1
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Shih MC, Long BD, Pecha PP, White DR, Liu YC, Brennan E, Nguyen MI, Clemmens CS. A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy. World J Otorhinolaryngol Head Neck Surg 2022; 9:9-26. [PMID: 37006744 PMCID: PMC10050970 DOI: 10.1002/wjo2.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research. Data Sources PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley). Methods A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs. Results One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons. Conclusion Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.
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Affiliation(s)
- Michael C. Shih
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
- Baylor College of Medicine Houston Texas USA
| | - Barry D. Long
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
- Department of Otolaryngology—Head and Neck Surgery Virginia Commonwealth University School of Medicine Richmond Virginia USA
| | - Phayvanh P. Pecha
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
| | - David R. White
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
| | - Yi‐Chun C. Liu
- Department of Otolaryngology—Head and Neck Surgery Baylor College of Medicine Houston Texas USA
- Department of Surgery ‐ Division of Pediatric Otolaryngology Texas Children's Hospital Houston Texas USA
| | - Emily Brennan
- Department of Research and Education Services Medical University of South Carolina Library Charleston South Carolina USA
| | - Mariam I. Nguyen
- Charleston County School of the Arts North Charleston South Carolina USA
| | - Clarice S. Clemmens
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
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2
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Tang Girdwood SC, Rossow KM, Van Driest SL, Ramsey LB. Perspectives from the Society for Pediatric Research: pharmacogenetics for pediatricians. Pediatr Res 2022; 91:529-538. [PMID: 33824446 PMCID: PMC8492778 DOI: 10.1038/s41390-021-01499-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/12/2021] [Indexed: 12/26/2022]
Abstract
This review evaluates the pediatric evidence for pharmacogenetic associations for drugs that are commonly prescribed by or encountered by pediatric clinicians across multiple subspecialties, organized from most to least pediatric evidence. We begin with the pharmacogenetic research that led to the warning of increased risk of death in certain pediatric populations ("ultrarapid metabolizers") who are prescribed codeine after tonsillectomy or adenoidectomy. We review the evidence for genetic testing for thiopurine metabolism, which has become routine in multiple pediatric subspecialties. We discuss the pharmacogenetic research in proton pump inhibitors, for which clinical guidelines have recently been made available. With an increase in the prevalence of behavioral health disorders including attention deficit hyperactivity disorder (ADHD), we review the pharmacogenetic literature on selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and ADHD medications. We will conclude this section on the current pharmacogenetic data on ondansetron. We also provide our perspective on how to integrate the current research on pharmacogenetics into clinical care and what further research is needed. We discuss how institutions are managing pharmacogenetic test results and implementing them clinically, and how the electronic health record can be leveraged to ensure testing results are available and taken into consideration when prescribing medications. IMPACT: While many reviews of pharmacogenetics literature are available, there are few focused on pediatrics. Pediatricians across subspecialties will become more comfortable with pharmacogenetics terminology, know resources they can use to help inform their prescribing habits for drugs with known pharmacogenetic associations, and understand the limitations of testing and where further research is needed.
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Affiliation(s)
- Sonya C. Tang Girdwood
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Katelyn M. Rossow
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Laura B. Ramsey
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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3
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Darney K, Lautz LS, Béchaux C, Wiecek W, Testai E, Amzal B, Dorne JLCM. Human variability in polymorphic CYP2D6 metabolism: Implications for the risk assessment of chemicals in food and emerging designer drugs. ENVIRONMENT INTERNATIONAL 2021; 156:106760. [PMID: 34256299 DOI: 10.1016/j.envint.2021.106760] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/03/2021] [Accepted: 07/04/2021] [Indexed: 06/13/2023]
Abstract
The major human cytochrome P450 CYP2D6 isoform enzyme plays important roles in the liver and in the brain with regards to xenobiotic metabolism. Xenobiotics as CYP2D6 substrates include a whole range of pharmaceuticals, pesticides and plant alkaloids to cite but a few. In addition, a number of endogenous compounds have been shown to be substrates of CYP2D6 including trace amines in the brain such as tyramine and 5-methoxytryptamine as well as anandamide and progesterone. Because of the polymorphic nature of CYP2D6, considerable inter-phenotypic and inter-ethnic differences in the pharmaco/toxicokinetics (PK/TK) and metabolism of CYP2D6 substrates exist with potential consequences on the pharmacology and toxicity of chemicals. Here, large extensive literature searches have been performed to collect PK data from published human studies for a wide range of pharmaceutical probe substrates and investigate human variability in CYP2D6 metabolism. The computed kinetic parameters resulted in the largest open source database, quantifying inter-phenotypic differences for the kinetics of CYP2D6 probe substrates in Caucasian and Asian populations, to date. The database is available in supplementary material (CYPD6 DB) and EFSA knowledge junction (DOI to added). Subsequently, meta-analyses using a hierarchical Bayesian model for markers of chronic oral exposure (oral clearance, area under the plasma concentration time curve) and acute oral exposure (maximum plasma concentration (Cmax) provided estimates of inter-phenotypic differences and CYP2D6-related uncertainty factors (UFs) for chemical risk assessment in Caucasian and Asian populations classified as ultra-rapid (UM), extensive (EMs), intermediate (IMs) and poor metabolisers (PMs). The model allowed the integration of inter-individual (i.e. inter-phenotypic and inter-ethnic), inter-compound and inter-study variability together with uncertainty in each PK parameter. Key findings include 1. Higher frequencies of PMs in Caucasian populations compared to Asian populations (>8% vs 1-2%) for which EM and IM were the most frequent phenotype. 2. Large inter-phenotypic differences in PK parameters for Caucasian EMs (coefficients of variation (CV) > 50%) compared with Caucasian PMs and Asian EMs and IMs (i.e CV < 40%). 3. Inter-phenotypic PK differences between EMs and PMs in Caucasian populations increase with the quantitative contribution of CYP2D6 for the metabolism (fm) for a range of substrates (fmCYP2D6 range: 20-95% of dose) (range: 1-54) to a much larger extent than those for Asian populations (range: 1-4). 4. Exponential meta-regressions between FmCYP2D6 in EMs and inter-phenotypic differences were also shown to differ between Caucasian and Asian populations as well as CYP2D6-related UFs. Finally, implications of these results for the risk assessment of food chemicals and emerging designer drugs of public health concern, as CYP2D6 substrates, are highlighted and include the integration of in vitro metabolism data and CYP2D6-variability distributions for the development of quantitative in vitro in vivo extrapolation models.
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Affiliation(s)
- K Darney
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), 14 rue Pierre et Marie Curie, 94701 Maisons-Alfort, France
| | - L S Lautz
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), 14 rue Pierre et Marie Curie, 94701 Maisons-Alfort, France
| | - C Béchaux
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), 14 rue Pierre et Marie Curie, 94701 Maisons-Alfort, France
| | - W Wiecek
- Certara UK Ltd, Audrey House, 5th Floor, 16-20 Ely Place, London EC1N 6SN, United Kingdom
| | - E Testai
- Istituto Superior di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - B Amzal
- Quinten Health, 75017 Paris, France
| | - J L C M Dorne
- European Food Safety Authority, Via Carlo Magno,1A, 43126 Parma, Italy.
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4
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Jensen DR. Pharmacologic management of post-tonsillectomy pain in children. World J Otorhinolaryngol Head Neck Surg 2021; 7:186-193. [PMID: 34430826 PMCID: PMC8356107 DOI: 10.1016/j.wjorl.2021.03.004] [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: 03/03/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022] Open
Abstract
Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.
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Affiliation(s)
- Daniel R. Jensen
- Division of Otolaryngology, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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5
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Nair AA, Farber HJ, Chen H. Utilization of opioid versus non-opioid analgesics in Medicaid and CHIP enrolled children with current asthma. Pharmacoepidemiol Drug Saf 2021; 30:1520-1531. [PMID: 34322934 DOI: 10.1002/pds.5336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/17/2021] [Accepted: 07/25/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE Opioid analgesics are frequently dispensed in children despite its known risk in children with a compromised airway function. The objectives of the study were to assess the prevalence of opioid analgesic dispensing in children with current asthma and to identify patient and prescriber factors associated with the dispensing of opioid versus non-opioid analgesics. METHODS Children <18 years of age, having current asthma and receiving an incident analgesic prescription were identified from a large Medicaid Managed Care Plan during years 2013 through 2018. Current asthma was defined as both receiving an asthma diagnosis and filling an anti-asthmatic medication during the 12-month period prior to the analgesic medication initiation. A scoring algorithm was applied to associate analgesic prescription with procedures and diagnoses according to perceived need for analgesia and time proximity. RESULTS Of the 9529 children meeting the inclusion criteria, 2681 (28.1%) received an opioid prescription. Opioid analgesic dispensing was most common among children who had an outpatient surgery/procedure (29.4%), trauma (19.4%) dental procedure (18.4%), and respiratory infection (10.6%). Multivariable analysis indicated that non-Hispanic Black (AOR: 0.39[0.3-0.5]) and Hispanic (AOR: 0.51[0.4-0.6]) children were less likely to receive an opioid analgesic compared to their non-Hispanic White counterparts. Children with prior history of asthma-related emergency department visit (AOR: 1.24[1.0-1.5]) and short acting beta agonist overuse (AOR: 1.33[1.1-1.7]) were more likely to fill an opioid analgesic prescription than those without. CONCLUSION Opioid analgesics are frequently dispensed to children with asthma. A higher dispensing rate was observed among non-Hispanic White children and among those with a history of uncontrolled asthma.
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Affiliation(s)
- Abhishek A Nair
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Harold J Farber
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.,Medical Affairs, Texas Children's Health Plan, Houston, Texas, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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6
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Umukoro NN, Aruldhas BW, Rossos R, Pawale D, Renschler JS, Sadhasivam S. Pharmacogenomics of oxycodone: a narrative literature review. Pharmacogenomics 2021; 22:275-290. [PMID: 33728947 DOI: 10.2217/pgs-2020-0143] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Oxycodone is a semisynthetic μ- and κ-opioid receptor with agonist with a broad scope of use including postoperative analgesia as well as control of neuropathic and cancer pain. Advantages over other opioids include prolonged duration of action, greater potency than morphine and lack of histamine release or ceiling effect. Individual responses to oxycodone can vary due to genetic differences. This review article aims to summarize the oxycodone literature and provide context on its pharmacogenomics and pharmacokinetics. The evidence for clinical effect of genetic polymorphisms on oxycodone is conflicting. There is stronger evidence linking polymorphic genetic enzymes CYP2D6 and CYP3A with therapeutic outcomes. Further, research is needed to discern all of oxycodone's metabolites and their contribution to the overall analgesic effect.
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Affiliation(s)
- Nelly N Umukoro
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Blessed W Aruldhas
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Ryan Rossos
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA.,Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Dhanashri Pawale
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA.,Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Janelle S Renschler
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA.,Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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7
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Studer A, Billings K, Thompson D, Ida J, Rastatter J, Patel M, Huetteman P, Hoeman E, Duggan S, Mudahar S, Birmingham P, King M, Lavin J. Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy. Laryngoscope 2020; 131:E2337-E2343. [PMID: 33314128 DOI: 10.1002/lary.29314] [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: 09/30/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools. STUDY DESIGN Prospective quality improvement initiative. METHODS Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED). RESULTS In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED. CONCLUSIONS Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2337-E2343, 2021.
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Affiliation(s)
- Abbey Studer
- Center for Quality and Safety, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Kathleen Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Dana Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Jonathan Ida
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Jeff Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Manisha Patel
- Center for Quality and Safety, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Patricia Huetteman
- Data, Analytics and Reporting, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Erin Hoeman
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sarah Duggan
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sukhraj Mudahar
- Department of Pharmacy, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Patrick Birmingham
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A.,Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Michael King
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A.,Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
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8
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Kaye AD, Koress CM, Novitch MB, Jung JW, Urits I, Viswanath O, Renschler JS, Alpaugh ES, Cornett EM. Pharmacogenomics, concepts for the future of perioperative medicine and pain management: A review. Best Pract Res Clin Anaesthesiol 2020; 34:651-662. [PMID: 33004174 DOI: 10.1016/j.bpa.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 02/07/2023]
Abstract
Pharmacogenomics is the study of how genetic differences between individuals affect pharmacokinetics and pharmacodynamics. These differences are apparent to clinicians when taking into account the wide range of responses to medications given in clinical practice. A review of literature involving pharmacogenomics and pain management was performed. The implementation of preoperative pharmacogenomics will allow us to better care for our patients by delivering personalized, safer medicine. This review describes the current state of pharmacogenomics as it relates to many aspects of clinical practice and how clinicians can use these tools to improve patient outcomes.
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Affiliation(s)
- Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
| | - Cody M Koress
- Tulane University School of Medicine, Department of Internal Medicine, New Orleans, LA, USA.
| | - Matthew B Novitch
- University of Washington, Department of Anesthesiology, Seattle, WA, USA; Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL, USA.
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA.
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology Phoenix, AZ, USA.
| | | | - Edward S Alpaugh
- Louisiana State University Health Sciences Center, Department of Anesthesiology, Orleans, LA, USA.
| | - Elyse M Cornett
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA.
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9
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Abstract
Experimental and clinical acute pain research in relation to biological sex and genetics started in the 1980s. Research methods became more powerful and sensitive with the advancement in affordable gene sequencing methods and high-throughput genetic assays. Decades of research has identified several potential pharmaceutical targets, providing insights into future research direction, and understanding of acute pain and opioid analgesic effects in the clinical setting. However, there is insufficient evidence to make generalized recommendations for using genetic tests for clinical practice of acute pain management.
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Affiliation(s)
- Albert Hyukjae Kwon
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA
| | - Pamela Flood
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
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10
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Meyers RS, Thackray J, Matson KL, McPherson C, Lubsch L, Hellinga RC, Hoff DS. Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List. J Pediatr Pharmacol Ther 2020; 25:175-191. [PMID: 32265601 DOI: 10.5863/1551-6776-25.3.175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The safe use of medications in pediatric patients requires practitioners to consider the unique pharmacokinetics and pharmacodynamics of drugs prescribed in this age group. In an effort to create a standard of care for the safe use of medications in this population, a list of drugs that are potentially inappropriate for use in pediatric patients has been developed and titled the "KIDs List." METHODS A panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association were recruited to evaluate primary, secondary, and tertiary literature; FDA Pediatric Safety Communications; the Lexicomp electronic database; and product information for drugs that should be considered potentially inappropriate for use in pediatric patients. Information was rated using predefined criteria. A PubMed search was conducted using the following terms: adverse drug events OR adverse drug reactions. The search was limited to humans; age <18 years; case reports, observational studies, or clinical trials; and English language. No date range was used. Results were used to create an evidence-based list of candidate drugs that was then peer-reviewed and subjected to a 30-day public comment period prior to being finalized. RESULTS A PubMed search yielded 4049 unique titles, of which 210 were deemed relevant for full review. Practitioner recommendations highlighted an additional 77 drugs. FDA Pediatric Safety Communications and the Lexicomp database yielded 22 and 619 drugs, respectively. After critical analysis, peer review, and public review the final KIDs List contains 67 drugs and/or drug classes and 10 excipients. CONCLUSIONS This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients. If avoidance is not clinically possible, the drug should be used with caution and accompanied by appropriate monitoring.
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11
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Abstract
Pharmacogenetics is a key component of precision medicine. Genetic variation in drug metabolism enzymes can lead to variable exposure to drugs and metabolites, potentially leading to inefficacy and drug toxicity. Although the evidence for pharmacogenetic associations in children is not as extensive as for adults, there are several drugs across diverse therapeutic areas with robust pediatric data indicating important, and relatively common, drug-gene interactions. Guidelines to assist gene-based dose optimization are available for codeine, thiopurine drugs, selective serotonin reuptake inhibitors, atomoxetine, tacrolimus, and voriconazole. For each of these drugs, there is an opportunity to clinically implement precision medicine approaches with children for whom genetic test results are known or are obtained at the time of prescribing. For many more drugs that are commonly used in pediatric patients, additional investigation is needed to determine the genetic factors influencing appropriate dose.
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Affiliation(s)
- Laura B Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA
- Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
| | - Jacob T Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, Minnesota 55812, USA
| | - Susan I Vear
- Department of Hematology & Oncology, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, and Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA;
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12
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Zhang Y, Yang Y, Barnard M, Bentley JP, Ramachandran S. Opioid Use for Treatment of Acute Pain Among Children and Adolescents Enrolled in the Mississippi Medicaid Program. J Pharm Pract 2019; 34:558-566. [PMID: 31665970 DOI: 10.1177/0897190019883767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Abuse of opioids among children and adolescents has become a major public concern in the United States. Understanding the epidemiology of opioid use in this vulnerable population is critical to address opioid abuse. OBJECTIVE The aim of this study is to characterize opioid use for the treatment of acute pain among children and adolescents enrolled in Mississippi Medicaid and to determine the effects of related clinical factors (ie, mental health disorders and obstructive sleep apnea [OSA] on patterns of opioid use. METHODS A retrospective cohort study was conducted using the Mississippi Medicaid administrative claims data from October 2015 through December 2017. We examined the proportion of children and adolescents less than 21 years of age using opioids within 7 days following any qualifying acute pain episode, as well as the difference in opioid use patterns between individuals with various demographic and clinical characteristics. RESULTS Over 5% of the eligible population received opioids within 7 days of a qualifying pain episode. The majority received schedule II or schedule III to IV short-acting opioids. There was no significant difference in opioid use for acute pain between individuals with and without a mental health disorder. Opioid use for acute pain was significantly more likely among those with a history of OSA than those without OSA. CONCLUSION This study characterizes the nature and patterns of opioid use among children and adolescents with acute pain. Further research is needed to understand the role of clinical and other demographic factors in the prescribing of opioids for acute pain in this population.
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Affiliation(s)
- Yiqiao Zhang
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - Yi Yang
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - Marie Barnard
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - John P Bentley
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - Sujith Ramachandran
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
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Wester N, Mynttinen E, Etula J, Lilius T, Kalso E, Kauppinen EI, Laurila T, Koskinen J. Simultaneous Detection of Morphine and Codeine in the Presence of Ascorbic Acid and Uric Acid and in Human Plasma at Nafion Single-Walled Carbon Nanotube Thin-Film Electrode. ACS OMEGA 2019; 4:17726-17734. [PMID: 31681878 PMCID: PMC6822113 DOI: 10.1021/acsomega.9b02147] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/02/2019] [Indexed: 05/21/2023]
Abstract
In clinical settings, the dosing and differential diagnosis of the poisoning of morphine (MO) and codeine (CO) is challenging due to interindividual variations in metabolism. However, direct electrochemical detection of these analytes from biological matrices is inherently challenging due to interference from large concentrations of anions, such as ascorbic acid (AA) and uric acid (UA), as well as fouling of the electrode by proteins. In this work, a disposable Nafion-coated single-walled carbon nanotube network (SWCNT) electrode was developed. We show facile electron transfer and efficient charge separation between the interfering anions and positively charged MO and CO, as well as significantly reduced matrix effect in human plasma. The Nafion coating alters the voltammetric response of MO and CO, enabling simultaneous detection. With this SWCNT/Nafion electrode, two linear ranges of 0.05-1 and 1-10 μM were found for MO and one linear range of 0.1-50 μM for CO. Moreover, the selective and simultaneous detection of MO and CO was achieved in large excess of AA and UA, as well as, for the first time, in unprocessed human plasma. The favorable properties of this electrode enabled measurements in plasma with only mild dilution and without the precipitation of proteins.
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Affiliation(s)
- Niklas Wester
- Department
of Chemistry and Materials Science, Aalto
University, Kemistintie 1, 02150 Espoo, Finland
- E-mail:
| | - Elsi Mynttinen
- Department
of Electrical Engineering and Automation, Aalto University, Tietotie 3, 02150 Espoo, Finland
| | - Jarkko Etula
- Department
of Chemistry and Materials Science, Aalto
University, Kemistintie 1, 02150 Espoo, Finland
| | - Tuomas Lilius
- Department
of Pharmacology, University of Helsinki, Haartmaninkatu 8, 00290 Helsinki, Finland
- Department
of Clinical Pharmacology, University of
Helsinki and Helsinki University Hospital, Tukholmankatu 8C, 00290 Helsinki, Finland
| | - Eija Kalso
- Department
of Pharmacology, University of Helsinki, Haartmaninkatu 8, 00290 Helsinki, Finland
- Pain
Clinic, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2A, 00290 Helsinki, Finland
| | - Esko I. Kauppinen
- Department
of Applied Physics, Aalto University School
of Science, P.O. Box 15100, FI-00076 Aalto, Finland
| | - Tomi Laurila
- Department
of Electrical Engineering and Automation, Aalto University, Tietotie 3, 02150 Espoo, Finland
| | - Jari Koskinen
- Department
of Chemistry and Materials Science, Aalto
University, Kemistintie 1, 02150 Espoo, Finland
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Yamamoto PA, Conchon Costa AC, Lauretti GR, de Moraes NV. Pharmacogenomics in chronic pain therapy: from disease to treatment and challenges for clinical practice. Pharmacogenomics 2019; 20:971-982. [DOI: 10.2217/pgs-2019-0066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pharmacogenomics (PGx) has emerged as an encouraging tool in chronic pain therapy. Genetic variations associated with drug effectiveness or adverse reactions (amitriptyline/nortriptyline/codeine/oxycodone/tramadol-CYP2D6, amitriptyline-CYP2C19, carbamazepine-HLA-A, carbamazepine/oxcarbazepine-HLA-B) can be used to guide chronic pain management. Despite this evidence, many obstacles still need to be overcome for the effective clinical implementation of PGx. To translate the pharmacogenetic testing into actionable clinical decisions, the Clinical Pharmacogenetics Implementation Consortium has been developing guidelines for several drug–gene pairs. This review will show the applicability of PGx in chronic pain from disease to treatment; report the drug–gene pairs with strongest evidences in the clinic; and the challenges for the clinical implementation of PGx.
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Affiliation(s)
- Priscila Akemi Yamamoto
- São Paulo State University, UNESP - School of Pharmaceutical Sciences, Araraquara, SP, Brazil
| | - Ana Carolina Conchon Costa
- São Paulo University, USP – School of Pharmaceutical Sciences of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Gabriela Rocha Lauretti
- São Paulo University, USP – School of Medicine of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Natália Valadares de Moraes
- São Paulo State University, UNESP - School of Pharmaceutical Sciences, Araraquara, SP, Brazil
- Queen's University Belfast, Belfast, UK
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 2019; 143:peds.2019-1000. [PMID: 31138666 DOI: 10.1542/peds.2019-1000] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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A Single Site Population Study to Investigate CYP2D6 Phenotype of Patients with Persistent Non-Malignant Pain. ACTA ACUST UNITED AC 2019; 55:medicina55060220. [PMID: 31141989 PMCID: PMC6631257 DOI: 10.3390/medicina55060220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/17/2019] [Accepted: 05/23/2019] [Indexed: 01/08/2023]
Abstract
Background and Objectives: Codeine requires biotransformation by the CYP2D6 enzyme, encoded by the polymorphic CYP2D6 gene, to morphine for therapeutic efficacy. CYP2D6 phenotypes of poor, intermediate, and ultra-rapid metabolisers are at risk of codeine non-response and adverse drug reactions due to altered CYP2D6 function. The aim of this study was to determine whether genotype, inferred phenotype, and urinary and oral fluid codeine O-demethylation metabolites could predict codeine non-response following a short course of codeine. Materials and Methods: There were 131 Caucasians with persistent pain enrolled. Baseline assessments were recorded, prohibited medications ceased, and DNA sampling completed before commencing codeine 30 mg QDS for 5 days. Day 4 urine samples were collected 1–2 h post morning dose for codeine O-demethylation metabolites analysis. Final pain assessments were conducted on day 5. Results: None of the poor, intermediate, ultra-rapid metabolisers and only 24.5% of normal metabolisers responded to codeine. A simple scoring system to predict analgesic response from day 4 urinary metabolites was devised with overall prediction success of 79% (sensitivity 0.8, specificity 0.78) for morphine and 79% (sensitivity 0.76, specificity 0.83) for morphine:creatinine ratio. Conclusions: In conclusion, this study provides tentative evidence that day 4 urinary codeine O-demethylation metabolites could predict non-response following a short course of codeine and could be utilised in the clinical assessment of codeine response at the point of care to improve analgesic efficacy and safety in codeine therapy. We offer a scoring system to predict codeine response from urinary morphine and urinary morphine:creatinine ratio collected on the morning of day 4 of codeine 30 mg QDS, but this requires validation before it could be considered for use to assess codeine response in clinical practice.
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18
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Lam YWF. Principles of Pharmacogenomics. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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19
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The Use of Codeine and Tramadol in the Pediatric Population-What is the Verdict Now? J Pediatr Health Care 2019; 33:117-123. [PMID: 30545525 DOI: 10.1016/j.pedhc.2018.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/23/2018] [Indexed: 12/21/2022]
Abstract
Codeine and tramadol are opioid analgesics approved for the management of pain in the United States. Both agents are metabolized in the liver to active compounds via the cytochrome P450 2D6 enzyme. Case reports of pediatric patients with overactive CYP2D6 enzymes have been reported. These ultra-rapid metabolizers experience an increase in the production of active metabolites of codeine and tramadol, which can lead to oversedation, respiratory depression, and death. In 2017, the U.S. Food and Drug Administration updated their warnings regarding codeine and tramadol use in the pediatric population, making their use contraindicated in patients under the age of 12 years.
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20
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Scalzitti NJ, Sarber KM. Diagnosis and perioperative management in pediatric sleep-disordered breathing. Paediatr Anaesth 2018; 28:940-946. [PMID: 30281185 DOI: 10.1111/pan.13506] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/30/2018] [Accepted: 09/04/2018] [Indexed: 12/17/2022]
Abstract
Sleep-disordered breathing has a prevalence of 12% in the pediatric population. It represents a spectrum of disorders encompassing abnormalities of the upper airway that lead to sleep disruption, including primary snoring, obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. Sleep-disordered breathing is the most common indication for adenotonsillectomy, one of the most common procedures performed in children. In recent years, the American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, and the American Society of Anesthesiologists have crafted guidelines to help safely manage children with sleep-disordered breathing. Each organization recommends in-laboratory polysomnography for definitive diagnosis of obstructive sleep apnea in certain cases. However, because this test is both costly and inconvenient, there has been significant interest in alternative methods for diagnosing clinically significant sleep-disordered breathing. Accurate diagnosis is critical because sleep-disordered breathing confers certain perioperative risks and increased mortality in some instances. Recent studies have elucidated the danger of anesthesia and opioids in worsening obstructive sleep apnea, and recommendations for alternative analgesia are being created. In addition, determining the most appropriate level and duration of monitoring in the postoperative period is actively being evaluated. This article presents an overview of the recent literature on the perioperative care of pediatric patients with sleep-disordered breathing. It highlights innovative modalities and limitations in diagnosing obstructive sleep apnea, the importance of a tailored anesthetic/analgesic approach to children with obstructive sleep apnea, and the need for postoperative monitoring. It also brings to focus that further studies on the perioperative care of these children are necessary.
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Affiliation(s)
- Nicholas J Scalzitti
- Departments of Otolaryngology and Sleep Medicine, San Antonio Military Medical Center, San Antonio, Texas
| | - Kathleen M Sarber
- Department of Pulmonary Medicine, Sleep Disorders Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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21
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Faria J, Solverson M, Faria M, Benoit M, McCormick M. Potential Cytochrome P450 Drug-Drug Interactions among Pediatric Patients Undergoing Tonsillectomy. Otolaryngol Head Neck Surg 2018; 160:145-149. [PMID: 30105930 DOI: 10.1177/0194599818793850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the frequency of potential cytochrome P450 (CYP) drug-drug interactions affecting opioid metabolism among children undergoing adenotonsillectomy. STUDY DESIGN Case series with chart review. SETTING Tertiary care children's hospital. SUBJECTS AND METHODS A retrospective review was conducted of 1000 patients undergoing adenotonsillectomy at Children's Hospital of Wisconsin. The discharge medication reconciliation form was reviewed. Each patient's list of medications was compared with various published sources to determine whether medications causing CYP inhibition or induction were present. RESULTS There were 157 unique medications with systemic absorption given postoperatively to this patient cohort. Eight percent of patients were on at least 5 medications after surgery other than their posttonsillectomy medication. The 5 most commonly prescribed medications were albuterol, cetirizine, fluticasone nasal spray, montelukast, and polyethylene glycol. Per a list of known CYP inducers and inhibitors published by the US Food and Drug Administration, 30 (3%) patients were on a medication that inhibited CYP3A4; 1 patient was on a CYP3A4 inducer, prednisone; and 46 (5%) patients were on a medication that inhibited CYP2D6. CONCLUSIONS A small fraction of patients undergoing adenotonsillectomy are on medications that potentially alter the metabolism of opioid pain medications. Given the narrow therapeutic index of opioids and increased sensitivity to opioids among patients with obstructive sleep apnea, drug-drug interactions need to be considered as they relate to whether an opioid is appropriate and at what dose.
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Affiliation(s)
- John Faria
- 1 University of Rochester, Rochester, New York, USA
| | | | | | - Margo Benoit
- 1 University of Rochester, Rochester, New York, USA
| | - Michael McCormick
- 2 Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,4 Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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22
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Patel JN, Wiebe LA, Dunnenberger HM, McLeod HL. Value of Supportive Care Pharmacogenomics in Oncology Practice. Oncologist 2018; 23:956-964. [PMID: 29622698 PMCID: PMC6156181 DOI: 10.1634/theoncologist.2017-0599] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/21/2018] [Indexed: 12/14/2022] Open
Abstract
Genomic medicine provides opportunities to personalize cancer therapy for an individual patient. Although novel targeted therapies prolong survival, most patients with cancer continue to suffer from burdensome symptoms including pain, depression, neuropathy, nausea and vomiting, and infections, which significantly impair quality of life. Suboptimal management of these symptoms can negatively affect response to cancer treatment and overall prognosis. The effect of genetic variation on drug response-otherwise known as pharmacogenomics-is well documented and directly influences an individual patient's response to antiemetics, opioids, neuromodulators, antidepressants, antifungals, and more. The growing body of pharmacogenomic data can now guide clinicians to select the safest and most effective supportive medications for an individual patient with cancer from the very first prescription. This review outlines a theoretical patient case and the implications of using pharmacogenetic test results to personalize supportive care throughout the cancer care continuum. IMPLICATIONS FOR PRACTICE Integration of palliative medicine into the cancer care continuum has resulted in increased quality of life and survival for patients with many cancer types. However, suboptimal management of symptoms such as pain, neuropathy, depression, and nausea and vomiting continues to place a heavy burden on patients with cancer. As demonstrated in this theoretical case, pharmacogenomics can have a major effect on clinical response to medications used to treat these conditions. Recognizing the value of supportive care pharmacogenomics in oncology and application into routine practice offers an objective choice for the safest and most effective treatment compared with the traditional trial and error method.
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Affiliation(s)
- Jai N Patel
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Lauren A Wiebe
- NorthShore University Health System, Evanston, Illinois, USA
| | | | - Howard L McLeod
- The DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
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23
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Kaye AD, Mahakian T, Kaye AJ, Pham AA, Hart BM, Gennuso S, Cornett EM, Gabriel RA, Urman RD. Pharmacogenomics, precision medicine, and implications for anesthesia care. Best Pract Res Clin Anaesthesiol 2018; 32:61-81. [DOI: 10.1016/j.bpa.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/30/2018] [Indexed: 01/28/2023]
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Schwerdtle T, Vollmer G, Wallace H, Benford D, Calò G, Dahan A, Dusemund B, Mulder P, Németh-Zámboriné É, Arcella D, Baert K, Cascio C, Levorato S, Schutte M, Vleminckx C. Update of the Scientific Opinion on opium alkaloids in poppy seeds. EFSA J 2018; 16:e05243. [PMID: 32625895 PMCID: PMC7009406 DOI: 10.2903/j.efsa.2018.5243] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.
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Aka I, Bernal CJ, Carroll R, Maxwell-Horn A, Oshikoya KA, Van Driest SL. Clinical Pharmacogenetics of Cytochrome P450-Associated Drugs in Children. J Pers Med 2017; 7:jpm7040014. [PMID: 29099060 PMCID: PMC5748626 DOI: 10.3390/jpm7040014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 10/26/2017] [Accepted: 10/26/2017] [Indexed: 01/23/2023] Open
Abstract
Cytochrome P450 (CYP) enzymes are commonly involved in drug metabolism, and genetic variation in the genes encoding CYPs are associated with variable drug response. While genotype-guided therapy has been clinically implemented in adults, these associations are less well established for pediatric patients. In order to understand the frequency of pediatric exposures to drugs with known CYP interactions, we compiled all actionable drug-CYP interactions with a high level of evidence using Clinical Pharmacogenomic Implementation Consortium (CPIC) data and surveyed 10 years of electronic health records (EHR) data for the number of children exposed to CYP-associated drugs. Subsequently, we performed a focused literature review for drugs commonly used in pediatrics, defined as more than 5000 pediatric patients exposed in the decade-long EHR cohort. There were 48 drug-CYP interactions with a high level of evidence in the CPIC database. Of those, only 10 drugs were commonly used in children (ondansetron, oxycodone, codeine, omeprazole, lansoprazole, sertraline, amitriptyline, citalopram, escitalopram, and risperidone). For these drugs, reports of the drug-CYP interaction in cohorts including children were sparse. There are adequate data for implementation of genotype-guided therapy for children for three of the 10 commonly used drugs (codeine, omeprazole and lansoprazole). For the majority of commonly used drugs with known CYP interactions, more data are required to support pharmacogenomic implementation in children.
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Affiliation(s)
- Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Christiana J Bernal
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Robert Carroll
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Angela Maxwell-Horn
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Kazeem A Oshikoya
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Pain after tonsillectomy: effectiveness of current guidelines? Eur Arch Otorhinolaryngol 2017; 275:281-286. [DOI: 10.1007/s00405-017-4788-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
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27
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Poonai N, Datoo N, Ali S, Cashin M, Drendel AL, Zhu R, Lepore N, Greff M, Rieder M, Bartley D. Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial. CMAJ 2017; 189:E1252-E1258. [PMID: 29018084 DOI: 10.1503/cmaj.170017] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Oral morphine for postoperative pain after minor pediatric surgery, while increasingly popular, is not supported by evidence. We evaluated whether oral morphine was superior to ibuprofen for at-home management of children's postoperative pain. METHODS We conducted a randomized superiority trial comparing oral morphine (0.5 mg/kg) with ibuprofen (10 mg/kg) in children 5 to 17 years of age who had undergone minor outpatient orthopedic surgery (June 2013 to September 2016). Participants took up to 8 doses of the intervention drug every 6 hours as needed for pain at home. The primary outcome was pain, according to the Faces Pain Scale - Revised, for the first dose. Secondary outcomes included additional analgesic requirements, adverse effects, unplanned health care visits and pain scores for doses 2 to 8. RESULTS We analyzed data for 77 participants in each of the morphine and ibuprofen groups. Both interventions decreased pain scores with no difference in efficacy. The median difference in pain score before and after the first dose of medication was 1 (interquartile range 0-1) for both morphine and ibuprofen (p = 0.2). For doses 2 to 8, the median differences in pain score before and after the dose were not significantly different between groups. Significantly more participants taking morphine reported adverse effects (45/65 [69%] v. 26/67 [39%], p < 0.001), most commonly drowsiness (31/65 [48%] v. 15/67 [22%] in the morphine and ibuprofen groups, respectively; p = 0.003). INTERPRETATION Morphine was not superior to ibuprofen, and both drugs decreased pain with no apparent difference in efficacy. Morphine was associated with significantly more adverse effects, which suggests that ibuprofen is a better first-line option after minor surgery. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01686802.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis.
| | - Natasha Datoo
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Megan Cashin
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Amy L Drendel
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Rongbo Zhu
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Natasha Lepore
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Michael Greff
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Michael Rieder
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
| | - Debra Bartley
- Division of Emergency Medicine (Poonai, Zhu, Lepore), London Health Sciences Centre; Department of Paediatrics (Poonai, Datoo, Greff, Rieder) and Department of Surgery (Cashin, Bartley), Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alta.; Children's Hospital of Wisconsin (Drendel), Milwaukee, Wis
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Owusu Obeng A, Hamadeh I, Smith M. Review of Opioid Pharmacogenetics and Considerations for Pain Management. Pharmacotherapy 2017; 37:1105-1121. [DOI: 10.1002/phar.1986] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine; Icahn School of Medicine at Mount Sinai; New York NY
- Pharmacy Department; The Mount Sinai Hospital; New York New York
- Division of General Internal Medicine; Department of Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Michael Smith
- University of Michigan College of Pharmacy; Ann Arbor Michigan
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Pierson BW, Cardon BS, Anderson MP, Glade RS. A Comparison of Nonopioid and Opioid Oral Analgesia following Pediatric Palatoplasty. Cleft Palate Craniofac J 2017; 54:170-174. [DOI: 10.1597/15-135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective This article evaluates postoperative analgesia in pediatric palatoplasty patients using nonopioid oral medications. Design This study was a retrospective chart review. Setting The setting for this study was a tertiary-care children's hospital. Participants Study participants were pediatric patients who underwent palatoplasty procedures performed by a single surgeon. Interventions Interventions included nonopioid and opioid oral medications for postoperative analgesia. Main Outcome Measures The adequacy of nonopioid versus opioid oral analgesia was assessed by (1) time to discontinue IV fluid, (2) total IV morphine doses for breakthrough pain, (3) daily IV morphine doses for breakthrough pain, (4) time to discharge from the hospital, and (5) perioperative weight change. Group comparisons of outcome measures were performed using a two one-sided test. Results A total of 61 patients were identified who received three standard pain regimens: acetaminophen + ibuprofen (12), hydrocodone/acetaminophen (23), and hydrocodone/acetaminophen + ibuprofen (26). There was sufficient evidence to suggest equivalence in outcome measures for acetaminophen + ibuprofen versus hydrocodone/acetaminophen and hydrocodone/acetaminophen + ibuprofen for the following: time to discontinue IV fluid ( P = .02, 90% confidence interval [CI] = –0.42 to 0.17; P = .007, 90% CI = –0.28 to 0.34), daily IV morphine doses ( P = .023, 90% [CI] = –0.83 to 0.65; P = .032, 90% [CI] = –0.92 to 0.28), time to discharge from the hospital ( P = .017, 90% [CI] = –0.40 to 0.27; P = .015, 90% [CI] = –0.24 to 0.39), and perioperative weight change ( P = .002; 90% CI = –0.25 to 0.46; P < .0001; 90% CI = –0.34 to 0.18). There was no sufficient evidence to suggest equivalence for total IV morphine doses ( P = .189, 90% CI = –1.51 to 1.78; P = .169, 90% CI = –1.51 to 0.88). Conclusions Oral acetaminophen and ibuprofen alone may provide similar analgesia to traditional regimens with reduced risks following pediatric palatoplasty.
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Affiliation(s)
- Brandon W. Pierson
- Department of Otolaryngology–Head and Neck Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Brandon S. Cardon
- College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Michael P. Anderson
- Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma
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Senagore AJ, Champagne BJ, Dosokey E, Brady J, Steele SR, Reynolds HL, Stein SL, Delaney CP. Pharmacogenetics-guided analgesics in major abdominal surgery: Further benefits within an enhanced recovery protocol. Am J Surg 2017; 213:467-472. [DOI: 10.1016/j.amjsurg.2016.11.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/03/2016] [Accepted: 11/05/2016] [Indexed: 11/15/2022]
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Abstract
Codeine has been prescribed to pediatric patients for many decades as both an analgesic and an antitussive agent. Codeine is a prodrug with little inherent pharmacologic activity and must be metabolized in the liver into morphine, which is responsible for codeine's analgesic effects. However, there is substantial genetic variability in the activity of the responsible hepatic enzyme, CYP2D6, and, as a consequence, individual patient response to codeine varies from no effect to high sensitivity. Drug surveillance has documented the occurrence of unanticipated respiratory depression and death after receiving codeine in children, many of whom have been shown to be ultrarapid metabolizers. Patients with documented or suspected obstructive sleep apnea appear to be at particular risk because of opioid sensitivity, compounding the danger among rapid metabolizers in this group. Recently, various organizations and regulatory bodies, including the World Health Organization, the US Food and Drug Administration, and the European Medicines Agency, have promulgated stern warnings regarding the occurrence of adverse effects of codeine in children. These and other groups have or are considering a declaration of a contraindication for the use of codeine for children as either an analgesic or an antitussive. Additional clinical research must extend the understanding of the risks and benefits of both opioid and nonopioid alternatives for orally administered, effective agents for acute and chronic pain.
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Cairns R, Brown JA, Buckley NA. The impact of codeine re-scheduling on misuse: a retrospective review of calls to Australia's largest poisons centre. Addiction 2016; 111:1848-53. [PMID: 27177599 DOI: 10.1111/add.13450] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/25/2016] [Accepted: 05/11/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Codeine is the most commonly used opioid in the world, and is available over the counter (OTC) in many countries, including Australia. Several countries are reconsidering codeine's OTC status due to concerns over addiction and misuse, with serious morbidity and mortality being reported. Australia's Therapeutic Goods Administration restricted codeine containing analgesics to 'Pharmacist Only' in 2010, and has recently been considering further up-scheduling to make codeine 'Prescription Only'. This paper estimated Australian trends of codeine misuse over the past 12 years, and examined whether trends changed following previous rescheduling efforts in 2010. DESIGN A retrospective review of calls regarding codeine misuse made to the New South Wales Poisons Information Centre (NSWPIC, Australia's largest poisons centre), 2004-15. Joinpoint software was used to quantify the average annual change in calls, and whether there was a significant change in trend at any time, including following rescheduling. SETTING Australia. PARTICIPANTS Four hundred patients about whom a call was made to the NSWPIC. MEASURES Calls per year, patient age, gender, tablets taken per day, formulation used, symptom disposition. FINDINGS The NSWPIC database contained 400 cases of codeine combination analgesic misuse from 2004 to 2015. Joinpoint analysis showed that the frequency of cases increased significantly from 2004 to 2015, with an average annual percentage change (AAPC) of 19.5% [95% confidence interval (CI) = 13.8-25.5% P < 0.0001] for paracetamol/codeine and 17.9% (95% CI = 7.9-28.9%, P < 0.01) for ibuprofen/codeine. No significant change in trend was seen at any time, including following 2010 rescheduling. The median age of patients was 34 and 27 years for paracetamol/codeine and ibuprofen/codeine cases, respectively. Gender distribution was approximately equal. Clinical features reported were consistent with codeine, paracetamol and ibuprofen toxicity. CONCLUSIONS Misuse of codeine combination products appears to be increasing in Australia. Limited rescheduling in 2010 failed to curb this increase.
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Affiliation(s)
- Rose Cairns
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, Australia. .,Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, The University of Sydney, NSW, Australia.
| | - Jared A Brown
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, The University of Sydney, NSW, Australia
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Pfaff JA, Hsu K, Chennupati SK. The Use of Ibuprofen in Posttonsillectomy Analgesia and Its Effect on Posttonsillectomy Hemorrhage Rate. Otolaryngol Head Neck Surg 2016; 155:508-13. [DOI: 10.1177/0194599816646363] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 04/05/2016] [Indexed: 11/16/2022]
Abstract
Objective To determine the effect of ibuprofen on posttonsillectomy bleeding when compared with codeine in posttonsillectomy analgesia. Study Design Case series with chart review. Setting Tertiary care children’s hospital, Philadelphia, Pennsylvania. Subjects and Methods On July 1, 2012, our institution transitioned from acetaminophen with codeine to ibuprofen for posttonsillectomy analgesia. Pediatric patients (0-18 years old) who underwent surgery from July 1, 2010, to June 30, 2012, were placed in the codeine cohort, and those who underwent surgery from July 1, 2012, to June 30, 2014, were placed in the ibuprofen cohort. Results A total of 6014 patients underwent tonsillectomy between July 1, 2010, and June 30, 2014, and 211 patients presented for posttonsillectomy hemorrhage during the same period. The incidence of readmission for posttonsillectomy hemorrhage was 3.4% and 3.6% ( P = .63; odds ratio [OR] = 1.07; 95% confidence interval [95% CI]: 0.811-1.410) for the codeine and ibuprofen groups, respectively, and the incidence of second operation for control of posttonsillectomy bleeding for the codeine and ibuprofen groups was 1.9% and 2.2% ( P = .54; OR = 1.117; 95% CI: 0.781-1.600), respectively. Patients aged 11 to 18 years demonstrated a higher incidence of posttonsillectomy bleeding events overall. When age is controlled, multivariate logistic regression demonstrated no statistically significant increase in posttonsillectomy bleeding events among pediatric patients treated with ibuprofen versus patients treated with codeine (readmission: P = .617; OR = 0.932; 95% CI: 0.707-1.228; reoperation: P = .513; OR = 0.887; 95% CI: 0.618-1.272). Conclusion Age is an independent risk factor for posttonsillectomy bleeding. When age is controlled, there is no statistically significant increase in the incidence of posttonsillectomy bleeding events among patients treated with ibuprofen when compared to patients treated with codeine.
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Affiliation(s)
- Julia A. Pfaff
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
- St Christopher’s Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Kevin Hsu
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
- St Christopher’s Hospital for Children, Philadelphia, Pennsylvania, USA
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Tverdohleb T, Dinc B, Knezevic I, Candido KD, Knezevic NN. The role of cytochrome P450 pharmacogenomics in chronic non-cancer pain patients. Expert Opin Drug Metab Toxicol 2016; 12:1303-1311. [PMID: 27388970 DOI: 10.1080/17425255.2016.1209482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pharmacogenomics is the field that studies an individualized treatment approach for patients' medication regimen that can impact drug safety, productivity, and personalized health care. Pharmacogenomics characterizes the genetic differences in metabolic pathways which can affect a patient's individual responses to drug treatments. Areas covered: The various responses to pharmacological agents are mainly determined by the different types of genetic variants of the CYP450. CYP2D6 polymorphism is well known for its variation in the metabolism of drugs from many therapeutic arenas, including some analgesic drugs such as codeine, hydromorphone, oxycodone and tramadol. Allele combinations determine the phenotypic expression, characterized as either: extensive metabolizer, intermediate metabolizer, ultra-rapid metabolizer and poor metabolizer. Expert opinion: The Human Genome Project (HGP) revolutionized the future of medicine and the way health care providers approach individualized patient treatment, and chronic pain management is one of those areas. The key findings in the literature appear to be related to the CYP2D6 expression and its high polymorphism influencing the metabolism of opioid medications, and the impact of that on the patient's therapeutic outcome thus exemplifying the importance of genetic testing for CYP2D6 in the process of physician therapeutic decision making.
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Affiliation(s)
- Tatiana Tverdohleb
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA
| | - Bora Dinc
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA
| | - Ivana Knezevic
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA
| | - Kenneth D Candido
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA.,b Department of Anesthesiology, College of Medicine , University of Illinois , Chicago , IL , USA.,c Department of Surgery, College of Medicine , University of Illinois , Chicago , IL , USA
| | - Nebojsa Nick Knezevic
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA.,b Department of Anesthesiology, College of Medicine , University of Illinois , Chicago , IL , USA.,c Department of Surgery, College of Medicine , University of Illinois , Chicago , IL , USA
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Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138:peds.2016-1212. [PMID: 27354454 DOI: 10.1542/peds.2016-1212] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.
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Green DJ, Mummaneni P, Kim IW, Oh JM, Pacanowski M, Burckart GJ. Pharmacogenomic information in FDA-approved drug labels: Application to pediatric patients. Clin Pharmacol Ther 2016; 99:622-32. [DOI: 10.1002/cpt.330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/18/2015] [Accepted: 12/17/2015] [Indexed: 01/05/2023]
Affiliation(s)
- DJ Green
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
| | - P Mummaneni
- Genomics and Targeted Therapy Group, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
| | - IW Kim
- School of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University; Seoul South Korea
| | - JM Oh
- School of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University; Seoul South Korea
| | - M Pacanowski
- Genomics and Targeted Therapy Group, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
| | - GJ Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration; Silver Spring Maryland USA
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Abstract
PURPOSE OF REVIEW To summarize recent evidence-based data regarding outcomes associated with children who have obstructive sleep apnea (OSA). RECENT FINDINGS Internet surveys conducted by pediatric otolaryngologists and pediatric anesthesiologists have reported a disturbing number of deaths within 24 h of tonsillectomy attributed to postsurgical/anesthesia apnea. Several occurred in the post anesthesia care unit after routine monitors had been removed. In addition, a number of deaths also have been attributed to children who have duplicated cytochromes allowing the rapid conversion of codeine to morphine, thus producing a relative drug overdose. Finally, there is some human and animal evidence suggesting that repeated episodes of hypoxemia result in altered opioid receptors causing relative opioid sensitivity. These factors have important clinical implications. SUMMARY Perioperative deaths in children with OSA occur at a low frequency. Hypoxia-induced opioid sensitivity combined with an approximate 1-2% incidence of rapid conversion of codeine to morphine suggest the need for new approaches for providing preoperative assessment of risk, extended postoperative observation and the need for alternative opioids to codeine. Additionally, new less painful surgical approaches may help to reduce postoperative opioid requirements and therefore perhaps less risk for opiate-induced apnea in this vulnerable population.
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Ford KA, Ryslik G, Sodhi J, Halladay J, Diaz D, Dambach D, Masuda M. Computational predictions of the site of metabolism of cytochrome P450 2D6 substrates: comparative analysis, molecular docking, bioactivation and toxicological implications. Drug Metab Rev 2015; 47:291-319. [DOI: 10.3109/03602532.2015.1047026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Haufroid V, Hantson P. CYP2D6 genetic polymorphisms and their relevance for poisoning due to amfetamines, opioid analgesics and antidepressants. Clin Toxicol (Phila) 2015; 53:501-10. [DOI: 10.3109/15563650.2015.1049355] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pharmacogenomics and Opioid Analgesics: Clinical Implications. Int J Genomics 2015; 2015:368979. [PMID: 26075211 PMCID: PMC4446490 DOI: 10.1155/2015/368979] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 04/22/2015] [Accepted: 04/26/2015] [Indexed: 11/17/2022] Open
Abstract
Variation exists in patient response on analgesic treatment in terms of efficacy and safety. This variation may be in part explained by pharmacogenomics. This paper aimed to review data on pharmacogenomics of opioid analgesics focusing on the effect of genetic variation on the efficacy and safety of these agents. Current evidence suggests that pharmacogenomics contribute to variation in efficacy and safety of opioids. However, most data come from case control studies and case reports. In addition, a recognized drawback in the field of pharmacogenomics is the common occurrence of false positive association between polymorphisms and the investigated outcome. Prospective studies are needed to further elucidate the clinical implications of available data as well as to define the guidelines for the clinical application of pharmacogenomic data. Furthermore, basic research should focus on the identification of biologically meaningful polymorphisms enabling a hypothesis with biological plausibility driven research in the field of pharmacogenomics of analgesics. Moreover, the publication of relevant negative results should be favoured.
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Lim KBL. Postfracture pain in children can be adequately managed with ibuprofen. ACTA ACUST UNITED AC 2015; 20:105. [DOI: 10.1136/ebmed-2015-110178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Confronting the challenges of effective pain management in children following tonsillectomy. Int J Pediatr Otorhinolaryngol 2014; 78:1813-27. [PMID: 25241379 DOI: 10.1016/j.ijporl.2014.08.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 12/29/2022]
Abstract
Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.
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Biesiada J, Chidambaran V, Wagner M, Zhang X, Martin LJ, Meller J, Sadhasivam S. Genetic risk signatures of opioid-induced respiratory depression following pediatric tonsillectomy. Pharmacogenomics 2014; 15:1749-1762. [PMID: 25493568 PMCID: PMC4287371 DOI: 10.2217/pgs.14.137] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/19/2014] [Indexed: 12/29/2022] Open
Abstract
Background: Respiratory depression is a clinically and economically important but preventable complication of opioids. Genetic factors can help identify patients with high risk for respiratory depression. Methods: In this prospective genotype blinded clinical study, we evaluated the effect of a panel of variants in candidate genes on opioid-related respiratory depression in 347 children following tonsillectomy. Results: Using unsupervised hierarchical clustering and a combination of candidate genotypes and clinical variables, we identified several distinct clusters of patients at high risk (36-38%) and low risk (10-17%) of respiratory depression; the relative risk of respiratory depression for high versus low risk clusters was 2.1-3.8 (p = 0.003). Conclusion: Genetic risk predictions (genetic signatures) along with clinical risk factors effectively identify children at higher and lower risks of opioid-induced respiratory depression. Genetic signatures of respiratory depression offer strategies for improved clinical decision support to guide clinicians to balance the risks of opioid adverse effects with analgesia. Original submitted 9 July 2014; Revision submitted 19 September 2014.
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Affiliation(s)
- Jacek Biesiada
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH, USA
- Division of Informatics in Industry, Technical University of Silesia, Gliwice, Poland
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Wagner
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Xue Zhang
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jaroslaw Meller
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH, USA
- Department of Informatics, Nicholas Copernicus University, Torun, Poland
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Poonai N, Bhullar G, Lin K, Papini A, Mainprize D, Howard J, Teefy J, Bale M, Langford C, Lim R, Stitt L, Rieder MJ, Ali S. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ 2014; 186:1358-63. [PMID: 25349008 DOI: 10.1503/cmaj.140907] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Recent warnings from Health Canada regarding codeine for children have led to increased use of nonsteroidal anti-inflammatory drugs and morphine for common injuries such as fractures. Our objective was to determine whether morphine administered orally has superior efficacy to ibuprofen in fracture-related pain. METHODS We used a parallel group, randomized, blinded superiority design. Children who presented to the emergency department with an uncomplicated extremity fracture were randomly assigned to receive either morphine (0.5 mg/kg orally) or ibuprofen (10 mg/kg) for 24 hours after discharge. Our primary outcome was the change in pain score using the Faces Pain Scale - Revised (FPS-R). Participants were asked to record pain scores immediately before and 30 minutes after receiving each dose. RESULTS We analyzed data from 66 participants in the morphine group and 68 participants in the ibuprofen group. For both morphine and ibuprofen, we found a reduction in pain scores (mean pre-post difference ± standard deviation for dose 1: morphine 1.5 ± 1.2, ibuprofen 1.3 ± 1.0, between-group difference [δ] 0.2 [95% confidence interval (CI) -0.2 to 0.6]; dose 2: morphine 1.3 ± 1.3, ibuprofen 1.3 ± 0.9, δ 0 [95% CI -0.4 to 0.4]; dose 3: morphine 1.3 ± 1.4, ibuprofen 1.4 ± 1.1, δ -0.1 [95% CI -0.7 to 0.4]; and dose 4: morphine 1.5 ± 1.4, ibuprofen 1.1 ± 1.2, δ 0.4 [95% CI -0.2 to 1.1]). We found no significant differences in the change in pain scores between morphine and ibuprofen between groups at any of the 4 time points (p = 0.6). Participants in the morphine group had significantly more adverse effects than those in the ibuprofen group (56.1% v. 30.9%, p < 0.01). INTERPRETATION We found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen. However, morphine was associated with a significantly greater number of adverse effects. Our results suggest that ibuprofen remains safe and effective for outpatient pain management in children with uncomplicated fractures. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01690780.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta.
| | - Gina Bhullar
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Kangrui Lin
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Adam Papini
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - David Mainprize
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Jocelyn Howard
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - John Teefy
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Michelle Bale
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Cindy Langford
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Rodrick Lim
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Larry Stitt
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Michael J Rieder
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Bhullar, Lin, Papini, Mainprize, Howard, Teefy, Bale, Langford, Lim, Stitt), London Health Sciences Centre; Department of Paediatrics (Poonai, Lim), Schulich School of Medicine and Dentistry, Western University; and Department of Paediatrics (Rieder), Children's Hospital of Western Ontario, London, Ont.; Department of Pediatrics (Ali), University of Alberta; and Women and Children's Health Research Institute (Ali), Edmonton, Alta
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Chidambaran V, Olbrecht V, Hossain M, Sadhasivam S, Rose J, Meyer MJ. Risk predictors of opioid-induced critical respiratory events in children: naloxone use as a quality measure of opioid safety. PAIN MEDICINE 2014; 15:2139-49. [PMID: 25319840 DOI: 10.1111/pme.12575] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Opioid-induced respiratory depression (OIRD) is a life-threatening complication of opioid therapy in children. Naloxone administration triggered by OIRD has been used to monitor safety of opioid therapy in adults. We used this trigger as a quality measure of opioid safety in hospitalized children to identify risk predictors of OIRD. METHODS We retrospectively reviewed medical records of 38 patients identified from the hospital risk management database as requiring naloxone for critical respiratory events between January 2010 and June 2012 for demographics, comorbidities, surgery, naloxone event details, and outcomes. These data were compared with baseline prevalence in contemporary patients followed by pain service, who did not receive naloxone, to calculate unadjusted odds ratios. Thematic classification of preventable events was undertaken based on analysis of each event. RESULTS The incidence of naloxone use among hospital inpatients, who received opioids at-least once, was 0.06% compared with 0.23% for patients on the pain service. A majority of naloxone events occurred in postoperative patients (n = 27/38, 71.1%) within the first 24 hours of surgery (n = 20/27, 75.1%) and in the critical care unit (50%). Patients undergoing airway surgeries had higher risk for OIRD (P = 0.01). Patient risk factors for naloxone use included age <1 year (P < 0.001), obstructive sleep apnea (P < 0.001), obesity (P = 0.019), being underweight (P < 0.0001), prematurity (P < 0.001), and developmental delay (P < 0.001). Majority of events (87%) were found to be preventable, which were classified into six main themes based on type of event. CONCLUSION OIRD is an important, albeit mostly preventable, complication of opioid therapy in children. Naloxone use can be used as a measure to track opioid safety in children, identify contributing factors, and formulate preventive strategies to reduce the risk for OIRD.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia and Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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Abstract
A recently published study in Pediatrics by Kaiser et al. (2014; Epub April 21, DOI: 10.1542/peds.2013-3171) reported that on average, over the past decade, children aged 3 to 17 were prescribed approximately 700,000 prescriptions for codeine-containing products each year in association with emergency department (ED) visits. Although, guidelines from the American Academy of Pediatrics issued warnings in 1997 and reaffirmed their concerns regarding the safety and effectiveness of codeine in 2006, it is still often prescribed for pain and cough associated with upper respiratory infection. With the impending rescheduling of hydrocodone combination products to Schedule II, physicians and mid-level prescribers may be compelled to prescribe codeine-containing products (e.g., with acetaminophen) due to reduced administrative burden and limits on Schedule II prescriptive authority for nurse practitioners and physician assistants in some states. This commentary expounds on the safety and effectiveness concerns of codeine, with a primary focus on patients in the ED setting.
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Constant I, Ayari Khalfallah S, Brunaud A, Deramoudt V, Fayoux P, Giovanni A, Mareau C, Marianowski R, Michel J, Mondain M, Paganelli A, Pondaven S, Schultz P, Treluyer JM, Wood C, Nicolas R. How to replace codeine after tonsillectomy in children under 12 years of age? Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL). Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131:233-8. [PMID: 25106698 DOI: 10.1016/j.anorl.2014.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/10/2014] [Indexed: 01/03/2023]
Abstract
The authors present the guidelines of the French Oto-rhino-laryngology--Head and Neck Surgery Society (SFORL) regarding pain management in children and adults following tonsillectomy. A multidisciplinary work group was entrusted with a literature review. Guidelines were drawn up based on the articles retrieved and the group members' experience. They were read over by an editorial group independent of the work group. A coordination meeting drew up the final version. Guidelines were graded A, B or C or as professional agreement in decreasing order of level of evidence. At home, non-steroid anti-inflammatory drugs (NSAIDs) are recommended in association with paracetamol in elevated respiratory risk and especially obstructive sleep apnea syndrome; in elevated hemorrhagic risk (hemostasis disorder, surgical problems, etc.), tramadol is recommended. Two other treatment schedules (modified NSAIDs and corticosteroids) have not undergone dedicated study and should be assessed. Management of post-tonsillectomy pain in children is founded on individual risk/benefit analysis.
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Affiliation(s)
- I Constant
- Service d'anesthésie réanimation, hôpital Armand-Trousseau, 26, avenue du docteur-Netter, 75012 Paris, France.
| | - S Ayari Khalfallah
- Service d'ORL, chirurgie cervico-faciale et audiophonologie, HCL Groupement Hospitalier Est, hôpital Femme-Mère-Enfant (BRON), 59, boulevard Pinel, 69677 Bron cedex, France
| | - A Brunaud
- Cabinet d'ORL, centre médical Alpha 128, 128, avenue des Champs-Lasniers, 91940 Les Ulis, France
| | - V Deramoudt
- Service ORL et chirurgie cervico-faciale, hôpital Pontchaillou, CHU de Rennes, rue Henri-Le-Guilloux, 35033 Rennes, France
| | - P Fayoux
- Service ORL et consultation chirurgique pédiatrique, hôpital Jeanne-de-Flandre, CHRU de Lille, 59037 Lille, France
| | - A Giovanni
- Service ORL et chirurgie cervico-faciale, CHU Timone, 264, rue St-Pierre, 13385 Marseille cedex, France
| | - C Mareau
- Centre de la douleur chronique, CHU La Timone, 264, rue St-Pierre, 13385 Marseille cedex, France
| | - R Marianowski
- Service ORL et chirurgie cervico-faciale, CHRU de Brest, 5, avenue Foch, 29200 Brest, France
| | - J Michel
- Service ORL et chirurgie cervico-faciale, CHU Timone, 264, rue St-Pierre, 13385 Marseille cedex, France
| | - M Mondain
- Service ORL et chirurgie cervico-faciale, CHU de Montpellier, 34295 Montpellier cedex 5, France
| | - A Paganelli
- Service ORL et chirurgie cervico-faciale, CHU Timone, 264, rue St-Pierre, 13385 Marseille cedex, France
| | - S Pondaven
- Service ORL et chirurgie cervico-faciale pédiatrique, hôpital Clocheville, boulevard Beranger, 37000 Tours, France
| | - P Schultz
- Service ORL et chirurgie cervico-faciale, CHU Hautepierre, 1, avenue Maline, 67098 Strasbourg, France
| | - J M Treluyer
- Faculté et université Paris Descartes, rue de l'école-de-medecine, 75006 Paris, France
| | - C Wood
- Centre de prise en charge de la douleur chronique, CHU Dupuytren, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - R Nicolas
- Service ORL et chirurgie cervico-faciale, CHU Timone, 264, rue St-Pierre, 13385 Marseille cedex, France
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Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem! Anesth Analg 2014; 118:1276-83. [PMID: 23842193 DOI: 10.1213/ane.0b013e318294fc47] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obesity is epidemic in the United States and with it comes an increased incidence of obstructive sleep apnea (OSA). Evidence regarding opioid sensitivity as well as recent descriptions of deaths after tonsillectomy prompted a survey of all members of the Society for Pediatric Anesthesia regarding adverse events in children undergoing tonsillectomy. METHODS An electronic survey was sent to 2377 members of the Society for Pediatric Anesthesia. Additionally, data from the American Society of Anesthesiologists Closed Claims Project were obtained. Adverse events during or after tonsillectomy with or without adenoidectomy in children were included. Children at risk for OSA were identified as either having a positive history for OSA or a post hoc application of the American Society of Anesthesiologists OSA practice guidelines. These children were compared with all other children by Fisher exact test for proportions and t test for continuous variables. RESULTS A total of 129 cases were identified from the 731 replies to the survey, with 92 meeting inclusion criteria for having adequate data. Another 19 cases with adequate data were identified from the 45 from the American Society of Anesthesiologists Closed Claims Project. A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, postanesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA. Children categorized as at risk for OSA were more likely than other children to be obese and to have comorbidities (P < 0.0001). A larger proportion of at risk children had the event attributed to apnea (P = 0.016), whereas all others had a larger proportion of events attributed to hemorrhage (P = 0.006). CONCLUSIONS Deaths or neurologic injury after tonsillectomy due to apparent apnea in children suggest that at least 16 children could have been rescued had respiratory monitoring been continued throughout first- and second-stage recovery, as well as on the ward during the first postoperative night. A validated pediatric-specific risk assessment scoring system is needed to assist with identifying children at risk for OSA who are not appropriate to be cared for on an outpatient basis.
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Affiliation(s)
- Charles J Coté
- From the *Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School/The MassGeneral Hospital for Children, Boston, Massachusetts; and †Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Whittaker MR. Opioid use and the risk of respiratory depression and death in the pediatric population. J Pediatr Pharmacol Ther 2014; 18:269-76. [PMID: 24719587 DOI: 10.5863/1551-6776-18.4.269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pediatric patients may be at an increased risk of adverse effects from various medications. Recently, there have been a number of serious adverse events, including several pediatric patients experiencing severe respiratory depression and death as a result of the use of codeine for pain control following tonsillectomy and adenoidectomy. OBJECTIVE To assess the safety of opioid agonists in pediatric patients undergoing operative procedures or have experienced trauma and to evaluate the risk of respiratory depression and death among this population. METHODS PubMed and Medline were searched to identify randomized controlled studies from 1994 to 2012 addressing postsurgery/trauma opioid use in pediatric patients. Relative risks and confidence intervals (CIs) were calculated using data available in clinical trials. RESULTS A total of 16 clinical trials were evaluated for this review. Randomized controlled trials included studies comparing opioids versus non-opioids for a variety of painful conditions. The relative risk of respiratory depression associated with opioid use in 1 trial was 1.63 (95% CI: 0.64-6.13). The remaining 15 trials reviewed described no significant difference in respiratory depression or adverse effects associated with treatment. No deaths were attributed to opioid use in any of these studies. CONCLUSION Opioid-associated respiratory depression was very rare and no deaths were reported in the reviewed studies. These findings under the well-defined conditions of controlled studies may not be the best means of determining overall opioid-associated side effects in pediatric patients.
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Affiliation(s)
- Marianne R Whittaker
- New Hampshire's Hospital for Children at Elliot Health System, Manchester, New Hampshire
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50
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Crews KR, Gaedigk A, Dunnenberger HM, Leeder JS, Klein TE, Caudle KE, Haidar CE, Shen DD, Callaghan JT, Sadhasivam S, Prows CA, Kharasch ED, Skaar TC. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther 2014; 95:376-82. [PMID: 24458010 DOI: 10.1038/clpt.2013.254] [Citation(s) in RCA: 457] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/17/2013] [Indexed: 11/09/2022]
Abstract
Codeine is bioactivated to morphine, a strong opioid agonist, by the hepatic cytochrome P450 2D6 (CYP2D6); hence, the efficacy and safety of codeine are governed by CYP2D6 activity. Polymorphisms are a major cause of CYP2D6 variability. We summarize evidence from the literature supporting this association and provide therapeutic recommendations for codeine based on CYP2D6 genotype. This document is an update to the 2012 Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines for CYP2D6 genotype and codeine therapy.
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Affiliation(s)
- K R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - A Gaedigk
- 1] Division of Clinical Pharmacology and Therapeutic Innovation, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA [2] Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - H M Dunnenberger
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - J S Leeder
- 1] Division of Clinical Pharmacology and Therapeutic Innovation, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA [2] Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - T E Klein
- Department of Genetics, Stanford University, Stanford, California, USA
| | - K E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - D D Shen
- 1] Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington, USA [2] Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - J T Callaghan
- 1] Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA [2] Department of Veterans Affairs, RLR VA Medical Center, Indianapolis, Indiana, USA
| | - S Sadhasivam
- 1] Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA [2] Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - C A Prows
- 1] Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA [2] Division of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - E D Kharasch
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - T C Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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