrupole time of flight mass spectrometry operating in data-dependent mode was used to analyse the hepatocyte samples, as well as the hydrolysed and non-hydrolysed authentic urine sample. Data were analysed by a targeted approach with a database of potential metabolites. The major metabolite formed in vitro was the N-dealkylation product norfluorofentanyl. In addition various hydroxylated metabolites, a N-oxide, dihydrodiol metabolites and a hydroxymethoxy metabolite were found. In total, 14 different metabolites were identified for each fluorofentanyl isomer. In the authentic urine sample, three metabolites were detected in addition to the ortho-fluorofentanyl parent compound, with hydroxymethoxy metabolite having the highest abundance followed by norfluorofentanyl and a metabolite hydroxylated on the ethylphenyl ring. This in vitro study showed that the metabolic pattern for ortho-, meta-, and para-fluorofentanyl was close to those previously reported for other fentanyl analogues. We suggest that the hydroxymethoxy metabolite and the metabolite hydroxylated on the ethylphenyl ring should be the metabolites primarily investigated in further studies to determine the most appropriate marker for intake of fluorofentanyl derivatives in urine drug screening for human subjects.
Collapse
Affiliation(s)
- Per Ole M Gundersen
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anna Åstrand
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Henrik Gréen
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| | - Martin Josefsson
- Department of Physics, Chemistry and Biology, Linköping University, Linköping, Sweden
- National Forensic Centre, Drug Unit, Linköping, Sweden
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Svante Vikingsson
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| |
Collapse
|
14
|
Völler S, Flint RB, Andriessen P, Allegaert K, Zimmermann LJI, Liem KD, Koch BCP, Simons SHP, Knibbe CAJ. Rapidly maturing fentanyl clearance in preterm neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104:F598-F603. [PMID: 31498775 DOI: 10.1136/archdischild-2018-315920] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fentanyl is frequently used off-label in preterm newborns. Due to very limited pharmacokinetic and pharmacodynamic data, fentanyl dosing is mostly based on bodyweight. This study describes the maturation of the pharmacokinetics in preterm neonates born before 32 weeks of gestation. METHODS 442 plasma samples from 98 preterm neonates (median gestational age: 26.9 (range 23.9-31.9) weeks, postnatal age: 3 (range 0-68) days, bodyweight 1.00 (range 0.39-2.37) kg) were collected in an opportunistic trial and fentanyl plasma levels were determined. NONMEM V.7.3 was used to develop a population pharmacokinetic model and to perform simulations. RESULTS Fentanyl pharmacokinetics was best described by a two-compartment model. A pronounced non-linear influence of postnatal and gestational age on clearance was identified. Clearance (L/hour/kg) increased threefold, 1.3-fold and 1.01-fold in the first, second and third weeks of life, respectively. In addition, clearance (L/hour/kg) was 1.4-fold and 1.7-fold higher in case of a gestational age of 28 and 31 weeks, respectively, compared with 25 weeks. Volume of distribution changed linearly with bodyweight and was 8.7 L/kg. To achieve similar exposure across the entire population, a continuous infusion (µg/kg/hour) dose should be reduced by 50% and 25% in preterm neonates with a postnatal age of 0-4 days and 5-9 days in comparison to 10 days and older. CONCLUSION Because of low clearance, bodyweight-based dosages may result in fentanyl accumulation in neonates with the lowest postnatal and gestational ages which may require dose reduction. Together with additional information on the pharmacodynamics, the results of this study can be used to guide dosing.
Collapse
Affiliation(s)
- Swantje Völler
- Division of Pharmacology, Division Systems Pharmacology and Biomedicine, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Robert B Flint
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Andriessen
- Division of Neonatology, Department of Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Luc J I Zimmermann
- Department of Pediatrics, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kian D Liem
- Division of Neonatology, Department of Pediatrics, Radboudumc, Nijmegen, The Netherlands
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Division of Pharmacology, Division Systems Pharmacology and Biomedicine, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | | |
Collapse
|
15
|
Geist MJP, Ziesenitz VC, Bardenheuer HJ, Burhenne J, Skopp G, Mikus G. Minor contribution of cytochrome P450 3A activity on fentanyl exposure in palliative care cancer patients. Sci Rep 2019; 9:14635. [PMID: 31601999 PMCID: PMC6786992 DOI: 10.1038/s41598-019-51279-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 09/29/2019] [Indexed: 12/02/2022] Open
Abstract
Transdermal fentanyl is widely used to control pain in cancer patients. The high pharmacokinetic variability of fentanyl is assumed to be due to cytochrome P450 3A-mediated (CYP3A) N-dealkylation to norfentanyl in humans. However, recently published clinical studies question the importance of the described metabolic pathway. In this small study in palliative cancer patients under real-life clinical conditions, the influence of CYP3A on fentanyl variability was investigated. In addition to the determination of midazolam plasma concentration to reveal CYP3A activity, plasma concentrations of fentanyl and its metabolite, norfentanyl, were measured in identical blood samples of 20 patients who participated in an ongoing trial and had been on transdermal fentanyl. Fentanyl, norfentanyl, midazolam, and 1′-OH-midazolam were quantified by liquid chromatography/tandem mass spectrometry. Plasma concentrations of fentanyl and norfentanyl exhibited a large variability. Mean estimated total clearance of fentanyl and mean metabolic clearance of midazolam (as a marker of CYP3A activity) were 75.5 and 36.3 L/h. Both clearances showed a weak correlation and hence a minimal influence of CYP3A on fentanyl elimination.
Collapse
Affiliation(s)
- Marcus J P Geist
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany.,Palliative-Care-Team Leuchtturm, Groß-Gerau, Germany
| | - Victoria C Ziesenitz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Pediatric Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hubert J Bardenheuer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Juergen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany.
| |
Collapse
|
16
|
Abstract
Introduction: Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplantation (HSCT); therefore, the prevention of GVHD is important for a successful treatment. Tacrolimus (Tac), a calcineurin inhibitor, has been widely used for the prophylaxis of GVHD in HSCT recipients. Areas covered: This review introduces phase II/III of clinical trials related with Tac's roles in the prevention of GVHD in HSCT. Furthermore, we discuss the normal ranges of Tac concentrations, pharmacogenetics, and drug interactions of Tac, as well as its side effects in adult HSCT recipients. Expert opinion: A series of studies has established the efficacy and safety of Tac alone or in combination with other agents in HSCT. However, successful administration of Tac is complicated by its narrow therapeutic window, inter-patient pharmacokinetic variability, and a spectrum of undesirable side effects. It is necessary to maintain concentrations of Tac within the desired ranges for GVHD prophylaxis. Moreover, various factors contribute to significant variability in Tac pharmacokinetics, including drug interactions and genomic variation.
Collapse
Affiliation(s)
- Yuan Gao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
| |
Collapse
|
17
|
Torralva R, Janowsky A. Noradrenergic Mechanisms in Fentanyl-Mediated Rapid Death Explain Failure of Naloxone in the Opioid Crisis. J Pharmacol Exp Ther 2019; 371:453-475. [PMID: 31492824 DOI: 10.1124/jpet.119.258566] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 09/03/2019] [Indexed: 12/25/2022] Open
Abstract
In December 2018, the Centers for Disease Control declared fentanyl the deadliest drug in America. Opioid overdose is the single greatest cause of death in the United States adult population (ages 18-50), and fentanyl and its analogs [fentanyl/fentanyl analogs (F/FAs)] are currently involved in >50% of these deaths. Anesthesiologists in the United States were introduced to fentanyl in the early 1970s when it revolutionized surgical anesthesia by combining profound analgesia with hemodynamic stability. However, they quickly had to master its unique side effect. F/FAs can produce profound rigidity in the diaphragm, chest wall and upper airway within an extremely narrow dosing range. This clinical effect was called wooden chest syndrome (WCS) by anesthesiologists and is not commonly known outside of anesthesiology or to clinicians or researchers in addiction research/medicine. WCS is almost routinely fatal without expert airway management. This review provides relevant clinical human pharmacology and animal data demonstrating that the significant increase in the number of F/FA-induced deaths may involve α-adrenergic and cholinergic receptor-mediated mechanical failure of the respiratory and cardiovascular systems with rapid development of rigidity and airway closure. Although morphine and its prodrug, heroin, can cause mild rigidity in abdominal muscles at high doses, neither presents with the distinct and rapid respiratory failure seen with F/FA-induced WCS, separating F/FA overdose from the slower onset of respiratory depression caused by morphine-derived alkaloids. This distinction has significant consequences for the design and implementation of new pharmacologic strategies to effectively prevent F/FA-induced death. SIGNIFICANCE STATEMENT: Deaths from fentanyl and F/FAs are increasing in spite of availability and awareness of the opioid reversal drug naloxone. This article reviews literature suggesting that naloxone may be ineffective against centrally mediated noradrenergic and cholinergic effects of F/FAs, which clinically manifest as severe muscle rigidity and airway compromise (e.g., wooden chest syndrome) that is rapid and distinct from respiratory depression seen with morphine-derived alkaloids. A physiologic model is proposed and implications for new drug development and treatment are discussed.
Collapse
Affiliation(s)
- Randy Torralva
- CODA Inc., Research Department, Portland, Oregon (R.T.); Research Service, VA Portland Health Care System, Portland, Oregon (R.T., A.J.); and Department of Psychiatry, Oregon Health & Science University, Portland, Oregon (R.T., A.J.)
| | - Aaron Janowsky
- CODA Inc., Research Department, Portland, Oregon (R.T.); Research Service, VA Portland Health Care System, Portland, Oregon (R.T., A.J.); and Department of Psychiatry, Oregon Health & Science University, Portland, Oregon (R.T., A.J.)
| |
Collapse
|
18
|
Brussee JM, Krekels EHJ, Calvier EAM, Palić S, Rostami-Hodjegan A, Danhof M, Barrett JS, de Wildt SN, Knibbe CAJ. A Pediatric Covariate Function for CYP3A-Mediated Midazolam Clearance Can Scale Clearance of Selected CYP3A Substrates in Children. AAPS JOURNAL 2019; 21:81. [PMID: 31250333 PMCID: PMC6597607 DOI: 10.1208/s12248-019-0351-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Recently a framework was presented to assess whether pediatric covariate models for clearance can be extrapolated between drugs sharing elimination pathways, based on extraction ratio, protein binding, and other drug properties. Here we evaluate when a pediatric covariate function for midazolam clearance can be used to scale clearance of other CYP3A substrates. A population PK model including a covariate function for clearance was developed for midazolam in children aged 1–17 years. Commonly used CYP3A substrates were selected and using the framework, it was assessed whether the midazolam covariate function accurately scales their clearance. For eight substrates, reported pediatric clearance values were compared numerically and graphically with clearance values scaled using the midazolam covariate function. For sildenafil, clearance values obtained with population PK modeling based on pediatric concentration-time data were compared with those scaled with the midazolam covariate function. According to the framework, a midazolam covariate function will lead to systemically accurate clearance scaling (absolute prediction error (PE) < 30%) for CYP3A substrates binding to albumin with an extraction ratio between 0.35 and 0.65 when binding < 10% in adults, between 0.05 and 0.55 when binding > 90%, and with an extraction ratio ranging between these values when binding between 10 and 90%. Scaled clearance values for eight commonly used CYP3A substrates were reasonably accurate (PE < 50%). Scaling of sildenafil clearance was accurate (PE < 30%). We defined for which CYP3A substrates a pediatric covariate function for midazolam clearance can accurately scale plasma clearance in children. This scaling approach may be useful for CYP3A substrates with scarce or no available pediatric PK information.
Collapse
Affiliation(s)
- Janneke M Brussee
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Elisa A M Calvier
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Semra Palić
- Dutch Cancer Institute (NKI), Amsterdam, The Netherlands
| | - Amin Rostami-Hodjegan
- Centre for Applied Pharmacokinetic Research, University of Manchester, Manchester, UK.,Simcyp Limited (A Certara Company), Sheffield, UK
| | - Meindert Danhof
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Jeffrey S Barrett
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA.,Department of Pediatrics, Division of Clinical Pharmacology & Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St. Antonius Hospital, PO Box 2500, 3430, EM, Nieuwegein, The Netherlands.
| |
Collapse
|
19
|
Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review. Clin Pharmacokinet 2019; 57:125-149. [PMID: 28688027 DOI: 10.1007/s40262-017-0569-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R 2 = 0.71, B max 876 mL/min, K 50 16.3 kg) and alfentanil (R 2 = 0.70, B max (fixed) 420 mL/min, K 50 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R 2 = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R 2 = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.
Collapse
|
20
|
Wilde M, Pichini S, Pacifici R, Tagliabracci A, Busardò FP, Auwärter V, Solimini R. Metabolic Pathways and Potencies of New Fentanyl Analogs. Front Pharmacol 2019; 10:238. [PMID: 31024296 PMCID: PMC6461066 DOI: 10.3389/fphar.2019.00238] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/26/2019] [Indexed: 12/11/2022] Open
Abstract
Up to now, little is known about the metabolic pathways of new fentanyl analogs that have recently emerged on the drug markets worldwide with high potential for producing addiction and severe adverse effects including coma and death. For some of the compounds, limited information on the metabolism has been published, however, for others so far no information is available. Considering the well characterized metabolism of the pharmaceutically used opioid fentanyl and the so far available data, the metabolism of the new fentanyl analogs can be anticipated to generally involve reactions like hydrolysis, hydroxylation (and further oxidation steps), N- and O-dealkylation and O-methylation. Furthermore, phase II metabolic reactions can be expected comprising glucuronide or sulfate conjugate formation. When analyzing blood and urine samples of acute intoxication cases or fatalities, the presence of metabolites can be crucial for confirmation of the uptake of such compounds and further interpretation. Here we present a review on the metabolic profiles of new fentanyl analogs responsible for a growing number of severe and fatal intoxications in the United States, Europe, Canada, Australia, and Japan in the last years, as assessed by a systematic search of the scientific literature and official reports.
Collapse
Affiliation(s)
- Maurice Wilde
- Department of Forensic Toxicology, Institute of Forensic Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Hermann Staudinger Graduate School, University of Freiburg, Freiburg im Breisgau, Germany
| | - Simona Pichini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | - Roberta Pacifici
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | - Adriano Tagliabracci
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Excellence SBSP, Università Politecnica delle Marche, Ancona, Italy
| | - Francesco Paolo Busardò
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Excellence SBSP, Università Politecnica delle Marche, Ancona, Italy
| | - Volker Auwärter
- Department of Forensic Toxicology, Institute of Forensic Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Renata Solimini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| |
Collapse
|
21
|
Busardò FP, Carlier J, Giorgetti R, Tagliabracci A, Pacifici R, Gottardi M, Pichini S. Ultra-High-Performance Liquid Chromatography-Tandem Mass Spectrometry Assay for Quantifying Fentanyl and 22 Analogs and Metabolites in Whole Blood, Urine, and Hair. Front Chem 2019; 7:184. [PMID: 31001514 PMCID: PMC6454115 DOI: 10.3389/fchem.2019.00184] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/11/2019] [Indexed: 12/22/2022] Open
Abstract
Recently, synthetic opioid-related overdose fatalities, led by illicitly manufactured fentanyl and analogs, increased at an alarming rate, posing a global public health threat. New synthetic fentanyl analogs have been constantly emerging onto the drug marked for the last few years, to circumvent the laws and avoid analytical detection. Analytical methods need to be regularly updated to keep up with the new trends. In this study, we aimed to develop a new method for detecting the newest fentanyl analogs with a high sensitivity, in whole blood, urine, and hair. The method is intended to provide to clinical and forensic toxicologists a tool for documenting consumption. We developed a comprehensive ultra-high-performance liquid chromatography-tandem mass spectrometry method for quantifying fentanyl and 22 analogs and metabolites. Urine samples were simply diluted before injection; a liquid-liquid extraction was performed for blood testing; and a solid phase extraction was performed in hair. The chromatographic separation was short (8 min). The method was validated with a high sensitivity; limits of quantifications ranged from 2 to 6 ng/L in blood and urine, and from 11 to 21 pg/g in hair. The suitability of the method was tested with 42 postmortem blood, urine, or hair specimens from 27 fatalities in which fentanyl analogs were involved. Average blood concentrations (±SD) were 7.84 ± 7.21 and 30.0 ± 18.0 μg/L for cyclopropylfentanyl and cyclopropyl norfentanyl, respectively (n = 8), 4.08 ± 2.30 μg/L for methoxyacetylfentanyl, (n = 4), 40.2 ± 38.6 and 44.5 ± 21.1 μg/L for acetylfentanyl and acetyl norfentanyl, respectively (n = 3), 33.7 and 7.17 μg/L for fentanyl and norfentanyl, respectively (n = 1), 3.60 and 0.90 μg/L for furanylfentanyl and furanyl norfentanyl, respectively (n = 1), 0.67 μg/L for sufentanil (n = 1), and 3.13 ± 2.37 μg/L for 4-ANPP (n = 9). Average urine concentrations were 47.7 ± 39.3 and 417 ± 296 μg/L for cyclopropylfentanyl and cyclopropyl norfentanyl, respectively (n = 11), 995 ± 908 μg/L for methoxyacetylfentanyl, (n = 3), 1,874 ± 1,710 and 6,582 ± 3,252 μg/L for acetylfentanyl and acetyl norfentanyl, respectively (n = 5), 146 ± 318 and 300 ± 710 μg/L for fentanyl (n = 5) and norfentanyl (n = 6), respectively, 84.0 and 23.0 μg/L for furanylfentanyl and furanyl norfentanyl, respectively (n = 1), and 50.5 ± 50.9 μg/L for 4-ANPP (n = 10). Average hair concentrations were 2,670 ± 184 and 82.1 ± 94.7 ng/g for fentanyl and norfentanyl, respectively (n = 2), and 10.8 ± 0.57 ng/g for 4-ANPP (n = 2).
Collapse
Affiliation(s)
| | - Jeremy Carlier
- Unit of Forensic Toxicology, Università la Sapienza, Rome, Italy
| | - Raffaele Giorgetti
- Section of Legal Medicine, Università Politecnica Delle Marche, Ancona, Italy
| | | | - Roberta Pacifici
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| | | | - Simona Pichini
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
| |
Collapse
|
22
|
Wang K, Xu B, Wu J, Zhu Y, Guo L, Xie J. Elucidating fentanyls differentiation from morphines in chemical and biological samples with surface‐enhanced Raman spectroscopy. Electrophoresis 2019; 40:2193-2203. [DOI: 10.1002/elps.201900004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Kai Wang
- State Key Laboratory of Toxicology and Medical Countermeasures and Laboratory of Toxicant Analysis Institute of Pharmacology and Toxicology Academy of Military Medical Sciences Beijing P. R. China
| | - Bin Xu
- State Key Laboratory of Toxicology and Medical Countermeasures and Laboratory of Toxicant Analysis Institute of Pharmacology and Toxicology Academy of Military Medical Sciences Beijing P. R. China
| | - Jianfeng Wu
- State Key Laboratory of Toxicology and Medical Countermeasures and Laboratory of Toxicant Analysis Institute of Pharmacology and Toxicology Academy of Military Medical Sciences Beijing P. R. China
| | - Yingjie Zhu
- State Key Laboratory of Toxicology and Medical Countermeasures and Laboratory of Toxicant Analysis Institute of Pharmacology and Toxicology Academy of Military Medical Sciences Beijing P. R. China
| | - Lei Guo
- State Key Laboratory of Toxicology and Medical Countermeasures and Laboratory of Toxicant Analysis Institute of Pharmacology and Toxicology Academy of Military Medical Sciences Beijing P. R. China
| | - Jianwei Xie
- State Key Laboratory of Toxicology and Medical Countermeasures and Laboratory of Toxicant Analysis Institute of Pharmacology and Toxicology Academy of Military Medical Sciences Beijing P. R. China
| |
Collapse
|
23
|
Burns SM, Cunningham CW, Mercer SL. DARK Classics in Chemical Neuroscience: Fentanyl. ACS Chem Neurosci 2018; 9:2428-2437. [PMID: 29894151 DOI: 10.1021/acschemneuro.8b00174] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Fentanyl rose to prominence as an alternative analgesic to morphine nearly 50 years ago; today, fentanyl has re-emerged as a dangerous recreational substance. The increased potency and analgesic effect of fentanyl are advantageous in the treatment of pain but are also responsible for the rise in unintentional opioid overdose deaths. In response to this crisis, fentanyl, its analogues, and even precursors are under heightened regulatory scrutiny. Despite this controversial history, derivatization of fentanyl has resulted in numerous synthetic analogues that provide valuable insights into opioid receptor binding and signaling events. In this review, the impact of fentanyl on chemical neuroscience is shown through its synthesis and properties, manufacturing, metabolism, pharmacology, approved and off-label indications, adverse effects, and the responsibility it has in the opioid epidemic.
Collapse
Affiliation(s)
- S. Mallory Burns
- Department of Pharmaceutical Sciences, Lipscomb University College of Pharmacy, Nashville, Tennessee 37204, United States
| | - Christopher W. Cunningham
- Department of Pharmaceutical Sciences, Concordia University Wisconsin School of Pharmacy, Mequon, Wisconsin 53097, United States
| | - Susan L. Mercer
- Department of Pharmaceutical Sciences, Lipscomb University College of Pharmacy, Nashville, Tennessee 37204, United States
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, United States
| |
Collapse
|
24
|
Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review. Clin Pharmacokinet 2017; 57:393-417. [PMID: 29178007 DOI: 10.1007/s40262-017-0609-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R 2 = 0.71, B max 876 mL/min, K 50 16.3 kg) and alfentanil (R 2 = 0.70, B max (fixed) 420 mL/min, K 50 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R 2 = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R 2 = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.
Collapse
|
25
|
Vaughns JD, Ziesenitz VC, Williams EF, Mushtaq A, Bachmann R, Skopp G, Weiss J, Mikus G, van den Anker JN. Use of Fentanyl in Adolescents with Clinically Severe Obesity Undergoing Bariatric Surgery: A Pilot Study. Paediatr Drugs 2017; 19:251-257. [PMID: 28238111 PMCID: PMC5861708 DOI: 10.1007/s40272-017-0216-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The number of obese pediatric patients requiring anesthesia is rapidly increasing. Although fentanyl is a commonly used narcotic during surgery, there are no pharmacokinetic (PK) data available for optimal dosing of fentanyl in adolescents with clinically severe obesity. MATERIALS AND METHODS An institutional review board-approved exploratory pilot study was conducted in six adolescents aged 14-19 years undergoing bariatric surgery. Mean total body weight (TBW) and mean BMI were 137.4 ± 14.3 kg and 49.6 ± 6.4 kg/m2 (99.5th BMI percentile), respectively. Fentanyl was administered intravenously for intraoperative analgesia based on ideal body weight per standard of care. PK blood samples were drawn over a 24-h post-dose period. Fentanyl PK parameters were calculated by non-compartmental analysis. RESULTS Mean fentanyl AUC0-∞ was 1.5 ± 0.5 h·ng/mL. Systemic clearance of fentanyl was 1522 ± 310 mL/min and 11.2 ± 2.6 mL/min·kg TBW. Volume of distribution was 635 ± 282 L and 4.7 ± 2.1 L/kg TBW. While absolute clearance was increased, absolute volume of distribution was comparable to previously established adult values. CONCLUSIONS These results suggest that fentanyl clearance is enhanced in adolescents with clinically severe obesity while volume of distribution is comparable to previously published studies. STUDY REGISTRATION NCT01955993 (clinicaltrials.gov).
Collapse
Affiliation(s)
- Janelle D Vaughns
- Division of Anesthesiology, Sedation and Perioperative Medicine, Children's National Health System, Washington, DC, USA
| | - Victoria C Ziesenitz
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA.
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany.
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, 4056, Basel, Switzerland.
| | - Elaine F Williams
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Alvina Mushtaq
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Ricarda Bachmann
- Institute of Legal and Traffic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Gisela Skopp
- Institute of Legal and Traffic Medicine, University of Heidelberg, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Johannes N van den Anker
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, 4056, Basel, Switzerland
| |
Collapse
|
26
|
Zhang H, Chen M, Wang X, Yu S. Patients with CYP3A4*1G genetic polymorphism consumed significantly lower amount of sufentanil in general anesthesia during lung resection. Medicine (Baltimore) 2017; 96:e6013. [PMID: 28121959 PMCID: PMC5287983 DOI: 10.1097/md.0000000000006013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
CYP3A4, an isoform of cytochrome P450 enzymes, is responsible for the metabolism of 45% to 60% of currently prescribed drugs. It has been shown that CYP3A4*1G, a single nucleotide polymorphism (SNP), affects the enzymatic activity of CYP3A4. Sufentanil, a synthetic opioid commonly used for the induction and maintenance of general anesthesia, analgesia, and sedation, is mainly metabolized by CYP3A4. So far, the impact of CYP3A4*1G on sufentanil metabolism has not been investigated. In the present study, we first determined the frequency of CYP3A4*1G polymorphism in patients of Chinese Han nationality who underwent lung resection, and then compared the amount of sufentanil used in general anesthesia during the surgical procedure between wild type and mutant patients.DNA sequencing was performed to genotype the CYP3A4*1G allele in 191 patients. The sufentanil dosages consumed in general anesthesia were recorded and compared between wild-type and mutant patients.The frequency of the CYP3A4*1G variant allele was 0.202 (77/382). No significant difference was observed in age, body weight, or operation time between wild-type and mutant patients. The amount of sufentanil consumed by patients with the point mutation was significantly lower than that in the wild type group. No significant difference in sufentanil dosages was observed between females and males within wild type or within mutant group.High frequency of CYP3A4*1G variants was detected in patients of Chinese Han nationality. Significantly lower amount of sufentanil was consumed in mutant patients compared with wild type subjects, likely a result of impaired CYP3A4 activity due to the point mutation. These findings suggest genotyping of CYP3A4 might be of value in providing guidance for the use of sufentanil.
Collapse
|
27
|
Effect of Pregnane X Receptor *1B genetic polymorphisms on postoperative analgesia with fentanyl in Chinese patients undergoing gynecological surgery. BMC MEDICAL GENETICS 2016; 17:87. [PMID: 27876007 PMCID: PMC5120516 DOI: 10.1186/s12881-016-0348-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 11/15/2016] [Indexed: 11/30/2022]
Abstract
Background The purpose of the study was to investigate the effects of the pregnane X receptor (PXR)*1B polymorphisms on CYP3A4 enzyme activity and postoperative fentanyl consumption in Chinese patients undergoing gynecological surgery. Methods A total of 287 females of Han ethnicity, aged 20 to 50 years old, ASA I or II, scheduled to abdominal total hysterectomy or myomectomy under general anesthesia were enrolled. The analgesic model used was fentanyl consumption via patient-controlled intravenous analgesia (PCIA) in the post-operative period. Additionally, pain was assessed using a visual analog score (VAS). Pain scores, occurrence of adverse reactions and consumption of fentanyl were recorded during the 24 h postoperative period. The enzyme activity of CYP3A4 was evaluated by measuring the plasma ratio of 1′-hydroxymidazolam to midazolam 1 h after intravenous administration of 0.1 mg/kg midazolam. PXR genotyping was performed by direct DNA sequencing and the PXR*1B haplotype was analyzed via PHASE V.2.1 software. Results The polymorphism frequency of PXR11156A > C/11193 T > C and 8055C > T were 49.6 and 49.3%, and the rate of PXR*1B haplotype was 48.8% in our study. None of the pain scores, consumption of fentanyl 24 h post-operatively or enzyme activity of CYP3A4, showed differences among different genotypes. Conclusions PXR11156A > C, PXR11193T > C, PXR8055C > T or the PXR*1B haplotype do not appear to be important factors contributing to CYP3A4 activity and interindividual variations in postoperative fentanyl consumption in Han female patients undergoing gynecological surgery. Trial registration The DNA samples were obtained since 2007 to 2010 year in our hospital, there was no registration at that time. So this section is not applicable to our research.
Collapse
|
28
|
Wei W, Tian Y, Zhao C, Sui Z, Liu C, Wang C, Yang R. Correlation of ADRB1 rs1801253 Polymorphism with Analgesic Effect of Fentanyl After Cancer Surgeries. Med Sci Monit 2015; 21:4000-5. [PMID: 26694722 PMCID: PMC4692569 DOI: 10.12659/msm.894060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Our study aimed to explore the association between β1-adrenoceptor (ADRB1) rs1801253 polymorphism and analgesic effect of fentanyl after cancer surgeries in Chinese Han populations. MATERIAL AND METHODS Postoperative fentanyl consumption of 120 patients for analgesia was recorded. Genotype distributions were detected by allele specific amplification-polymerase chain reaction (ASA-PCR) method. Postoperative pain was measured by visual analogue scale (VAS) method. Differences in postoperative VAS score and postoperative fentanyl consumption for analgesia in different genotype groups were compared by analysis of variance (ANOVA). Preoperative cold pressor-induced pain test was also performed to test the analgesic effect of fentanyl. RESULTS Frequencies of Gly/Gly, Gly/Arg, Arg/Arg genotypes were 45.0%, 38.3%, and 16.7%, respectively, and passed the Hardy-Weinberg Equilibrium (HWE) test. The mean arterial pressure (MAP) and the heart rate (HR) had no significant differences at different times. After surgery, the VAS score and fentanyl consumption in Arg/Arg group were significantly higher than in other groups at the postoperative 2nd hour, but the differences were not obvious at the 4th hour, 24th hour, and the 48th hour. The results suggest that the Arg/Arg homozygote increased susceptibility to postoperative pain. The preoperative cold pressor-induced pain test suggested that individuals with Arg/Arg genotype showed worse analgesic effect of fentanyl compared to other genotypes. CONCLUSIONS In Chinese Han populations, ADRB1 rs1801253 polymorphism might be associated with the analgesic effect of fentanyl after cancer surgery.
Collapse
Affiliation(s)
- Wei Wei
- Department of Dermatology, The General Hospital of Beijing Military Command, Beijing, China (mainland)
| | - Yanli Tian
- Department of Dermatology, The General Hospital of Beijing Military Command, Beijing, China (mainland)
| | - Chunlei Zhao
- Hengshui Cardiovascular Hospital, Hengshui, Hebei, China (mainland)
| | - Zhifu Sui
- Department of Dermatology, The General Hospital of Beijing Military Command, Beijing, China (mainland)
| | - Chang Liu
- Department of Dermatology, The General Hospital of Beijing Military Command, Beijing, China (mainland)
| | - Congmin Wang
- Department of Dermatology, The General Hospital of Beijing Military Command, Beijing, China (mainland)
| | - Rongya Yang
- Department of Dermatology, The General Hospital of Beijing Military Command, Beijing, China (mainland)
| |
Collapse
|
29
|
Fields MD, Abate MA, Hu L, Long DL, Blommel ML, Haikal NA, Kraner JC. Parent and Metabolite Opioid Drug Concentrations in Unintentional Deaths Involving Opioid and Benzodiazepine Combinations. J Forensic Sci 2015; 60:950-6. [PMID: 26223761 PMCID: PMC4944848 DOI: 10.1111/1556-4029.12807] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 04/28/2014] [Accepted: 05/12/2014] [Indexed: 11/29/2022]
Abstract
Effects of benzodiazepines on postmortem opioid parent and parent/metabolite blood concentration ratios were determined for fentanyl-, hydrocodone-, methadone-, or oxycodone-related accidental deaths. These opioids are partially metabolized by the CYP3A4 enzyme system, which is also affected by diazepam and alprazolam. Opioid/metabolite combinations examined were as follows: fentanyl/norfentanyl, hydrocodone/dihydrocodeine, methadone/EDDP, and oxycodone/oxymorphone. Parent opioid concentrations were analyzed for 877 deaths. Parent/metabolite concentration ratios were analyzed for 349 deaths, excluding cases with co-intoxicants present known to interfere with opioid elimination. Alprazolam in combination with diazepam significantly decreased median hydrocodone concentrations by 48% (p = 0.01) compared to hydrocodone alone. The methadone parent/metabolite concentration ratio was reduced by 35% in the presence of diazepam compared to methadone alone (p = 0.03). Benzodiazepines did not statistically significantly affect fentanyl or oxycodone concentrations. Possible factors affecting opioid concentrations and possible toxicity development, including any differential effects on specific opioids, should continue to be explored.
Collapse
Affiliation(s)
- Marcia D. Fields
- West Virginia University School of Pharmacy, 1124 Health Sciences North, Morgantown, WV
| | - Marie A. Abate
- West Virginia University School of Pharmacy, 1124 Health Sciences North, Morgantown, WV
| | - Lan Hu
- West Virginia University School of Public Health, Morgantown, WV
| | - D. Leann Long
- West Virginia University School of Public Health, Morgantown, WV
| | - Matthew L. Blommel
- West Virginia University School of Pharmacy, 1124 Health Sciences North, Morgantown, WV
| | - Nabila A. Haikal
- West Virginia Office of the Chief Medical Examiner, Charleston, WV
| | - James C. Kraner
- West Virginia Office of the Chief Medical Examiner, Charleston, WV
| |
Collapse
|
30
|
Challenges in the optimisation of post-operative pain management with opioids in obese patients: a literature review. Obes Surg 2014; 23:1458-75. [PMID: 23700237 DOI: 10.1007/s11695-013-0998-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
An increasing number of obese patients are undergoing surgery, particularly bariatric and orthopaedic surgery. The physiological differences between obese and normal-weight subjects may modify not only anaesthetic requirements during surgery but also post-operative analgesic management, raising a number of challenges in a critical period. In this review, we analyse studies of post-operative pain management with opioids in obese subjects. We discuss the genetic factors common to pain and obesity and the factors potentially modifying opioid pharmacokinetics and pharmacodynamics in obese patients, and we analyse the overall efficacy and safety of opioids for pain management during the post-operative period in obese patients. Both modifications to surgical methods and additional analgesic treatments to decrease the requirement for opioids may improve early rehabilitation and quality of care and reduce adverse effects in obese patients.
Collapse
|
31
|
Brill MJE, Diepstraten J, van Rongen A, van Kralingen S, van den Anker JN, Knibbe CAJ. Impact of obesity on drug metabolism and elimination in adults and children. Clin Pharmacokinet 2012; 51:277-304. [PMID: 22448619 DOI: 10.2165/11599410-000000000-00000] [Citation(s) in RCA: 255] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The prevalence of obesity in adults and children is rapidly increasing across the world. Several general (patho)physiological alterations associated with obesity have been described, but the specific impact of these alterations on drug metabolism and elimination and its consequences for drug dosing remains largely unknown. In order to broaden our knowledge of this area, we have reviewed and summarized clinical studies that reported clearance values of drugs in both obese and non-obese patients. Studies were classified according to their most important metabolic or elimination pathway. This resulted in a structured review of the impact of obesity on metabolic and elimination processes, including phase I metabolism, phase II metabolism, liver blood flow, glomerular filtration and tubular processes. This literature study shows that the influence of obesity on drug metabolism and elimination greatly differs per specific metabolic or elimination pathway. Clearance of cytochrome P450 (CYP) 3A4 substrates is lower in obese as compared with non-obese patients. In contrast, clearance of drugs primarily metabolized by uridine diphosphate glucuronosyltransferase (UGT), glomerular filtration and/or tubular-mediated mechanisms, xanthine oxidase, N-acetyltransferase or CYP2E1 appears higher in obese versus non-obese patients. Additionally, in obese patients, trends indicating higher clearance values were seen for drugs metabolized via CYP1A2, CYP2C9, CYP2C19 and CYP2D6, while studies on high-extraction-ratio drugs showed somewhat inconclusive results. Very limited information is available in obese children, which prevents a direct comparison between data obtained in obese children and obese adults. Future clinical studies, especially in children, adolescents and morbidly obese individuals, are needed to extend our knowledge in this clinically important area of adult and paediatric clinical pharmacology.
Collapse
Affiliation(s)
- Margreke J E Brill
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | | | | |
Collapse
|
32
|
Effect of Animal Condition and Fluvoxamine on the Result of [(18)F]N-3-Fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl) Nortropane ([(18)F]FP-CIT) PET Study in Mice. Nucl Med Mol Imaging 2012; 46:27-33. [PMID: 24900029 DOI: 10.1007/s13139-011-0117-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 10/26/2011] [Accepted: 11/02/2011] [Indexed: 10/15/2022] Open
Abstract
PURPOSE PET (positron emission tomography) is a noninvasive imaging technique, visualizing biological aspects in vivo. In animal models, the result of PET study can be affected more prominently than in humans by the animal conditions or drug pretreatment. We assessed the effects of anesthesia, body temperature, and pretreatment with selective serotonin reuptake inhibitor on the results of [(18)F]N-3-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl) nortropane ([(18)F]FP-CIT) PET in mice. METHODS [(18)F]FP-CIT PET of C57BL/6 mice was performed in three different conditions: (1) anesthesia (isoflurane) with active warming (38°C) as a reference; (2) no anesthesia or warming; (3) anesthesia without warming at room temperature. Additional groups of mice pretreated with escalating doses of fluvoxamine (5, 20, 40, 80 mg/kg) were imaged in condition (1). The time activity curve and standardized uptake value of the striatum, cerebral cortex, and bone were compared among these conditions. RESULTS In all conditions, radioactivities of the striatum and cortex tended to form a plateau after rapid uptake and washout, but that of bone tended to increase gradually. When anesthetized without any warming, all the mice developed hypothermia and showed reduced bone uptake with slightly increased striatal and cortical uptakes compared to the reference condition. In conditions without anesthesia, striatal and cortical uptakes were reduced, whereas the bone uptake showed no change. Pretreatment with fluvoxamine increased the striatal uptake and striatal specific to cortical non-specific uptake ratio, whereas the bone uptake was reduced. CONCLUSION Anesthesia, body temperature, and fluvoxamine affect the result of [(18)F]FP-CIT PET in mice by altering striatal and bone uptakes.
Collapse
|
33
|
Influence of CYP3A5*3 polymorphism and interaction between CYP3A5*3 and CYP3A4*1G polymorphisms on post-operative fentanyl analgesia in Chinese patients undergoing gynaecological surgery. Eur J Anaesthesiol 2011. [DOI: 10.1097/eja.0b013e3283438b39] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Lundeberg S, Roelofse JA. Aspects of pharmacokinetics and pharmacodynamics of sufentanil in pediatric practice. Paediatr Anaesth 2011; 21:274-9. [PMID: 20849451 DOI: 10.1111/j.1460-9592.2010.03411.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sufentanil is a potent synthetic opioid. Like other opioids, sufentanil creates a stable hemodynamic environment in cardiovascularly compromised pediatric patients. Clearance, expressed as per kilogram, is increased in children compared to adults. The P450 CYP3A4 enzyme is responsible for the major metabolic N-dealkylation pathway. Enzyme activity is reduced in neonates but the maturation of sufentanil clearance is not described. The free active fraction is affected by age because of the reduced α(1) -acid glycoprotein plasma concentrations in neonates. Intranasal administration of sufentanil is a possible option for premedication, procedural sedation and analgesia in children, as this option has been found to be safe and effective. Studies concerning the pharmacokinetics and dynamics of sufentanil administered as a bolus or continuous infusion in children are few.
Collapse
Affiliation(s)
- Stefan Lundeberg
- Department of Pediatric Anesthesia and Intensive Care, Pain Treatment Service, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
| | | |
Collapse
|
35
|
Kummer O, Hammann F, Moser C, Schaller O, Drewe J, Krähenbühl S. Effect of the inhibition of CYP3A4 or CYP2D6 on the pharmacokinetics and pharmacodynamics of oxycodone. Eur J Clin Pharmacol 2010; 67:63-71. [PMID: 20857093 DOI: 10.1007/s00228-010-0893-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 08/25/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE The main metabolic pathways of oxycodone, a potent opioid analgetic, are N-demethylation (CYP3A4) to inactive noroxycodone and O-demethylation (CYP2D6) to active oxymorphone. We performed a three-way, placebo-controlled, double-blind cross-over study to assess the pharmacokinetic and pharmacodynamic consequences of drug interactions with oxycodone. METHODS The 12 participants (CYP2D6 extensive metabolizers) were pre-treated with placebo, ketoconazole or paroxetine before oral oxycodone ingestion (0.2 mg/kg). RESULTS Pre-treatment with ketoconazole increased the AUC for oxycodone 2- to 3-fold compared with placebo or paroxetine. In combination with placebo, oxycodone induced the expected decrease in pupil diameter. This decrease was accentuated in the presence of ketoconazole, but blunted by paroxetine. In comparison to pre-treatment with placebo, ketoconazole increased nausea, drowsiness, and pruritus associated with oxycodone. In contrast, the effect of pre-treatment with paroxetine on the above-mentioned adverse events was not different from that of placebo. Ketoconazole increased the analgetic effect of oxycodone, whereas paroxetine was not different from placebo. CONCLUSIONS Inhibition of CYP3A4 by ketoconazole increases the exposure and some pharmacodynamic effects of oxycodone. Paroxetine pretreatment inhibits CYP2D6 without inducing relevant changes in oxycodone exposure, and partially blunts the pharmacodynamic effects of oxycodone due to intrinsic pharmacological activities. Pharmacodynamic changes associated with CYP3A4 inhibition may be clinically important in patients treated with oxycodone.
Collapse
Affiliation(s)
- Oliver Kummer
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine, University Hospital, 4031 Basel, Switzerland
| | | | | | | | | | | |
Collapse
|
36
|
Miyazaki T, Hanaoka K, Namiki A, Ogawa S, Kitajima T, Hosokawa T, Ishida T, Nogami S, Mashimo S. Efficacy, safety and pharmacokinetic study of a novel fentanyl-containing matrix transdermal patch system in Japanese patients with cancer pain. Clin Drug Investig 2008; 28:313-25. [PMID: 18407717 DOI: 10.2165/00044011-200828050-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES A novel transdermal matrix patch delivery system for fentanyl has been developed to deliver improved management of cancer pain compared with that obtained using current fentanyl reservoir patches. This study was carried out to assess the efficacy, safety and pharmacokinetic profiles of a 12.5 microg/h transdermal matrix fentanyl patch administered with the objective of replacing morphine, oral oxycodone or fentanyl injection formulations. The study also evaluated how the pharmacokinetic profiles of higher dose fentanyl patches (25, 37.5 and 50 microg/h) changed following dose adjustments to optimize management of cancer pain. METHODS This open-label, multicentre study involved 87 patients of both sexes (> or =20 years) with a confirmed diagnosis of cancer. Patients were receiving any one of the following at the time of enrollment for the management of their cancer pain: (a) morphine <45 mg/day orally, <30 mg/day as suppositories, or <15 mg/day by injection; (b) oral oxycodone <30 mg/day; or (c) fentanyl injectable preparations <0.3 mg/day. The patients were administered a 3-day course of fentanyl transdermal matrix patch application three times. The initial dose was 12.5 microg/h, which could be increased when a new patch was applied if the physician deemed this to be appropriate based on pain intensity ratings and use of rescue medications. Efficacy outcomes included patients' global assessment scores (primary efficacy endpoint) measured on a five-step scale and dichotomous scores for physicians' global assessment. The occurrence of adverse events and changes in laboratory tests were evaluated as safety variables. Serum fentanyl levels were measured immediately after removal of the old patch on days 4, 7 and 10 to obtain data on trough serum concentrations. RESULTS The percentage of patients in category 3 or higher (very satisfied, satisfied, or neither satisfied nor dissatisfied) for the patient's global assessment score was 89.4% (76/85), indicating high patient satisfaction and attainment of sufficient pain control after patients switched from their previously used opioid analgesics. Similar findings were obtained on physicians' global assessment scores. A total of 316 adverse events occurred in 78 (90.7%) of 86 patients who were administered at least one patch. These included nausea (31 [36.0%]), somnolence (26 [30.2%]), vomiting (22 [25.6%]), diarrhoea (17 [19.8%]), constipation (14 [16.3%]), pyrexia (11 [12.8%]) and insomnia (9 [10.5%]). The mean (+/- SD) serum fentanyl concentration determined on day 4 was 169.9 +/- 103.4 pg/mL (n = 83). Serum fentanyl measurement results indicated that the same fentanyl patch dose resulted in similar serum fentanyl levels, while increased doses produced higher serum fentanyl concentrations. CONCLUSION The fentanyl matrix transdermal patch formulation employed in this study demonstrated sufficient cancer pain control for patients switching from morphine or oral oxycodone preparations. The patch tested was well tolerated and its use did not result in any increased incidence of adverse drug reactions over those commonly found with opioid analgesics.
Collapse
|
37
|
Darwish M, Tempero K, Jiang JG, Simonson PG. Extent of Fentanyl Accumulation Following Multiple Doses of Fentanyl Buccal Tablet 400 microg in Healthy Japanese Volunteers. ARCHIVES OF DRUG INFORMATION 2008; 1:50-55. [PMID: 19915714 PMCID: PMC2773539 DOI: 10.1111/j.1753-5174.2008.00008.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective This study was conducted to characterize the pharmacokinetics, including extent of accumulation, and safety and tolerability of fentanyl following multiple doses of fentanyl buccal tablet (FBT) in healthy Japanese volunteers. Methods Healthy Japanese adults received 10 successive doses of open-label FBT 400 µg at 6-hour intervals. Naltrexone was given to minimize the opioid effects of fentanyl. FBT was placed above a molar tooth between the gum and cheek. Peak serum fentanyl concentration (Cmax), time to Cmax (tmax), and area under the serum fentanyl concentration-time curve from 0 to 6 hours (AUC0–6) were summarized using descriptive statistics. Accumulation ratio was calculated as Cmax for dose 10/Cmax for dose 1, and was calculated similarly for AUC0–6. Results Fourteen volunteers (mean age 33 years) were enrolled, and 13 completed the study. After doses 1 and 10, respectively, mean (SD) Cmax was 1.70 (0.49) ng/mL and 1.97 (0.42) ng/mL, AUC0–6 was 4.46 (1.14) ng·h/mL and 6.81 (0.90) ng·h/mL, and median (range) tmax was 50 (30–110) minutes and 30 (15–120) minutes. Following 10 successive doses, systemic exposure (AUC0–6) was 55% higher than after dose 1, and Cmax was 23% higher. Steady state was achieved within 3 days of dosing at 6-hour intervals, i.e., prior to dose 10. The most frequent adverse events (AEs) were somnolence (N = 9), decreased oxygen saturation (N = 4), headache (N = 3), application-site pain (N = 8), application-site erythema (N = 6), and application-site reaction (N = 5). All AEs were mild or moderate. Conclusions Following administration of FBT at 6-hour intervals to healthy Japanese volunteers, at steady state, fentanyl exposure was higher by 55% (AUC0–6) and 23% (Cmax) than after a single dose of FBT. Adverse events were mild or moderate.
Collapse
|
38
|
Abstract
A class of endogenous opioids is upregulated in liver disease particular to cholestasis, which contributes to symptoms in liver disease such as pruritus, hypotension and encephalopathy. Symptoms associated with cholestasis are reversed or at least ameliorated by mu opioid receptor antagonists. Palliation of symptoms related to cholestatic liver disease also involves bile acid binding agents. Opioid receptor antagonists, unlike bile acid binding agents, have been reported to relieve multiple symptoms, except for pruritus, and improve liver function as demonstrated in experimental cholestasis. Exogenous opioid pharmacology is altered by liver disease. Dose reduction or prolongation of dose intervals is necessary depending on the severity of liver disease.
Collapse
Affiliation(s)
- Mellar Davis
- The Harry R Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
| |
Collapse
|
39
|
Saari TI, Laine K, Neuvonen M, Neuvonen PJ, Olkkola KT. Effect of voriconazole and fluconazole on the pharmacokinetics of intravenous fentanyl. Eur J Clin Pharmacol 2007; 64:25-30. [PMID: 17987285 DOI: 10.1007/s00228-007-0398-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Accepted: 10/08/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fentanyl is a widely used opioid analgesic, which is extensively metabolized by hepatic cytochrome P450 (CYP) 3A. Recent reports suggest that concomitant administration of CYP3A inhibitors with fentanyl may lead to dangerous drug interactions. METHODS The potential interactions of fentanyl with triazole antifungal agents voriconazole and fluconazole were studied in a randomized crossover study in three phases. Twelve healthy volunteers were given 5 microg/kg of intravenous fentanyl without pretreatment (control), after oral voriconazole (400 mg twice on the first day and 200 mg twice on the second day), or after oral fluconazole (400 mg once on the first day and 200 mg once on the second day). Plasma concentrations of fentanyl, norfentanyl, voriconazole, and fluconazole were determined up to 24 h. Pharmacokinetic parameters were calculated using compartmental methods. RESULTS The mean plasma clearance of intravenous fentanyl was decreased by 23% (range -22 to 48%; p < 0.05) and 16% (-34 to 53%; p < 0.05) after voriconazole and fluconazole administration, respectively. Voriconazole increased the area under the fentanyl plasma concentration-time curve by 1.4-fold (p < 0.05). The initial plasma concentrations and volume of distribution of fentanyl did not differ significantly between phases. CONCLUSION Both voriconazole and fluconazole delay the elimination of fentanyl significantly. Caution should be exercised, especially in patients who are given voriconazole or fluconazole during long-lasting fentanyl treatment, because insidiously elevated fentanyl concentration may lead to respiratory depression.
Collapse
Affiliation(s)
- Teijo I Saari
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku, P.O. Box 52, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland.
| | | | | | | | | |
Collapse
|
40
|
Ailawadhi S, Sung KW, Carlson LA, Baer MR. Serotonin syndrome caused by interaction between citalopram and fentanyl. J Clin Pharm Ther 2007; 32:199-202. [PMID: 17381671 DOI: 10.1111/j.1365-2710.2007.00813.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To report a case of serotonin syndrome associated with interaction between fentanyl and citalopram, as evidenced by medication history, clinical features and reversal following discontinuation of fentanyl. CASE SUMMARY A 65-year-old patient chronically treated with the selective serotonin reuptake inhibitor (SSRI) citalopram developed confusion, agitation, tachycardia, tremors, myoclonic jerks and unsteady gait, consistent with serotonin syndrome, following initiation of fentanyl, and all symptoms and signs resolved following discontinuation of fentanyl. Based on the Naranjo probability scale, serotonin syndrome was a probable adverse reaction associated with co-administration of citalopram and fentanyl. DISCUSSION Serotonin syndrome is a potentially lethal pharmacodynamic interaction between medications that increase serotonergic transmission at the synaptic junction. The development of new pharmacological agents with varied properties and actions has increased the risk of serotonin syndrome as a clinical diagnosis. SSRIs and fentanyl are commonly co-administered, especially in the setting of chronic or malignant pain, as underlying depression may contribute to the pathogenesis of pain. CONCLUSION Healthcare professionals should be aware of the possible development of serotonin syndrome as a complication of initiation of fentanyl and other phenylpiperidine opioids in patients treated with SSRIs.
Collapse
Affiliation(s)
- S Ailawadhi
- Department of Medicine, State University of New York, Buffalo, NY, USA
| | | | | | | |
Collapse
|
41
|
Tanaka E, Takano Y, Inomata S, Toyooka H, Honda K. Premedication medicines do not cause drug metabolic interaction with propofol using human liver microsomes in vitro. Eur J Clin Pharmacol 2004; 60:565-8. [PMID: 15351923 DOI: 10.1007/s00228-004-0807-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Accepted: 07/01/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Propofol (2,6-diisopropylphenol) is widely used for anesthetic induction as well as for chronic sedation in intensive care units. In this study, we investigated the interaction between propofol and premedications, i.e., psychotropic and antianxiety agents (diazepam, midazolam), hypnotics (thiamylal), local anesthetics (lidocaine), depolarizing muscular relaxants (vecuronium), an antihypertensive (clonidine) and an H2-receptor antagonist (cimetidine) using human liver microsomes in vitro. METHODS The interaction effects between propofol and premedications were examined using human liver microsomal preparation in vitro. The concentration of propofol was determined by HPLC with UV detection. RESULTS The apparent Michaelis-Menten constant (Km) and the maximal velocity of total metabolic formation (Vmax) of propofol in human liver microsomes were 123 microM and 26.1 micromol/min per milligram of mg protein, respectively. Seven premedications (diazepam, midazolam, thiamylal, lidocaine, cimetidine, vecuronium, and clonidine) did not inhibit propofol metabolism in human liver microsomes at concentrations within the therapeutic range. CONCLUSIONS These results showed no interactions between propofol and seven premedication drugs within the therapeutic range of propofol using human liver microsomes in vitro.
Collapse
Affiliation(s)
- Einosuke Tanaka
- Institute of Community Medicine, University of Tsukuba, 305-8575, Tsukuba-shi, Ibaraki-ken, Japan.
| | | | | | | | | |
Collapse
|
42
|
Pea F, Furlanut M. Pharmacokinetic aspects of treating infections in the intensive care unit: focus on drug interactions. Clin Pharmacokinet 2002; 40:833-68. [PMID: 11735605 DOI: 10.2165/00003088-200140110-00004] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Pharmacokinetic interactions involving anti-infective drugs may be important in the intensive care unit (ICU). Although some interactions involve absorption or distribution, the most clinically relevant interactions during anti-infective treatment involve the elimination phase. Cytochrome P450 (CYP) 1A2, 2C9, 2C19, 2D6 and 3A4 are the major isoforms responsible for oxidative metabolism of drugs. Macrolides (especially troleandomycin and erythromycin versus CYP3A4), fluoroquinolones (especially enoxacin, ciprofloxacin and norfloxacin versus CYP1A2) and azole antifungals (especially fluconazole versus CYP2C9 and CYP2C19, and ketoconazole and itraconazole versus CYP3A4) are all inhibitors of CYP-mediated metabolism and may therefore be responsible for toxicity of other coadministered drugs by decreasing their clearance. On the other hand, rifampicin is a nonspecific inducer of CYP-mediated metabolism (especially of CYP2C9, CYP2C19 and CYP3A4) and may therefore cause therapeutic failure of other coadministered drugs by increasing their clearance. Drugs frequently used in the ICU that are at risk of clinically relevant pharrmacokinetic interactions with anti-infective agents include some benzodiazepines (especially midazolam and triazolam), immunosuppressive agents (cyclosporin, tacrolimus), antiasthmatic agents (theophylline), opioid analgesics (alfentanil), anticonvulsants (phenytoin, carbamazepine), calcium antagonists (verapamil, nifedipine, felodipine) and anticoagulants (warfarin). Some lipophilic anti-infective agents inhibit (clarithromycin, itraconazole) or induce (rifampicin) the transmembrane transporter P-glycoprotein, which promotes excretion from renal tubular and intestinal cells. This results in a decrease or increase, respectively, in the clearance of P-glycoprotein substrates at the renal level and an increase or decrease, respectively, of their oral bioavailability at the intestinal level. Hydrophilic anti-infective agents are often eliminated unchanged by renal glomerular filtration and tubular secretion, and are therefore involved in competition for excretion. Beta-lactams are known to compete with other drugs for renal tubular secretion mediated by the organic anion transport system, but this is frequently not of major concern, given their wide therapeutic index. However, there is a risk of nephrotoxicity and neurotoxicity with some cephalosporins and carbapenems. Therapeutic failure with these hydrophilic compounds may be due to haemodynamically active coadministered drugs, such as dopamine, dobutamine and furosemide, which increase their renal clearance by means of enhanced cardiac output and/or renal blood flow. Therefore, coadministration of some drugs should be avoided, or at least careful therapeutic drug monitoring should be performed when available. Monitoring may be especially helpful when there is some coexisting pathophysiological condition affecting drug disposition, for example malabsorption or marked instability of the systemic circulation or of renal or hepatic function.
Collapse
Affiliation(s)
- F Pea
- Institute of Clinical Pharmacology and Toxicology, Department of Experimental and Clinical Pathology and Medicine, Medical School, University of Udine, Italy.
| | | |
Collapse
|
43
|
Muijsers RB, Wagstaff AJ. Transdermal fentanyl: an updated review of its pharmacological properties and therapeutic efficacy in chronic cancer pain control. Drugs 2002; 61:2289-307. [PMID: 11772140 DOI: 10.2165/00003495-200161150-00014] [Citation(s) in RCA: 189] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
UNLABELLED Fentanyl is a synthetic opioid agonist which interacts primarily with the mu-opioid receptor. The low molecular weight, high potency and lipid solubility of fentanyl make it suitable for delivery by the transdermal therapeutic system. These patches are designed to deliver fentanyl at a constant rate (25, 50, 75 and 100 microg/h), and require replacement every 3 days. Data from randomised, nonblind trials suggest that transdermal fentanyl is as effective as sustained-release oral morphine in the treatment of chronic cancer pain, as reported by patients using visual and numerical analogue scales as well as verbal description scales. No obvious differences in health-related quality of life were found in patients with chronic cancer pain when comparing transdermal fentanyl with sustained-release oral morphine. Nevertheless, significantly more patients expressed a preference for transdermal fentanyl than for sustained-release oral morphine after a randomised, nonblind, crossover trial. Because of the formation of a fentanyl depot in the skin tissue, serum fentanyl concentrations increase gradually following initial application, generally levelling off between 12 and 24 hours. Thereafter, they remain relatively constant, with some fluctuation, for the remainder of the 72-hour application period. Once achieved, steady-state plasma fentanyl concentrations can be maintained for as long as the patches are renewed. The most frequently observed adverse events during transdermal fentanyl administration (as with other opioid agonists) included vomiting, nausea and constipation. Data from a nonblind, randomised trials suggest that constipation occurs less frequently in patients receiving transdermal fentanyl than in those given sustained-release oral morphine. The most serious adverse event reported in US premarketing trials was hypoventilation, which occurred with an incidence of approximately 2%. Adverse reactions related to skin and appendages (i.e. rash and application site reactions - erythema, papules, itching and oedema) were reported in 153 patients with cancer at a frequency between 1 and 3%. CONCLUSION Transdermal fentanyl is a useful opioid-agonist for the treatment of moderate to severe chronic cancer pain. The advantages of transdermal fentanyl include ease of administration and the 3-day application interval. These factors coupled with a lower incidence of constipation are likely to contribute to the reported patient preference of transdermal fentanyl over sustained-release oral morphine.
Collapse
Affiliation(s)
- R B Muijsers
- Adis International Limited, Auckland, New Zealand.
| | | |
Collapse
|
44
|
Kharasch ED, Mautz D, Senn T, Lentz G, Cox K. Menstrual Cycle Variability in Midazolam Pharmacokinetics. J Clin Pharmacol 1999. [DOI: 10.1177/009127009903900311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Evan D. Kharasch
- Anesthesiology Service, Puget Sound Veterans Affairs Health Care System, Seattle, Washington
- Departments of Anesthesiology
- Medicinal Chemistry
| | | | | | - Gretchen Lentz
- Obstetrics‐Gynecology, University of Washington, Seattle
| | | |
Collapse
|