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Anversa RG, Barron ML, Walker LC, Lawrence AJ. Emerging GPCR targets for AUD: Insights from preclinical studies. Curr Opin Neurobiol 2024; 87:102896. [PMID: 38971113 DOI: 10.1016/j.conb.2024.102896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/13/2024] [Accepted: 06/13/2024] [Indexed: 07/08/2024]
Abstract
G protein-coupled receptors (GPCRs) are the largest group of membrane receptors in the central nervous system and one of the key proteins for signal transduction between cells. Currently, many drugs available on the market act via GPCRs and these receptors remain attractive targets for the treatment of brain disorders, including alcohol use disorder (AUD). Here, we describe the most recent literature, with a primary focus on the past 5 years, on GPCR targets with the potential for reducing behaviours associated with excessive alcohol intake. Specifically, we focus on preclinical evidence of compounds with attractive pharmacological profiles and potential for future clinical investigation for the treatment of AUD.
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Affiliation(s)
- Roberta Goncalves Anversa
- Florey Institute of Neuroscience and Mental Health, Melbourne 3052, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, Melbourne 3052, Australia
| | - Maiya L Barron
- Florey Institute of Neuroscience and Mental Health, Melbourne 3052, Australia; School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, United Kingdom
| | - Leigh C Walker
- Florey Institute of Neuroscience and Mental Health, Melbourne 3052, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, Melbourne 3052, Australia
| | - Andrew J Lawrence
- Florey Institute of Neuroscience and Mental Health, Melbourne 3052, Australia; Florey Department of Neuroscience and Mental Health, University of Melbourne, Melbourne 3052, Australia.
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Aubin HJ, Berlin I, Guiraud J, Bruhwyler J, Batel P, Perney P, Trojak B, Bendimerad P, Guillou M, Bisch M, Grall-Bronnec M, Labarrière D, Delsart D, Questel F, Moirand R, Bernard P, Trovero F, Pham HP, Tassin JP, Puech A. Prazosin and cyproheptadine in combination in the treatment of alcohol use disorder: A randomized, double-blind, placebo-controlled trial. Addiction 2024; 119:1211-1223. [PMID: 38597214 DOI: 10.1111/add.16484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/23/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND AIMS Pre-clinical studies suggest that the simultaneous blockade of the α1b and 5HT2A receptors may be effective in reducing alcohol consumption. This study aimed to assess the efficacy and safety of prazosin (α1b blocker) and cyproheptadine (5HT2A blocker) combination in decreasing total alcohol consumption (TAC) in alcohol use disorder (AUD). DESIGN, SETTING AND PARTICIPANTS This was a double-blind, parallel group, placebo-controlled, Phase 2, randomized clinical trial conducted in 32 addiction treatment centres in France. A total of 108 men and 46 women with severe AUD took part. INTERVENTION Participants were randomly assigned to one of the following 3-month treatments: (1) low-dose group (LDG) receiving 8 mg cyproheptadine and 5 mg prazosin extended-release (ER) formulation daily; (2) high-dose group (HDG) receiving 12 mg cyproheptadine and 10 mg prazosin ER daily; and (3) placebo group (PG) receiving placebo of cyproheptadine and prazosin ER. A total of 154 patients were randomized: 54 in the PG, 54 in the LDG and 46 in the HDG. MEASUREMENTS The primary outcome was TAC change from baseline to month 3. FINDINGS A significant main treatment effect in the change in TAC was found in the intent-to-treat population (P = 0.039). The HDG and LDG showed a benefit in the change in TAC from baseline to month 3 compared with PG: -23.6 g/day, P = 0.016, Cohen's d = -0.44; -18.4 g/day, P = 0.048 (Bonferroni correction P < 0.025), Cohen's d = -0.36. In a subgroup of very high-risk drinking-level participants (> 100 g/day of pure alcohol for men and > 60 g/day for women), the difference between the HDG and the PG in the primary outcome was -29.8 g/day (P = 0.031, Cohen's d = -0.51). The high and low doses were well-tolerated with a similar safety profile. CONCLUSIONS A randomized controlled trial of treatment of severe alcohol use disorder with a cyproheptadine-prazosin combination for 3 months reduced drinking by more than 23 g per day compared with placebo. A higher dose combination was associated with a larger magnitude of drinking reduction than a lower dose combination while showing similar safety profile.
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Affiliation(s)
| | - Ivan Berlin
- Hopital Pitie-Salpetriere, Sorbonne Université, Paris, France
| | - Julien Guiraud
- University of Amsterdam, Amsterdam, the Netherlands
- Vergio, Clichy, France
| | | | | | - Pascal Perney
- Hôpital Carémeau, Nîmes, Université Montpellier 1, Villejuif, France
| | - Benoît Trojak
- Centre hospitalier Universitaire Dijon Bourgogne, Université Bourgogne Franche-Comté, Besançon, France
| | - Patrick Bendimerad
- Addiction Department, Groupe Hospitalier Littoral Atlantique, La Rochelle, France
| | - Morgane Guillou
- ER 7479 SPURBO, Université Bretagne Occidentale, Brest, France
| | - Michaël Bisch
- Centre Psychothérapique de Nancy, Addiction Medicine department, Laxou, France
| | - Marie Grall-Bronnec
- Addictology and Liaison Psychiatry Department, Nantes University Hospital, Nantes and Tours Universities, Nantes, France
| | | | | | - Frank Questel
- Université Paris Diderot, GH Lariboisière-Saint-Louis-Fernand Widal, Paris, France
| | - Romain Moirand
- Université Rennes, Rennes, Institut NUMECAN (Nutrition Metabolisms and Cancer), UF Addictologie, Rennes, France
| | | | | | | | - Jean-Pol Tassin
- Inserm, Sorbonne-Université, Laboratoire Neuroscience Paris-Seine, Paris, France
| | - Alain Puech
- Kinnov-Therapeutics, Orléans, France
- Inserm, Sorbonne-Université, Laboratoire Neuroscience Paris-Seine, Paris, France
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Kotake K, Hosokawa T, Tanaka M, So R, Banno M, Kataoka Y, Shiroshita A, Hashimoto Y. Efficacy and safety of alcohol reduction pharmacotherapy according to treatment duration in patients with alcohol dependence or alcohol use disorder: A systematic review and network meta-analysis. Addiction 2024; 119:815-832. [PMID: 38173342 DOI: 10.1111/add.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND AIMS Relapse is common in alcohol dependence (AD) and alcohol use disorder (AUD), so alcohol reduction therapy should be measured over as long a period as possible; however, existing reviews do not consider the duration of treatment and therefore alcohol reduction therapy may not have been appropriately evaluated. This review evaluated the efficacy and safety of alcohol reduction pharmacotherapy in patients with AD or AUD according to the duration of treatment. METHODS We conducted a systematic review and network meta-analysis of randomized controlled trials (RCTs) that assessed 15 pharmacological agents. MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, the ClinicalTrials.gov and the International Clinical Trials Registry Platform were searched for eligible trials through to May 2021. Outcomes were heavy drinking days (HDD), total alcohol consumption (TAC), any adverse event and days without drinking. RESULTS Fifty-five RCTs (n = 8891) were included. Nalmefene was superior to placebo for reducing HDD (standard mean difference [SMD] -0.28, 95% confidence interval [CI] -0.37, -0.18) and TAC (SMD -0.25, 95% CI -0.35, -0.16) in the long-term, but not in the short-term. Topiramate was superior to placebo for reducing HDD (SMD -0.35, 95% CI -0.59, -0.12) and days without drinking (SMD 0.46, 95% CI 0.11, 0.82), and baclofen was superior for reducing TAC (SMD -0.70, 95% CI -1.29, -0.11), in the short-term. The frequency of adverse events was higher with nalmefene and topiramate than with placebo. CONCLUSION Nalmefene, topiramate and baclofen may be effective as alcohol reduction pharmacotherapy; however, only nalmefene has demonstrated long-term efficacy, and nalmefene and topiramate have a significantly higher frequency of adverse events compared with placebo.
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Affiliation(s)
- Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Okayama, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Tomonari Hosokawa
- Department of Psychiatry, Zikei Hospital/Zikei Institute of Psychiatry, Okayama, Japan
| | - Masuo Tanaka
- Department of Psychiatry, Zikei Hospital/Zikei Institute of Psychiatry, Okayama, Japan
| | - Ryuhei So
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Masahiro Banno
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Psychiatry, Seichiryo Hospital, Nagoya, Japan
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Shiroshita
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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Guiraud J, Spanagel R, van den Brink W. Substitution therapy for patients with alcohol dependence: Mechanisms of action and efficacy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 175:187-239. [PMID: 38555116 DOI: 10.1016/bs.irn.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
New approaches for the treatment of alcohol dependence (AD) may improve patient outcomes. Substitution maintenance therapy is one of the most effective treatment options for opioid and nicotine use disorders. So far, there has been little attention to substitution therapy for the treatment of AD. Here, we explain the mechanistic foundations of alcohol substitution maintenance therapy. Alcohol has many primary targets in the brain (and other organs) and the physical interaction of ethanol molecules with these specific ethanol-sensitive sites on a variety of ionotropic receptors (e.g. GABA-A, NMDA, and nicotinic acetylcholine (nACh) receptors) and ion channels provides the rationale for substitution. As such, a variety of compounds can interact with those ethanol-sensitive sites and can thus substitute for some of the effects of alcohol. For some of these compounds, alcohol discrimination studies have shown their substitution potential. Accordingly, potential substitution treatments include agonists acting at GABA receptors such as sodium oxybate, baclofen and benzodiazepines, NMDA receptor antagonists such as ketamine and memantine, or nAChRs agonists such as varenicline. All these compounds are already approved for other indications and we present clinical evidence for these drugs in the treatment of alcohol withdrawal syndrome (AWS) and in the long-term treatment of AD, and outline future steps for their acceptance as substitution treatment in AD. Finally, we discuss the substitution approach of managed alcohol programs for the most severely affected homeless populations. Results showed that sodium oxybate is probably the closest to a substitution therapy for AD and is already approved for the treatment of AWS and in the long-term treatment of AD in some countries. In conclusion, we argue that better AD treatment can be provided if substitution maintenance treatments for alcohol are implemented at a similar scale as for opioid and nicotine use disorder.
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Affiliation(s)
- Julien Guiraud
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands; Vergio, Clichy, France.
| | - Rainer Spanagel
- Institute of Psychopharmacology, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Wim van den Brink
- Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Department of Psychiatry, Amsterdam Neuroscience, Amsterdam, The Netherlands
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de Beaurepaire R, Jaury P. Baclofen in the treatment of alcohol use disorder: tailored doses matter. Alcohol Alcohol 2024; 59:agad090. [PMID: 38266071 PMCID: PMC10807704 DOI: 10.1093/alcalc/agad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/03/2023] [Accepted: 12/16/2023] [Indexed: 01/26/2024] Open
Abstract
AIMS To address the question of tailored baclofen prescribing in alcohol use disorder (AUD) in relation to dose-dependent efficacy and the potential danger of high doses and to provide suggestions for the use of high doses of baclofen in the treatment of AUD. The context is the approvement in France of baclofen in the treatment of AUD without dose limitation, making French physicians, who usually prescribe baclofen in a tailored manner, often use high or very high doses. METHODS A narrative review of the results of randomized controlled trials (RCTs) and observational studies that used tailored baclofen prescribing and of the severe adverse effects of baclofen that have been reported in the literature. RESULTS The results show that RCTs using tailored doses of baclofen in AUD are not completely demonstrative, though they are encouraging according to certain meta-analyses, while observational studies that used tailored doses constantly show a good effectiveness of baclofen treatment. The results suggest that many severe adverse effects of baclofen could be related to a nonrespect by physicians of prescription rules and appropriate treatment monitoring. CONCLUSIONS The use of tailored doses shows that the dose required to suppress cravings is highly variable, low or high, depending on each case. Analysis of the circumstances in which severe adverse effects occur suggest that a careful monitoring of baclofen prescribing might prevent a large majority of severe adverse effects. We propose that the education of the patients and the prescription skills, seriousness, and availability of the prescribing physicians are of major importance in the managing of tailored baclofen treatment of AUD.
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Affiliation(s)
- Renaud de Beaurepaire
- Renaud de Beaurepaire, GH Paul-Guiraud, 54 Avenue de La République, 94806 Villejuif, France
| | - Philippe Jaury
- Faculté de Médecine, Université Paris Cité, Paris, France
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Agabio R, Saulle R, Rösner S, Minozzi S. Baclofen for alcohol use disorder. Cochrane Database Syst Rev 2023; 1:CD012557. [PMID: 36637087 PMCID: PMC9837849 DOI: 10.1002/14651858.cd012557.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Alcohol use disorder (AUD) is one of the most widespread psychiatric disorders leading to detrimental consequences to people with this disorder and others. Worldwide, the prevalence of heavy episodic drinking (30-day prevalence of at least one occasion of 60 g of pure alcohol intake among current drinkers) is estimated at 20% and the prevalence of AUD at 5% of the adult general population, with highest prevalence in Europe and North America. Therapeutic approaches, including pharmacotherapy, play an important role in treating people with AUD. This is an update of a Cochrane Review first published in 2018. OBJECTIVES To evaluate the benefits and harms of baclofen on achieving and maintaining abstinence or reducing alcohol consumption in people with AUD compared to placebo, no treatment or any other pharmacological relapse prevention treatment. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 22 November 2021. SELECTION CRITERIA Randomised controlled trials (RCTs) of at least four weeks' treatment duration and 12 weeks' overall study duration comparing baclofen for AUD treatment with placebo, no treatment or other treatments. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. relapse, 2. frequency of use, 3. amount of use, 4. adverse events, 5. dropouts from treatment and 6. dropouts from treatment due to adverse events. Our secondary outcomes were 7. craving, 8. anxiety, 9. depression and 10. frequency of most relevant adverse events. MAIN RESULTS We included 17 RCTs (1818 participants) with a diagnosis of alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition or International Classification of Diseases 10th edition criteria. Mean age was 46.5 years and 70% were men. Ten studies compared baclofen to placebo or another medication; seven compared two baclofen doses to placebo or another medication. Globally, 15 studies compared baclofen to placebo, two baclofen to acamprosate and two baclofen to naltrexone. In 16 studies, participants received psychosocial treatments. We judged most studies at low risk of selection, performance, detection (subjective outcome), attrition and reporting bias. Ten studies detoxified participants before treatment; in seven studies, participants were still drinking at the beginning of treatment. Treatment duration was 12 weeks for 15 RCTs and longer in two studies. Baclofen daily dose was 30 mg to 300 mg: 10 RCTs used low doses (30 mg or less); eight RCTs medium doses (above 30 and 100 mg or less) and four RCTs high doses (above 100 mg). Compared to placebo, moderate-certainty evidence found that baclofen probably decreases the risk to relapse (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.77 to 0.99; 12 studies, 1057 participants). This result was confirmed among detoxified participants but not among other subgroups of participants. High-certainty evidence found that baclofen increases the percentage of days abstinent (mean difference (MD) 9.07, 95% CI 3.30 to 14.85; 16 studies, 1273 participants). This result was confirmed among all subgroups of participants except non-detoxified or those who received medium doses. There was no difference between baclofen and placebo in the other primary outcomes: heavy drinking days (standardised mean difference (SMD) -0.18, 95% CI -0.48 to 0.11; 13 studies, 840 participants; moderate-certainty evidence); number of drinks per drinking days (MD -0.45, 95% CI -1.20 to 0.30; 9 studies, 392 participants; moderate-certainty evidence); number of participants with at least one adverse event (RR 1.05, 95% CI 0.99 to 1.11; 10 studies, 738 participants; high-certainty evidence); dropouts (RR 0.88, 95% CI 0.74 to 1.03; 17 studies, 1563 participants; high-certainty evidence); dropouts due to adverse events (RR 1.39, 95% CI 0.89 to 2.18; 16 studies, 1499 participants; high-certainty evidence). These results were confirmed by subgroup analyses except than for the dropouts that resulted lower among participants who received high doses of baclofen and studies longer than 12 weeks. Compared to placebo, there was no difference in craving (SMD -0.16, 95% CI -0.37 to 0.04; 17 studies, 1275 participants), anxiety (MD -0.01, 95% CI -0.14 to 0.11; 15 studies, 1123 participants) and depression (SMD 0.07, 95% CI -0.12 to 0.27; 11 studies, 1029 participants). Concerning the specific adverse events, baclofen increases fatigue, dizziness, somnolence/sedation, dry mouth, paraesthesia and muscle spasms/rigidity. There was no difference in the other adverse events. Compared to acamprosate, one study (60 participants) found no differences in any outcomes but the evidence was very uncertain: relapse (RR 1.25, 95% CI 0.71 to 2.20; very low-certainty evidence); number of participants with at least one adverse event (RR 0.63, 95% CI 0.23 to 1.69; very low-certainty evidence); dropouts (RR 0.56, 95% CI 0.21 to 1.46; very low-certainty evidence); dropouts due to adverse events (RR 0.33, 95% CI 0.01 to 7.87; very low-certainty evidence) and craving (MD 5.80, 95% CI -11.84 to 23.44); and all the adverse events evaluated. Compared to naltrexone, baclofen may increase the risk of relapse (RR 2.50, 95% CI 1.12 to 5.56; 1 study, 60 participants; very low-certainty evidence) and decrease the number of participants with at least one adverse event (RR 0.35, 95% CI 0.15 to 0.80; 2 studies, 80 participants; very low-certainty evidence) but the evidence is very uncertain. One study (60 participants) found no difference between baclofen and naltrexone in the dropouts at the end of treatment (RR 1.00, 95% CI 0.32 to 3.10; very low-certainty evidence), craving (MD 2.08, 95% CI -3.71 to 7.87), and all the adverse events evaluated. AUTHORS' CONCLUSIONS Baclofen likely reduces the risk of relapse to any drinking and increases the percentage of abstinent days, mainly among detoxified participants. It does not increase the number of participants with at least one adverse event, those who dropout for any reason or due to adverse events. It probably does not reduce number of heavy drinking days and the number of drinks per drinking days. Current evidence suggests that baclofen may help people with AUD in maintaining abstinence. The results of comparisons of baclofen with acamprosate and naltrexone were mainly based on only one study.
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Affiliation(s)
- Roberta Agabio
- Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Monserrato (CA), Italy
| | - Rosella Saulle
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Antonelli M, Sestito L, Tarli C, Addolorato G. Perspectives on the pharmacological management of alcohol use disorder: Are the approved medications effective? Eur J Intern Med 2022; 103:13-22. [PMID: 35597734 DOI: 10.1016/j.ejim.2022.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/27/2022] [Accepted: 05/13/2022] [Indexed: 12/18/2022]
Abstract
INTRODUCTION In the last decades, many medications have been tested for the treatment of Alcohol Use Disorder (AUD). Among them, disulfiram, acamprosate, naltrexone, nalmefene, sodium oxybate and baclofen have been approved in different countries, with different specific indications. Topiramate is not approved for the treatment of AUD, however, it is suggested as a therapeutic option by the American Psychiatric Association for patients who do not tolerate or respond to approved therapies. AREAS COVERED In this narrative review we have analyzed the main studies available in literature, investigating the efficacy and safety of these medications, distinguishing whether they were oriented towards abstinence or not. Randomized controlled studies, analyzing larger populations for longer periods were the main focus of our analysis. CONCLUSIONS The medications currently available for the treatment of AUD are quite effective, yet further progress can still be achieved through the personalized strategies. Also, these medications are still markedly underutilized in clinical practice and many patients do not have access to specialized treatment.
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Affiliation(s)
- Mariangela Antonelli
- Internal Medicine and Alcohol Related Disease Unit, Columbus-Gemelli Hospital, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luisa Sestito
- Internal Medicine and Alcohol Related Disease Unit, Columbus-Gemelli Hospital, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Tarli
- Internal Medicine and Alcohol Related Disease Unit, Columbus-Gemelli Hospital, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Columbus-Gemelli Hospital, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; CEMAD Digestive Disease Center, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy.
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Response to 'acamprosate better than baclofen for alcohol use disorder in cirrhosis: fact or myth?'. Eur J Gastroenterol Hepatol 2022; 34:976. [PMID: 35913782 DOI: 10.1097/meg.0000000000002410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Martins B, Rutland W, De Aquino JP, Kazer BL, Funaro M, Potenza MN, Angarita GA. Helpful or Harmful? The Therapeutic Potential of Medications with Varying Degrees of Abuse Liability in the Treatment of Substance Use Disorders. CURRENT ADDICTION REPORTS 2022; 9:647-659. [PMID: 35990796 PMCID: PMC9376579 DOI: 10.1007/s40429-022-00432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/06/2022]
Abstract
Purpose of Review This review summarizes recent clinical trial research on pharmacological treatments for substance use disorders, with a specific focus on agents with potential abuse liability. Recent Findings Pharmacological treatments for substance use disorders may include gabapentinoids, baclofen, modafinil, ketamine, cannabinoids, gamma-hydroxybutyrate, and psychedelics. Gabapentinoids may decrease negative subjective effects of withdrawal in alcohol and cannabis use disorders. Cannabinoids similarly appear to decrease use and withdrawal symptoms in cannabis use disorder, while research shows stimulant medications may reduce cravings and increase abstinence in cocaine use disorder. Ketamine and psychedelics may help treat multiple substance use disorders. Ketamine may reduce withdrawal symptoms, promote abstinence, and diminish cravings in alcohol and cocaine use disorders and psychedelics may promote remission, decrease use, and reduce cravings in alcohol and opioid use disorders. Summary Regardless of current regulatory approval statuses and potentials for abuse, multiple agents should not be dismissed prematurely as possible treatments for substance use disorders. However, further clinical research is needed before effective implementation can begin in practice. Supplementary Information The online version contains supplementary material available at 10.1007/s40429-022-00432-9.
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Affiliation(s)
- Bradford Martins
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511 USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519 USA
| | - Will Rutland
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511 USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519 USA
| | - Joao P. De Aquino
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511 USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519 USA
| | - Benjamin L. Kazer
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511 USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519 USA
| | - Melissa Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT 06510 USA
| | - Marc N. Potenza
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511 USA
- Child Study Center, Yale University School of Medicine, New Haven, CT 06510 USA
- Department of Neuroscience, Yale University, New Haven, CT 06510 USA
- Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519 USA
- Connecticut Council On Problem Gambling, Wethersfield, CT 06109 USA
- Wu Tsai Institute, Yale University, New Haven, CT 06510 USA
| | - Gustavo A. Angarita
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511 USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, 34 Park Street, New Haven, CT 06519 USA
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McKee SA, McRae-Clark AL. Consideration of sex and gender differences in addiction medication response. Biol Sex Differ 2022; 13:34. [PMID: 35761351 PMCID: PMC9235243 DOI: 10.1186/s13293-022-00441-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/08/2022] [Indexed: 12/22/2022] Open
Abstract
Substance use continues to contribute to significant morbidity and mortality in the United States, for both women and men, more so than another other preventable health condition. To reduce the public health burden attributable to substances, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism have identified that medication development for substance use disorder is a high priority research area. Furthermore, both Institutes have stated that research on sex and gender differences in substance use medication development is a critical area. The purpose of the current narrative review is to highlight how sex and gender have been considered (or not) in medication trials for substance use disorders to clarify and summarize what is known regarding sex and gender differences in efficacy and to provide direction to the field to advance medication development that is consistent with current NIH 'sex as a biological variable' (SABV) policy. To that end, we reviewed major classes of abused substances (nicotine, alcohol, cocaine, cannabis, opioids) demonstrating that, sex and gender have not been well-considered in addiction medication development research. However, when adequate data on sex and gender differences have been evaluated (i.e., in tobacco cessation), clinically significant differences in response have been identified between women and men. Across the other drugs of abuse reviewed, data also suggest sex and gender may be predictive of outcome for some agents, although the relatively low representation of women in clinical research samples limits making definitive conclusions. We recommend the incorporation of sex and gender into clinical care guidelines and improved access to publicly available sex-stratified data from medication development investigations.
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Affiliation(s)
- Sherry A. McKee
- grid.47100.320000000419368710Yale School of Medicine, 2 Church St South, Suite 109, New Haven, CT 06519 USA
| | - Aimee L. McRae-Clark
- grid.259828.c0000 0001 2189 3475Medical University of South Carolina, Charleston, USA
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11
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Tarli C, Mirijello A, Addolorato G. Treating Alcohol Use Disorder in Patients with Alcohol-Associated Liver Disease: Controversies in Pharmacological Therapy. Semin Liver Dis 2022; 42:138-150. [PMID: 35292951 DOI: 10.1055/a-1798-2872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Alcohol use disorder (AUD) is one of the main causes of global death and disability. The liver represents the main target of alcohol damage, and alcohol-associated liver disease (ALD) represents the first cause of liver cirrhosis in Western countries. Alcohol abstinence is the main goal of treatment in AUD patients with ALD, as treatments for ALD are less effective when drinking continues. Moreover, the persistence of alcohol consumption is associated with higher mortality, increased need for liver transplantation, and graft loss. The most effective treatment for AUD is the combination of psychosocial interventions, pharmacological therapy, and medical management. However, the effectiveness of these treatments in patients with ALD is doubtful even because AUD patients with ALD are usually excluded from pharmacological trials due to concerns on liver safety. This narrative review will discuss the treatment options for AUD-ALD patients focusing on controversies in pharmacological therapy.
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Affiliation(s)
- Claudia Tarli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - Antonio Mirijello
- Internal Medicine Unit, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy.,CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, l.go Gemelli, Rome, Italy.,Internal Medicine Unit, Department of Internal Medicine and Gastroenterology, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
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12
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Acamprosate may be safer than baclofen for the treatment of alcohol use disorder in patients with cirrhosis: a first description of use in real-world clinical practice. Eur J Gastroenterol Hepatol 2022; 34:567-575. [PMID: 35421022 DOI: 10.1097/meg.0000000000002304] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Patients with alcohol use disorder (AUD) and liver cirrhosis benefit from stopping alcohol intake. Baclofen has been trialled for AUD in cirrhosis and appears to be effective. However, in patients without cirrhosis acamprosate is safer and more efficacious. Acamprosate is rarely used in cirrhosis due to safety concerns: the only published report was for 24 h in a controlled setting. Our centre uses both medications off-label in cirrhotic patients. We performed an audit to pragmatically compare the safety of acamprosate to baclofen in these patients. METHODS The electronic records of patients prescribed acamprosate or baclofen between 01/04/17 and 31/03/20 were retrospectively reviewed. Adverse events and abstinence at last follow-up were compared by Student's t-test, Mann-Whitney U or chi-square test. Confounding variables were evaluated by logistic regression. RESULTS In total 48 cirrhotic patients taking acamprosate (median 84 days, range 2-524); 44 baclofen (247 days, 8-910) met inclusion criteria. At baseline, 41% had Childs-Pugh B or C cirrhosis. More patients taking baclofen had an unplanned hospital admission or attendance (23 vs 13; P = 0.013) and the mean number per patient was higher (1.6 vs 0.6; P = 0.032). Sub-group analysis revealed increased admissions in actively drinking patients prescribed baclofen to achieve abstinence (mean 2.4 vs 0.6; P = 0.020); acamprosate use was associated with a reduced chance of admission or attendance (OR, 0.284; 0.095-0.854; P = 0.025) independent of treatment length. No difference in efficacy was observed. CONCLUSIONS In patients with cirrhosis, acamprosate was associated with fewer unplanned admissions than baclofen, hence may be safer despite historical concerns.
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13
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de Beaurepaire R, Rolland B. Baclofen in alcohol use disorder: An analysis of the data provided by the French "Temporary Recommendation for Use" 2014-2017 cohort. Front Psychiatry 2022; 13:949750. [PMID: 36311508 PMCID: PMC9597083 DOI: 10.3389/fpsyt.2022.949750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Alcohol use disorder (AUD) is a devastating illness for which effective treatments are lacking. Studies over the last two decades have shown that baclofen, a GABA-B agonist, could be a promising treatment for AUD. However, the efficacy of baclofen is still controversial, and studies have shown that it may be associated with an excess of hospitalizations and deaths. In March 2014, the French Health Safety Agency granted a "Temporary Recommendation for Use" (TRU) regulating the prescription of baclofen in subjects with AUD. The TRU allowed physicians to prescribe high-dose baclofen (up to 300 mg/d). The doses were adjusted, and tailored to the needs of each patient. Between March 2014 and March 2017, TRU clinical data were collected for a total of 6,939 subjects. The recorded data included information on alcohol consumption, the intensity of alcohol cravings, and adverse events. The present article proposes an analysis of the data provided by the TRU. Subjects for which data were missing regarding baclofen daily dosage, alcohol consumption or craving scores were discarded from the analyses. A cohort of two groups of subjects was analyzed. The first group included all TRU subjects suitable for analyses (5,550 subjects), and the second group included subjects followed for at least 365 days (169 subjects). Comparisons were made between baseline and endpoint of the follow-up period. The results show that a majority of subjects in the whole cohort had received doses of over 80 mg/d. The mean dose of baclofen at the endpoint was >110 mg/d in the second group of subjects. Doses of >80 mg/d were not associated with an increase in adverse events after adjustment for the follow-up duration. In terms of efficacy, comparisons between baseline and endpoint show that baclofen treatment significantly decreased alcohol consumption and alcohol cravings, and significantly increased the number of subjects with null or low-risk alcohol consumption according to WHO criteria.
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Affiliation(s)
| | - Benjamin Rolland
- Academic Department of Addiction Medicine in Lyon, Centre Hospitalier Le Vinatier, Hospices Civils de Lyon, Lyon, France
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14
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Romito JW, Turner ER, Rosener JA, Coldiron L, Udipi A, Nohrn L, Tausiani J, Romito BT. Baclofen therapeutics, toxicity, and withdrawal: A narrative review. SAGE Open Med 2021; 9:20503121211022197. [PMID: 34158937 PMCID: PMC8182184 DOI: 10.1177/20503121211022197] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/13/2021] [Indexed: 12/11/2022] Open
Abstract
Baclofen is an effective therapeutic for the treatment of spasticity related to multiple sclerosis, spinal cord injuries, and other spinal cord pathologies. It has been increasingly used off-label for the management of several disorders, including musculoskeletal pain, gastroesophageal reflux disease, and alcohol use disorder. Baclofen therapy is associated with potential complications, including life-threatening toxicity and withdrawal syndrome. These disorders require prompt recognition and a high index of suspicion. While these complications can develop following administration of either oral or intrathecal baclofen, the risk is greater with the intrathecal route. The management of baclofen toxicity is largely supportive while baclofen withdrawal syndrome is most effectively treated with re-initiation or supplementation of baclofen dosing. Administration of other pharmacologic adjuncts may be required to effectively treat associated withdrawal symptoms. This narrative review provides an overview of the historical and emerging uses of baclofen, offers practical dosing recommendations for both oral and intrathecal routes of administration, and reviews the diagnosis and management of both baclofen toxicity and withdrawal.
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Affiliation(s)
- Jia W Romito
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
- Department of Neurological Surgery, The
University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Neurology, The University
of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emily R Turner
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - John A Rosener
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Landon Coldiron
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Ashutosh Udipi
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Linsey Nohrn
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Jacob Tausiani
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain
Management, The University of Texas Southwestern Medical Center, Dallas, TX,
USA
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15
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Augier E. Recent Advances in the Potential of Positive Allosteric Modulators of the GABAB Receptor to Treat Alcohol Use Disorder. Alcohol Alcohol 2021; 56:139-148. [PMID: 33561865 PMCID: PMC7906877 DOI: 10.1093/alcalc/agab003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 12/11/2022] Open
Abstract
Aims The effects of alcohol on gamma-aminobutyric acid (GABA) transmission are key for the development and maintenance of alcohol use disorder (AUD). Previous research consistently indicates that GABAB receptor agonists such as baclofen can attenuate addiction-related behaviors in preclinical models of AUD. More importantly, baclofen has also shown promise in clinical studies, particularly in severely alcohol-dependent patients. However, despite this promise, other clinical studies have not confirmed its efficacy and chiefly, larger clinical trials have not been conducted. Therefore, with the exception of France, baclofen is not approved for the treatment of AUD in any other country. Furthermore, it is also important to keep in mind that some patients treated with baclofen may experience important side-effects, including sedation, drowsiness and sleepiness. Methods This short review will first discuss the history of baclofen for AUD treatment. We will then summarize preclinical behavioral results that have investigated the efficacy of GABAB PAMs for addiction treatment, with a special focus on our recent work that investigated the effects of ADX71441, a novel GABAB PAM, on several alcohol-related behaviors in rats that model important aspects of human AUD. Finally, in light of the recent criticism about the translational value of animal models of addiction, the specific translational potential of our work and of other preclinical studies that have unanimously reported the efficacy of GABAB PAMs to attenuate multiple alcohol-related behaviors will be discussed. Results Positive allosteric modulators (PAMs) of the GABAB receptor offer an attractive alternative approach to baclofen and have the potential to achieve mechanistic and therapeutic effects similar to GABAB agonists, while avoiding the tolerance and toxicity issues associated with baclofen. To date, all preclinical behavioral results have invariably shown the efficacy of GABAB PAMs for addiction treatment. Conclusions Preclinical studies indicate that GABAB PAMs have a higher therapeutic index than orthosteric agonists, at least in terms of mitigating the sedative effects of GABAB agonism. This predicts that GABAB PAMs have a high translational potential in humans and merit being tested clinically, in particular in patients with severe AUD.
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Affiliation(s)
- Eric Augier
- Center for Social and Affective Neuroscience, BKV, Linköping University, Linköping 58183, Sweden
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16
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Agabio R, Baldwin DS, Amaro H, Leggio L, Sinclair JMA. The influence of anxiety symptoms on clinical outcomes during baclofen treatment of alcohol use disorder: A systematic review and meta-analysis. Neurosci Biobehav Rev 2021; 125:296-313. [PMID: 33454289 DOI: 10.1016/j.neubiorev.2020.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/17/2020] [Accepted: 12/27/2020] [Indexed: 12/22/2022]
Abstract
Given the high coexistence of anxiety symptoms in people with alcohol use disorder (AUD), we aimed to determine the influence of anxiety symptoms on outcomes in patients with AUD treated with the GABAB receptor agonist baclofen. A meta-analysis of 13 comparisons (published 2010-2020) including baseline and outcome data on alcohol consumption and anxiety after 12 weeks was undertaken. There were significantly higher rates of abstinent days in patients treated with baclofen compared to placebo (p = 0.004; high certainty evidence); specifically in those with higher baseline anxiety levels (p < 0.00001; high certainty evidence) compared to those with lower baseline anxiety levels (p = 0.20; moderate certainty evidence). The change in anxiety ratings over 12 weeks did not differ between those treated with baclofen or placebo (p = 0.84; moderate certainty evidence). This may be due to different anxiety constructs being measured by scales not validated in this patient group, or that anxiety is not a biobehavioral mechanism by which baclofen may reduce alcohol drinking. Given the prevalence of anxiety symptoms in AUD all these factors warrant further research.
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Affiliation(s)
- Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Italy.
| | - David S Baldwin
- Faculty of Medicine, University of Southampton, Southampton, UK; University Department of Psychiatry and Mental Health, University of Cape Town, South Africa.
| | - Hugo Amaro
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore and Bethesda, MD, United States; Medication Development Program, National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Baltimore, MD, United States; Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI, United States; Division of Addiction Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States; Department of Neuroscience, Georgetown University Medical Center, Washington DC, United States.
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17
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Naudet F, Braillon A, Cristea IA, Lexchin J. Restoring the Bacloville trial: efficacy and harms. Addiction 2020; 115:2184-2186. [PMID: 32364248 DOI: 10.1111/add.15109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Florian Naudet
- University of Rennes, CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], F- 35000, Rennes, France
| | - Alain Braillon
- Alcohol treatment unit, University Hospital, Amiens, France
| | - Ioana A Cristea
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Canada
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18
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Rigal L, Sidorkiewicz S, Le Jeunne C, Porcher R, Jaury P. Reply to comments on the Rigal et al. (2019) Bacloville trial. Addiction 2020; 115:2186-2187. [PMID: 32364260 DOI: 10.1111/add.15104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/27/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Laurent Rigal
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France.,Université Paris-Saclay, Département de Médecine Générale, Le Kremlin-Bicêtre, France.,Institut national d'études démographiques (INED), Paris, France
| | - Stéphanie Sidorkiewicz
- Université de Paris, Faculté de Santé, UFR de Médecine,Département de Médecine Générale, Paris, France.,Universitét de Paris, CRESS, INSERM, INRA, Paris, France
| | - Claire Le Jeunne
- Service de médecine interne APHP-Hôpital Cochin, Paris, France.,Université de Paris, Paris, France
| | - Raphaël Porcher
- Universitét de Paris, CRESS, INSERM, INRA, Paris, France.,Centre d'épidémiologie clinique, AP-HP, Hôpital Hôtel-Dieu, Paris, France
| | - Philippe Jaury
- Université de Paris, Faculté de Santé, UFR de Médecine,Département de Médecine Générale, Paris, France
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Straus C, Teulier M, Morel S, Wattiez N, Hajage D, Giboin C, Charbit B, Dasque E, Bodineau L, Chenuel B, Straus N, Attali V, Similowski T. Baclofen destabilises breathing during sleep in healthy humans: A randomised, controlled, double-blind crossover trial. Br J Clin Pharmacol 2020; 87:1814-1823. [PMID: 32986891 DOI: 10.1111/bcp.14569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/31/2020] [Accepted: 09/13/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS Periodic breathing is frequent in patients with severe heart failure. Apart from being an indicator of severity, periodic breathing has its own deleterious consequences (sleep-related oxygen desaturations, sleep fragmentation), which justifies attempts to correct it irrespective of the underlying disease. Animal models and human data suggest that baclofen can reconfigure respiratory central pattern generators. We hypothesised that baclofen, a GABAB agonist, may thus be able to correct periodic breathing in humans. METHODS Healthy volunteers were exposed to hypoxia during sleep. Participants who developed periodic breathing (n = 14 [53 screened]) were randomly assigned to double-blind oral baclofen (progressively increased to 60 mg/d) or placebo. The primary outcome was the coefficient of variation (CoVar) of respiratory cycle total time considered as an indicator of breathing irregularity. Secondary outcomes included the CoVar of tidal volume, apnoea-hypopnoea index, sleep fragmentation index and ventilatory complexity (noise limit). RESULTS The analysis was conducted in 9 subjects after exclusion of incomplete datasets. CoVar of respiratory cycle total time significantly increased with baclofen during non-rapid eye movement sleep (median with placebo 56.00% [37.63-78.95]; baclofen 85.42% [68.37-86.40], P = .020; significant difference during the N1-N2 phases of sleep but not during the N3 phase). CoVar of tidal volume significantly increased during N1-N2 sleep. The apnoea-hypopnoea index, sleep fragmentation index and ventilatory complexity were not significantly different between placebo and baclofen. CONCLUSION Baclofen did not stabilise breathing in our model. On the contrary, it increased respiratory variability. Baclofen should probably not be used in patients with or at risk of periodic breathing.
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Affiliation(s)
- Christian Straus
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Département R3S, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, Paris, France
| | - Marion Teulier
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Sébastien Morel
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Nicolas Wattiez
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - David Hajage
- Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, Département de Santé Publique, Unité de Recherche Clinique Salpêtrière-Charles Foix, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Paris, France
| | - Caroline Giboin
- AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Unité de Recherche Clinique Salpêtrière-Charles Foix, Paris, France
| | - Beny Charbit
- INSERM and AP-HP, CIC-1901 module Paris-Est, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Department of Anesthesiology and Intensive Care, CHU Reims, Hôpital Robert Debré, Reims, France
| | - Eric Dasque
- INSERM and AP-HP, CIC-1901 module Paris-Est, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Laurence Bodineau
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Bruno Chenuel
- CHRU de Nancy, Service des Explorations Fonctionnelles Respiratoires et Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, Vandoeuvre-lès-Nancy, France.,Faculté de Médecine de Nancy, EA DevAH - Universié de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Nicolas Straus
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Valérie Attali
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Hôpital Pitié-Salpêtrière, Département R3S, Service des Pathologies du Sommeil, Paris, France
| | - Thomas Similowski
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Hôpital Pitié-Salpêtrière, Département R3S, Service de Pneumologie, Médecine Intensive et Réanimation, Paris, France
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