1
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Ghalkhani M, Sohouli E, Dehkordi ZS. Electrochemical sensor based on mesoporous g-C 3N 4/N-CNO/gold nanoparticles for measuring oxycodone. Sci Rep 2024; 14:17221. [PMID: 39060331 PMCID: PMC11282311 DOI: 10.1038/s41598-024-68310-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 07/22/2024] [Indexed: 07/28/2024] Open
Abstract
Oxycodone, often used as an analgesic, is a potent opioid. While its effectiveness has been proven in the control of moderate to acute pain, excessive use of oxycodone imposes heart failure, heart palpitations, reduction of red blood cells, bone pain, and even death. Therefore, monitoring the oxycodone concentration in blood is vital for emergency care. For this purpose, a novel electrochemical sensor was designed based on a glassy carbon electrode modified with mesoporous g-C3N4 (M-C3N4), carbon nano-onions doped with nitrogen (N-CNO), and gold nanoparticles. At first, the SEM and XRD techniques were employed to characterize prepared M-C3N4 and N-CNO samples. The electro-oxidation behavior of the oxycodone was evaluated by cyclic and differential pulse voltammetric methods. Based on the influence of the potential scanning rate and solution pH on the voltammetric response of oxycodone oxidation, a redox mechanism was proposed. A 16 nM detection limit was acquired for the oxycodone analysis with a linear response in the 0.05-150 µM range. This sensor showed a remarkable ability for oxycodone detection in plasma samples. The long-term stability, superior selectivity, and reproducibility of this sensor prove its ability to measure oxycodone accurately and precisely in authentic spices.
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Affiliation(s)
- Masoumeh Ghalkhani
- Electrochemical Sensors Research Laboratory, Department of Chemistry, Faculty of Science, Shahid Rajaee Teacher Training University, Lavizan, P.O. Box 1678815811, Tehran, Iran.
| | - Esmail Sohouli
- Electrochemical Sensors Research Laboratory, Department of Chemistry, Faculty of Science, Shahid Rajaee Teacher Training University, Lavizan, P.O. Box 1678815811, Tehran, Iran
| | - Zeinab Saberi Dehkordi
- Department of Chemistry, Faculty of Science, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran
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2
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Coates S, Lazarus P. Hydrocodone, Oxycodone, and Morphine Metabolism and Drug-Drug Interactions. J Pharmacol Exp Ther 2023; 387:150-169. [PMID: 37679047 PMCID: PMC10586512 DOI: 10.1124/jpet.123.001651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/09/2023] Open
Abstract
Awareness of drug interactions involving opioids is critical for patient treatment as they are common therapeutics used in numerous care settings, including both chronic and disease-related pain. Not only do opioids have narrow therapeutic indexes and are extensively used, but they have the potential to cause severe toxicity. Opioids are the classical pain treatment for patients who suffer from moderate to severe pain. More importantly, opioids are often prescribed in combination with multiple other drugs, especially in patient populations who typically are prescribed a large drug regimen. This review focuses on the current knowledge of common opioid drug-drug interactions (DDIs), focusing specifically on hydrocodone, oxycodone, and morphine DDIs. The DDIs covered in this review include pharmacokinetic DDI arising from enzyme inhibition or induction, primarily due to inhibition of cytochrome p450 enzymes (CYPs). However, opioids such as morphine are metabolized by uridine-5'-diphosphoglucuronosyltransferases (UGTs), principally UGT2B7, and glucuronidation is another important pathway for opioid-drug interactions. This review also covers several pharmacodynamic DDI studies as well as the basics of CYP and UGT metabolism, including detailed opioid metabolism and the potential involvement of metabolizing enzyme gene variation in DDI. Based upon the current literature, further studies are needed to fully investigate and describe the DDI potential with opioids in pain and related disease settings to improve clinical outcomes for patients. SIGNIFICANCE STATEMENT: A review of the literature focusing on drug-drug interactions involving opioids is important because they can be toxic and potentially lethal, occurring through pharmacodynamic interactions as well as pharmacokinetic interactions occurring through inhibition or induction of drug metabolism.
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Affiliation(s)
- Shelby Coates
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
| | - Philip Lazarus
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington
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3
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Wiss FM, Stäuble CK, Meyer Zu Schwabedissen HE, Allemann SS, Lampert ML. Pharmacogenetic Analysis Enables Optimization of Pain Therapy: A Case Report of Ineffective Oxycodone Therapy. J Pers Med 2023; 13:jpm13050829. [PMID: 37240999 DOI: 10.3390/jpm13050829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Patients suffering from chronic pain may respond differently to analgesic medications. For some, pain relief is insufficient, while others experience side effects. Although pharmacogenetic testing is rarely performed in the context of analgesics, response to opiates, non-opioid analgesics, and antidepressants for the treatment of neuropathic pain can be affected by genetic variants. We describe a female patient who suffered from a complex chronic pain syndrome due to a disc hernia. Due to insufficient response to oxycodone, fentanyl, and morphine in addition to non-steroidal anti-inflammatory drug (NSAID)-induced side effects reported in the past, we performed panel-based pharmacogenotyping and compiled a medication recommendation. The ineffectiveness of opiates could be explained by a combined effect of the decreased activity in cytochrome P450 2D6 (CYP2D6), an increased activity in CYP3A, and an impaired drug response at the µ-opioid receptor. Decreased activity for CYP2C9 led to a slowed metabolism of ibuprofen and thus increased the risk for gastrointestinal side effects. Based on these findings we recommended hydromorphone and paracetamol, of which the metabolism was not affected by genetic variants. Our case report illustrates that an in-depth medication review including pharmacogenetic analysis can be helpful for patients with complex pain syndrome. Our approach highlights how genetic information could be applied to analyze a patient's history of medication ineffectiveness or poor tolerability and help to find better treatment options.
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Affiliation(s)
- Florine M Wiss
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
- Institute of Hospital Pharmacy, Solothurner Spitäler, 4600 Olten, Switzerland
| | - Céline K Stäuble
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
- Institute of Hospital Pharmacy, Solothurner Spitäler, 4600 Olten, Switzerland
- Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
| | | | - Samuel S Allemann
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
| | - Markus L Lampert
- Pharmaceutical Care, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
- Institute of Hospital Pharmacy, Solothurner Spitäler, 4600 Olten, Switzerland
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4
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Bates J, Fudin J, Patel JN. Integrating pharmacogenomics into precision pain management. Support Care Cancer 2022; 30:10453-10459. [PMID: 36271058 DOI: 10.1007/s00520-022-07404-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/07/2022] [Indexed: 11/27/2022]
Abstract
Studies suggest wide heterogeneity in pain management response. Improved methods of pain pharmacotherapy are urgently needed to improve clinical response and safety profile of analgesics. The study or application of how genetics influence response to medications is called pharmacogenomics (PGx). PGx testing is a tool that may support more precise selection and dosing of pain medicines. PGx guidelines exist for drug-gene interactions with high levels of evidence and can be applied in clinical practice for more precise care in patients with cancer. The Clinical Pharmacogenetics Implementation Consortium (CPIC) is a publicly funded international consortium of experts who curate published PGx data and create peer-reviewed guidelines on how to translate PGx results into actionable prescribing decisions. Given the immense need to improve pain management, it is important to increase awareness and consider application of CPIC guidelines to pain management strategies. This commentary concisely describes how PGx can be used to aid in more precise applications of pain pharmacotherapy based on the CPIC guidelines.
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Affiliation(s)
- Jill Bates
- Department of Veterans Affairs, Durham, NC, USA
| | | | - Jai N Patel
- Department of Cancer Pharmacology and Pharmacogenomics, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.
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5
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Matic M, Nijenhuis M, Soree B, de Boer-Veger NJ, Buunk AM, Houwink EJF, Mulder H, Rongen GAPJM, Weide JVD, Wilffert B, Swen JJ, Guchelaar HJ, Deneer VHM, van Schaik RHN. Dutch Pharmacogenetics Working Group (DPWG) guideline for the gene-drug interaction between CYP2D6 and opioids (codeine, tramadol and oxycodone). Eur J Hum Genet 2022; 30:1105-1113. [PMID: 34267337 PMCID: PMC9553935 DOI: 10.1038/s41431-021-00920-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022] Open
Abstract
The current Dutch Pharmacogenetics Working Group (DPWG) guideline, describes the gene-drug interaction between CYP2D6 and the opioids codeine, tramadol and oxycodone. CYP2D6 genotype is translated into normal metaboliser (NM), intermediate metaboliser (IM), poor metaboliser (PM) or ultra-rapid metaboliser (UM). Codeine is contraindicated in UM adults if doses >20 mg every 6 h (q6h), in children ≥12 years if doses >10 mg q6h, or with additional risk factors. In PMs, an alternative analgesic should be given which is not or to a lesser extent metabolised by CYP2D6 (not tramadol). In IMs with insufficient analgesia, a higher dose or alternative analgesic should be given. For tramadol, the recommendations for IMs and PMs are the same as the recommendation for codeine and IMs. UMs should receive an alternative drug not or to a lesser extent metabolised by CYP2D6 or the dose should be decreased to 40% of the commonly prescribed dose. Due to the absence of effect on clinical outcomes of oxycodone in PMs, IMs and UMs no action is required. DPWG classifies CYP2D6 genotyping for codeine "beneficial" and recommends testing prior to, or shortly after initiation of treatment in case of higher doses or additional risk factors. CYP2D6 genotyping is classified as "potentially beneficial" for tramadol and can be considered on an individual patient basis.
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Affiliation(s)
- Maja Matic
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marga Nijenhuis
- Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands.
| | - Bianca Soree
- Royal Dutch Pharmacists Association (KNMP), The Hague, The Netherlands
| | | | | | - Elisa J F Houwink
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Centre, Leiden, The Netherlands
- National eHealth Living Lab (NELL), Leiden, The Netherlands
| | - Hans Mulder
- Department of Clinical Pharmacy, Wilhelmina Hospital, Assen, The Netherlands
| | - Gerard A P J M Rongen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan van der Weide
- Department of Clinical Chemistry, St. Jansdal Hospital, Harderwijk, The Netherlands
| | - Bob Wilffert
- Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of PharmacoTherapy, PharmacoEpidemiology & PharmacoEconomics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vera H M Deneer
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
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6
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Verdez S, Albuisson J, Duffourd Y, Boidot R, Reda M, Thauvin-Robinet C, Fumet JD, Ladoire S, Nambot S, Callier P, Faivre L, Ghiringhelli F, Picard N. Detection of relevant pharmacogenetic information through exome sequencing in oncology. Pharmacogenomics 2022; 23:759-770. [PMID: 36043386 DOI: 10.2217/pgs-2022-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Germline sequencing of individual genomes can detect alleles responsible for adverse drug reactions (ADRs) in relation to chemotherapy, targeted agents, antiemetics or pain treatment. Materials & methods: To evaluate the interest of such pharmacogenetic information, the authors retrospectively analyzed genes known to have an impact on cancer therapy in a cohort of 445 solid cancers patients. Results: Six patients treated with 5-fluorouracil carrying one DPYD variant classified as 1A showed decreased drug mean clearance (p = 0.01). Regarding CYP2D6, all patients (n = 5) with predicted CYP2D6 poor or ultra-rapid metabolizer status experienced adverse drug reactions related to opioid therapy. Conclusion: Genomic germline sequencing performed for theragnostic issues in patients with a solid tumor, can provide relevant information about common pharmacogenetic alleles.
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Affiliation(s)
- Simon Verdez
- UMR1231 GAD, Inserm - Université Bourgogne-Franche Comté, Dijon, France.,Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Juliette Albuisson
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France
| | - Yannis Duffourd
- UMR1231 GAD, Inserm - Université Bourgogne-Franche Comté, Dijon, France.,Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Romain Boidot
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Department of Tumour Biology & Pathology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France
| | - Manon Reda
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Department of Tumour Biology & Pathology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Christel Thauvin-Robinet
- Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Centre de Référence Maladies Rares "Anomalies du Développement et Syndromes Malformatifs", Centre de Génétique, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Jean-David Fumet
- Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Sylvain Ladoire
- Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Sophie Nambot
- Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France.,Centre de Référence Maladies Rares "Anomalies du Développement et Syndromes Malformatifs", Centre de Génétique, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Patrick Callier
- UMR1231 GAD, Inserm - Université Bourgogne-Franche Comté, Dijon, France.,Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - Laurence Faivre
- Unité Fonctionnelle Innovation en Diagnostic génomique des maladies rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Centre de Référence Maladies Rares "Anomalies du Développement et Syndromes Malformatifs", Centre de Génétique, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, 21000, France
| | - François Ghiringhelli
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Genomic & Immunotherapy Medical Institute, Dijon, 21000, France.,Department of Tumour Biology & Pathology, Georges François Leclerc Cancer Center - UNICANCER, Dijon, 21000, France.,Department of Medical Oncology, Georges François Leclerc Cancer Center - UNICANCER, 1 rue Professeur Marion, Dijon, 21000, France
| | - Nicolas Picard
- Inserm U1248, Service de Pharmacologie et Toxicologie, Université de Limoges, CHU de Limoges, Limoges, 87000, France
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7
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Beierle JA, Yao EJ, Goldstein SI, Lynch WB, Scotellaro JL, Shah AA, Sena KD, Wong AL, Linnertz CL, Averin O, Moody DE, Reilly CA, Peltz G, Emili A, Ferris MT, Bryant CD. Zhx2 Is a Candidate Gene Underlying Oxymorphone Metabolite Brain Concentration Associated with State-Dependent Oxycodone Reward. J Pharmacol Exp Ther 2022; 382:167-180. [PMID: 35688478 PMCID: PMC9341249 DOI: 10.1124/jpet.122.001217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/16/2022] [Indexed: 11/22/2022] Open
Abstract
Understanding the pharmacogenomics of opioid metabolism and behavior is vital to therapeutic success, as mutations can dramatically alter therapeutic efficacy and addiction liability. We found robust, sex-dependent BALB/c substrain differences in oxycodone behaviors and whole brain concentration of oxycodone metabolites. BALB/cJ females showed robust state-dependent oxycodone reward learning as measured via conditioned place preference when compared with the closely related BALB/cByJ substrain. Accordingly, BALB/cJ females also showed a robust increase in brain concentration of the inactive metabolite noroxycodone and the active metabolite oxymorphone compared with BALB/cByJ mice. Oxymorphone is a highly potent, full agonist at the mu opioid receptor that could enhance drug-induced interoception and state-dependent oxycodone reward learning. Quantitative trait locus (QTL) mapping in a BALB/c F2 reduced complexity cross revealed one major QTL on chromosome 15 underlying brain oxymorphone concentration that explained 32% of the female variance. BALB/cJ and BALB/cByJ differ by fewer than 10,000 variants, which can greatly facilitate candidate gene/variant identification. Hippocampal and striatal cis-expression QTL (eQTL) and exon-level eQTL analysis identified Zhx2, a candidate gene coding for a transcriptional repressor with a private BALB/cJ retroviral insertion that reduces Zhx2 expression and sex-dependent dysregulation of cytochrome P450 enzymes. Whole brain proteomics corroborated the Zhx2 eQTL and identified upregulated CYP2D11 that could increase brain oxymorphone in BALB/cJ females. To summarize, Zhx2 is a highly promising candidate gene underlying brain oxycodone metabolite levels. Future studies will validate Zhx2 and its site of action using reciprocal gene editing and tissue-specific viral manipulations in BALB/c substrains. SIGNIFICANCE STATEMENT: Our findings show that genetic variation can result in sex-specific alterations in whole brain concentration of a bioactive opioid metabolite after oxycodone administration, reinforcing the need for sex as a biological factor in pharmacogenomic studies. The cooccurrence of female-specific increased oxymorphone and state-dependent reward learning suggests that this minor yet potent and efficacious metabolite of oxycodone could increase opioid interoception and drug-cue associative learning of opioid reward, which has implications for cue-induced relapse of drug-seeking behavior and for precision pharmacogenetics.
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Affiliation(s)
- Jacob A Beierle
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Emily J Yao
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Stanley I Goldstein
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - William B Lynch
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Julia L Scotellaro
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Anyaa A Shah
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Katherine D Sena
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Alyssa L Wong
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Colton L Linnertz
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Olga Averin
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - David E Moody
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Christopher A Reilly
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Gary Peltz
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Andrew Emili
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Martin T Ferris
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
| | - Camron D Bryant
- Ph.D. Program in Biomolecular Pharmacology (J.A.B., S.I.G.), Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry (J.A.B., E.J.Y., W.B.L., J.L.S., A.A.S., K.D.S., A.L.W., C.D.B.), Department of Biology and Biochemistry, Center for Network Systems Biology (S.I.G., A.E.), and Graduate Program in Neuroscience (W.B.L), Boston University School of Medicine, Boston, Massachusetts; Transformative Training Program in Addiction Science (TTPAS) (J.A.B., W.B.L.) and Undergraduate Research Opportunity Program (J.L.S., K.D.S.), Boston University, Boston, Massachusetts; Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (C.L.L., M.T.F.); Department of Pharmacology and Toxicity, Center for Human Toxicology, University of Utah, Salt Lake City, Utah (O.A., D.E.M., C.A.R.); and Department of Anesthesiology, Pain, and Preoperative Medicine Stanford University School of Medicine, Stanford, California (G.P.)
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8
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Zhu GD, Whitley P, LaRue L, Adkins B, Dawson E, Huskey A, Capparelli EV, Del Tredici AL. Impact of genetic variation in CYP2C19, CYP2D6, and CYP3A4 on oxycodone and its metabolites in a large database of clinical urine drug tests. THE PHARMACOGENOMICS JOURNAL 2022; 22:25-32. [PMID: 34480108 DOI: 10.1038/s41397-021-00253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 02/07/2023]
Abstract
Urine drug testing (UDT) is a tool for monitoring drug use, including oxycodone. While variation in cytochrome P450 (CYP) genes is known to alter oxycodone metabolism, its impact on UDT results of oxycodone and its metabolites has not been well-studied. Here, multivariate analysis was performed on retrospective UDT results of 90,379 specimens collected from 14,684 genotyped patients prescribed oxycodone. Genetic variation in CYP2D6 and CYP2C19 had a significant impact on oxymorphone/oxycodone ratios, with a 6.9-fold difference between CYP2D6 ultrarapid metabolizers (UMs) and poor metabolizers (PMs; p < 10-300) and a 1.6-fold difference between CYP2C19 UMs and PMs (p = 1.50 × 10-4). CYP2D6 variation also significantly impacted noroxycodone/oxycodone ratios (p = 6.95 × 10-38). Oxycodone-positive specimens from CYP2D6 PMs were ~5-fold more likely to be oxymorphone-negative compared to normal metabolizers. These findings indicate that multivariate analysis of UDT data may be used to reveal the real-world impact of genetic and non-genetic factors on drug metabolism.
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Affiliation(s)
| | | | - Leah LaRue
- Millennium Health, LLC, San Diego, CA, USA
| | | | | | | | - Edmund V Capparelli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA.,Department of Pediatrics, School of Medicine, University of California San Diego, La Jolla, CA, USA
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9
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Appraisal and development of evidence-based clinical decision support to enable perioperative pharmacogenomic application. THE PHARMACOGENOMICS JOURNAL 2021; 21:691-711. [PMID: 34376788 PMCID: PMC9267777 DOI: 10.1038/s41397-021-00248-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/06/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
Variable responses to medications complicates perioperative care. As a potential solution, we evaluated and synthesized pharmacogenomic evidence that may inform anesthesia and pain prescribing to identify clinically actionable drug/gene pairs. Clinical decision-support (CDS) summaries were developed and were evaluated using Appraisal of Guidelines for Research and Evaluation (AGREE) II. We found that 93/180 (51%) of commonly-used perioperative medications had some published pharmacogenomic information, with 18 having actionable evidence: celecoxib/diclofenac/flurbiprofen/ibuprofen/piroxicam/CYP2C9, codeine/oxycodone/tramadol CYP2D6, desflurane/enflurane/halothane/isoflurane/sevoflurane/succinylcholine/RYR1/CACNA1S, diazepam/CYP2C19, phenytoin/CYP2C9, succinylcholine/mivacurium/BCHE, and morphine/OPRM1. Novel CDS summaries were developed for these 18 medications. AGREE II mean ± standard deviation scores were high for Scope and Purpose (95.0 ± 2.8), Rigor of Development (93.2 ± 2.8), Clarity of Presentation (87.3 ± 3.0), and Applicability (86.5 ± 3.7) (maximum score = 100). Overall mean guideline quality score was 6.7 ± 0.2 (maximum score = 7). All summaries were recommended for clinical implementation. A critical mass of pharmacogenomic evidence exists for select medications commonly used in the perioperative setting, warranting prospective examination for clinical utility.
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10
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Magarbeh L, Gorbovskaya I, Le Foll B, Jhirad R, Müller DJ. Reviewing pharmacogenetics to advance precision medicine for opioids. Biomed Pharmacother 2021; 142:112060. [PMID: 34523422 DOI: 10.1016/j.biopha.2021.112060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Adequate opioid prescribing is critical for therapeutic success of pain management. Despite the widespread use of opioids, optimized opioid therapy remains unresolved with risk of accidental lethal overdosing. With the emergence of accumulating evidence linking genetic variation to opioid response, pharmacogenetic based treatment recommendations have been proposed. OBJECTIVE The aim of this review is to evaluate pharmacogenetic evidence and provide an overview on genes involved in the pharmacokinetics and pharmacodynamics of opioids. METHODS For this review, a systematic literature search of published articles was used in PubMed®, with no language restriction and between the time period of January 2000 to December 2020. We reviewed randomized clinical studies, study cohorts and case reports that investigated the influence of genetic variants on selected opioid pharmacokinetics and pharmacodynamics. In addition, we reviewed current CPIC clinical recommendations for pharmacogenetic testing. RESULTS Results of this review indicate consistent evidence supporting the association between selected genetic variants of CYP2D6 for opioid metabolism. CPIC guidelines include recommendations that indicate the avoidance of tramadol use, in addition to codeine, in CYP2D6 poor metabolizers and ultrarapid metabolizers, and to monitor intermediate metabolizers for less-than-optimal response. While there is consistent evidence for OPRM1 suggesting increased postoperative morphine dosing requirements in A118G G-allele carriers, the clinical relevance remains limited. CONCLUSION There is emerging evidence of clinical relevance of CYP2D6 and, to a lesser extent, OPRM1 polymorphism in personalized opioid drug dosing. As a result, first clinics have started to implement pharmacogenetic guidelines for CYP2D6 and codeine.
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Affiliation(s)
- Leen Magarbeh
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Ilona Gorbovskaya
- Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Reuven Jhirad
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Office of the Chief Coroner and Ontario Forensic Pathology Service, Toronto, ON, Canada
| | - Daniel J Müller
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada.
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11
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Deodhar M, Turgeon J, Michaud V. Contribution of CYP2D6 Functional Activity to Oxycodone Efficacy in Pain Management: Genetic Polymorphisms, Phenoconversion, and Tissue-Selective Metabolism. Pharmaceutics 2021; 13:1466. [PMID: 34575542 PMCID: PMC8468517 DOI: 10.3390/pharmaceutics13091466] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/26/2021] [Accepted: 09/03/2021] [Indexed: 02/01/2023] Open
Abstract
Oxycodone is a widely used opioid for the management of chronic pain. Analgesic effects observed following the administration of oxycodone are mediated mostly by agonistic effects on the μ-opioid receptor. Wide inter-subject variability observed in oxycodone efficacy could be explained by polymorphisms in the gene coding for the μ-opioid receptor (OPRM1). In humans, oxycodone is converted into several metabolites, particularly into oxymorphone, an active metabolite with potent μ-opioid receptor agonist activity. The CYP2D6 enzyme is principally responsible for the conversion of oxycodone to oxymorphone. The CYP2D6 gene is highly polymorphic with encoded protein activities, ranging from non-functioning to high-functioning enzymes. Several pharmacogenetic studies have shown the importance of CYP2D6-mediated conversion of oxycodone to oxymorphone for analgesic efficacy. Pharmacogenetic testing could optimize oxycodone therapy and help achieve adequate pain control, avoiding harmful side effects. However, the most recent Clinical Pharmacogenetics Implementation Consortium guidelines fell short of recommending pharmacogenomic testing for oxycodone treatment. In this review, we (1) analyze pharmacogenomic and drug-interaction studies to delineate the association between CYP2D6 activity and oxycodone efficacy, (2) review evidence from CYP3A4 drug-interaction studies to untangle the nature of oxycodone metabolism and its efficacy, (3) report on the current knowledge linking the efficacy of oxycodone to OPRM1 variants, and (4) discuss the potential role of CYP2D6 brain expression on the local formation of oxymorphone. In conclusion, we opine that pharmacogenetic testing, especially for CYP2D6 with considerations of phenoconversion due to concomitant drug administration, should be appraised to improve oxycodone efficacy.
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Affiliation(s)
- Malavika Deodhar
- Precision Pharmacotherapy Research and Development Institute, Tabula Rasa HealthCare, Orlando, FL 32827, USA; (M.D.); (J.T.)
| | - Jacques Turgeon
- Precision Pharmacotherapy Research and Development Institute, Tabula Rasa HealthCare, Orlando, FL 32827, USA; (M.D.); (J.T.)
- Faculty of Pharmacy, Université de Montréal, Montréal, QC H3T 1J4, Canada
| | - Veronique Michaud
- Precision Pharmacotherapy Research and Development Institute, Tabula Rasa HealthCare, Orlando, FL 32827, USA; (M.D.); (J.T.)
- Faculty of Pharmacy, Université de Montréal, Montréal, QC H3T 1J4, Canada
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12
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Reizine N, Danahey K, Schierer E, Liu P, Middlestadt M, Ludwig J, Truong TM, van Wijk XMR, Yeo KTJ, Malec M, Ratain MJ, O'Donnell PH. Impact of CYP2D6 Pharmacogenomic Status on Pain Control Among Opioid-Treated Oncology Patients. Oncologist 2021; 26:e2042-e2052. [PMID: 34423496 DOI: 10.1002/onco.13953] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Several opioids have pharmacogenomic associations impacting analgesic efficacy. However, germline pharmacogenomic testing is not routinely incorporated into supportive oncology. We hypothesized that CYP2D6 profiling would correlate with opioid prescribing and hospitalizations. MATERIALS AND METHODS We analyzed 61,572 adult oncology patients from 2012 to 2018 for opioid exposures. CYP2D6 metabolizer phenotype (ultra-rapid [UM], normal metabolizer [NM], intermediate [IM], or poor [PM]), the latter two of which may cause inefficacy of codeine, tramadol, and standard-dose hydrocodone, was determined for patients genotyped for reasons unrelated to pain. The primary endpoint was number of opioid medications received during longitudinal care (IM/PMs vs. NMs). Secondary endpoint was likelihood of pain-related hospital encounters. RESULTS Most patients with cancer (n = 34,675, 56%) received multiple opioids (average 2.8 ± 1.6/patient). Hydrocodone was most commonly prescribed (62%), followed by tramadol, oxycodone, and codeine. In the CYP2D6 genotyped cohort (n = 105), IM/PMs received a similar number of opioids (3.4 ± 1.4) as NMs (3.3 ± 1.9). However, IM/PMs were significantly more likely to experience pain-related hospital encounters compared with NMs, independent of other variables (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-23.6; p = .03). IM/PMs were also more likely to be treated with later-line opioids that do not require CYP2D6 metabolism, such as morphine and hydromorphone (OR = 3.3; 95% CI, 1.1-9.8; p = .03). CONCLUSION CYP2D6 genotype may identify patients with cancer at increased risk for inadequate analgesia when treated with typical first-line opioids like codeine, tramadol, or standard-dose hydrocodone. Palliative care considerations are an integral part of optimal oncology care, and these findings justify prospective evaluation of preemptive genotyping as a strategy to improve oncology pain management. IMPLICATIONS FOR PRACTICE Genomic variation in metabolic enzymes can predispose individuals to inefficacy when receiving opioid pain medications. Patients with intermediate and/or poor CYP2D6 metabolizer status do not adequately convert codeine, tramadol, and hydrocodone into active compounds, with resulting increased risk of inadequate analgesia. This study showed that patients with cancer frequently receive CYP2D6-dependent opioids. However, patients with CYP2D6 intermediate and poor metabolizer status had increased numbers of pain-related hospitalizations and more frequently required the potent non-CYP2D6 opioids morphine and hydromorphone. This may reflect inadequate initial analgesia with the common "first-line" CYP2D6-metabolized opioids. Preemptive genotyping to guide opioid prescribing during cancer care may improve pain-related patient outcomes.
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Affiliation(s)
- Natalie Reizine
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA.,Center for Research Informatics, University of Chicago, Chicago, Illinois, USA
| | - Emily Schierer
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Ping Liu
- Department of Public Health Services, University of Chicago, Chicago, Illinois, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Jenna Ludwig
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Tien M Truong
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Xander M R van Wijk
- Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Kiang-Teck J Yeo
- Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Monica Malec
- Section of Geriatric and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Mark J Ratain
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
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13
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Brandl E, Halford Z, Clark MD, Herndon C. Pharmacogenomics in Pain Management: A Review of Relevant Gene-Drug Associations and Clinical Considerations. Ann Pharmacother 2021; 55:1486-1501. [PMID: 33771051 DOI: 10.1177/10600280211003875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To provide an overview of clinical recommendations regarding genomic medicine relating to pain management and opioid use disorder. DATA SOURCES A literature review was conducted using the search terms pain management, pharmacogenomics, pharmacogenetics, pharmacokinetics, pharmacodynamics, and opioids on PubMed (inception to February 1, 2021), CINAHL (2016 through February 1, 2021), and EMBASE (inception through February 1, 2021). STUDY SELECTION AND DATA EXTRACTION All relevant clinical trials, review articles, package inserts, and guidelines evaluating applicable pharmacogenotypes were considered for inclusion. DATA SYNTHESIS More than 300 Food and Drug Administration-approved medications contain pharmacogenomic information in their labeling. Genetic variability may alter the therapeutic effects of commonly prescribed pain medications. Pharmacogenomic-guided therapy continues to gain traction in clinical practice, but a multitude of barriers to widespread pharmacogenomic implementation exist. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Pain is notoriously difficult to treat given the need to balance safety and efficacy when selecting pharmacotherapy. Pharmacogenomic data can help optimize outcomes for patients with pain. With improved technological advances, more affordable testing, and a better understanding of genomic variants resulting in treatment disparities, pharmacogenomics continues to gain popularity. Unfortunately, despite these and other advancements, pharmacogenomic testing and implementation remain underutilized and misunderstood in clinical care, in part because of a lack of health care professionals trained in assessing and implementing test results. CONCLUSIONS A one-size-fits-all approach to pain management is inadequate and outdated. With increasing genomic data and pharmacogenomic understanding, patient-specific genomic testing offers a comprehensive and personalized treatment alternative worthy of additional research and consideration.
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Affiliation(s)
- Emily Brandl
- Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | | | - Matthew D Clark
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chris Herndon
- Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, USA.,St Louis University School of Medicine, MO, USA
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14
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Jakobsson G, Larsson R, Pellè L, Kronstrand R, Gréen H. Oxycodone findings and CYP2D6 function in postmortem cases. Forensic Sci Int Genet 2021; 53:102510. [PMID: 33799050 DOI: 10.1016/j.fsigen.2021.102510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/04/2020] [Accepted: 03/21/2021] [Indexed: 12/25/2022]
Abstract
Genetic disposition can cause variation in oxycodone pharmacokinetic characteristics and decrease or increase the expected clinical response. In forensic medicine, determination of cause of death or assessing time between drug intake and death can be facilitated by knowledge of parent and metabolite concentrations. In this study, the aim was to investigate if CYP2D6 genotyping can facilitate interpretation by investigating the frequency of the four CYP2D6 phenotypes, poor metabolizer, intermediate metabolizer, extensive metabolizer, and ultra-rapid metabolizer in postmortem cases, and to study if the CYP2D6 activity was associated with a certain cause of death, concentration, or metabolic ratio. Cases positive for oxycodone in femoral blood (n = 174) were genotyped by pyrosequencing for CYP2D6*3, *4, and *6 and concentrations of oxycodone, noroxycodone, oxymorphone, and noroxymorphone were determined by LC-MS/MS (LLOQ 0.005 µg/g). Digital droplet PCR was used to determine the copy number variation for CYP2D6*5. Cases were categorized by cause of death. It was found that poor and intermediate CYP2D6 metabolizers had significantly higher oxycodone and noroxycodone concentrations compared to extensive and ultra-rapid metabolizers. CYP2D6 phenotype were equally distributed between cause of death groups, showing that no phenotype was overrepresented in any of the cause of death groups. We also found that the concentration ratio between oxymorphone and oxycodone depended on the CYP2D6 activity when death was unrelated to intoxication. In general, a low metabolite to parent ratio indicate an acute intake. By using receiver operating characteristic (ROC) analysis, we conclude that an oxymorphone/oxycodone ratio lower than 0.075 has a high sensitivity for separating intoxications with oxycodone from other intoxications and non-intoxications. However, the phenotype needs to be known to reach a high specificity. Therefore, the ratio should not be used as a biomarker on its own to distinguish between different causes of death but needs to be complemented by genotyping.
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Affiliation(s)
- Gerd Jakobsson
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, 58758 Linkoping, Sweden; Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Health and Science, Linkoping University, 58183 Linkoping, Sweden.
| | - Ronja Larsson
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, 58758 Linkoping, Sweden
| | - Lucia Pellè
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Health and Science, Linkoping University, 58183 Linkoping, Sweden
| | - Robert Kronstrand
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, 58758 Linkoping, Sweden; Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Health and Science, Linkoping University, 58183 Linkoping, Sweden
| | - Henrik Gréen
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, 58758 Linkoping, Sweden; Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Health and Science, Linkoping University, 58183 Linkoping, Sweden
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15
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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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16
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Crews KR, Monte AA, Huddart R, Caudle KE, Kharasch ED, Gaedigk A, Dunnenberger HM, Leeder JS, Callaghan JT, Samer CF, Klein TE, Haidar CE, Van Driest SL, Ruano G, Sangkuhl K, Cavallari LH, Müller DJ, Prows CA, Nagy M, Somogyi AA, Skaar TC. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2D6, OPRM1, and COMT Genotypes and Select Opioid Therapy. Clin Pharmacol Ther 2021; 110:888-896. [PMID: 33387367 DOI: 10.1002/cpt.2149] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/02/2020] [Indexed: 11/08/2022]
Abstract
Opioids are mainly used to treat both acute and chronic pain. Several opioids are metabolized to some extent by CYP2D6 (codeine, tramadol, hydrocodone, oxycodone, and methadone). Polymorphisms in CYP2D6 have been studied for an association with the clinical effect and safety of these drugs. Other genes that have been studied for their association with opioid clinical effect or adverse events include OPRM1 (mu receptor) and COMT (catechol-O-methyltransferase). This guideline updates and expands the 2014 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 genotype and codeine therapy and includes a summation of the evidence describing the impact of CYP2D6, OPRM1, and COMT on opioid analgesia and adverse events. We provide therapeutic recommendations for the use of CYP2D6 genotype results for prescribing codeine and tramadol and describe the limited and/or weak data for CYP2D6 and hydrocodone, oxycodone, and methadone, and for OPRM1 and COMT for clinical use.
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Affiliation(s)
- Kristine R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Andrew A Monte
- Department of Emergency Medicine & Colorado Center for Personalized Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Kelly E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kanas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Henry M Dunnenberger
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Kansas City, Kanas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John T Callaghan
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caroline Flora Samer
- Clinical Pharmacology and Toxicology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Cyrine E Haidar
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gualberto Ruano
- Institute of Living Hartford Hospital, Genomas Lab of Personalized Health, University of Connecticut School of Medicine and University of Puerto Rico Medical Sciences, Hartford, Connecticut, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Daniel J Müller
- Department of Psychiatry, Campbell Family Mental Health Research Institute of CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mohamed Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt 57357, Cairo, Egypt
| | - Andrew A Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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17
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Jose A, Thomas L, Baburaj G, Munisamy M, Rao M. Cannabinoids as an Alternative Option for Conventional Analgesics in Cancer Pain Management: A Pharmacogenomics Perspective. Indian J Palliat Care 2020; 26:129-133. [PMID: 32132797 PMCID: PMC7017683 DOI: 10.4103/ijpc.ijpc_155_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/10/2019] [Indexed: 12/24/2022] Open
Abstract
The global cancer burden is significantly increasing at an alarming rate affecting patients, relatives, communities, and health-care system. Cancer patients require adequate pain relief and palliative care throughout the life course, especially in terminal illness. Although opioid treatment is successful in majority of patients, around 40% do not achieve enough analgesia or are prone to serious side effects and toxicity. The treatment of medical conditions with cannabis and cannabinoid compounds is constantly expanding. This review organizes the current knowledge in the context of SNPs associated with opioids and nonopioids and its clinical consequences in pain management and pharmacogenetic targets of cannabinoids, for use in clinical practice.
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Affiliation(s)
- Anmi Jose
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Levin Thomas
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Gayathri Baburaj
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Murali Munisamy
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
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18
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Luo Z, Miao J, Shu S, Wang Y, Zhu X, Hu C, Shen Y. Pharmacokinetics and Bioequivalence Evaluation of a New Oxycodone Tamper-Resistant Tablet Administered with an Opioid Antagonist in Patients with Chronic Pain. Clin Drug Investig 2019; 40:139-148. [PMID: 31679120 DOI: 10.1007/s40261-019-00870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Oxycodone tamper resistant (OTR) is a new extended-release abuse-deterrent formulation providing improvements in the tamper resistant characteristics. This study aimed to investigate the pharmacokinetic properties of the new OTR tablets and evaluate the bioequivalence of oxycodone from OTR and the original extended release (ER) formulation tablets administered with an opioid antagonist in patients with chronic pain. METHODS In this open-label, randomized, cross-over study, the enrolled patients were randomised to receive a single dose of 40 mg OTR or 40 mg OXYCONTIN® (OXY) tablet administered with naltrexone blockade under fasting conditions. Serial blood samples for pharmacokinetic analysis were collected. Plasma oxycodone was quantified by a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method. Tolerability was evaluated by monitoring adverse events, physical examinations, 12-lead ECG and laboratory tests. RESULTS A total of 38 patients were enrolled and 33 subjects completed the study. After a single dose of 40 mg tablets, pharmacokinetic results of the new OTR tablet were found to be similar to those of original extended-release oxycodone tablet. OTR 40 mg was bioequivalent to OXY 40 mg and was well tolerated in patients with chronic pain. CONCLUSIONS The new OTR formulation could provide a new choice in the treatment of chronic pain and reduce the potential for oxycodone abuse. Chictr.org identifier: ChiCTR1800017253.
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Affiliation(s)
- Zhu Luo
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Jia Miao
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Shiqing Shu
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ying Wang
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xiaohong Zhu
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Chao Hu
- GCP Center/Institute of Drug Clinical Trials, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yali Shen
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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19
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Johnson D, Hughes D, Pirmohamed M, Jorgensen A. Evidence to Support Inclusion of Pharmacogenetic Biomarkers in Randomised Controlled Trials. J Pers Med 2019; 9:E42. [PMID: 31480618 PMCID: PMC6789450 DOI: 10.3390/jpm9030042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 01/01/2023] Open
Abstract
Pharmacogenetics and biomarkers are becoming normalised as important technologies to improve drug efficacy rates, reduce the incidence of adverse drug reactions, and make informed choices for targeted therapies. However, their wider clinical implementation has been limited by a lack of robust evidence. Suitable evidence is required before a biomarker's clinical use, and also before its use in a clinical trial. We have undertaken a review of five pharmacogenetic biomarker-guided randomised controlled trials (RCTs) and evaluated the evidence used by these trials to justify biomarker inclusion. We assessed and quantified the evidence cited in published rationale papers, or where these were not available, obtained protocols from trial authors. Very different levels of evidence were provided by the trials. We used these observations to write recommendations for future justifications of biomarker use in RCTs and encourage regulatory authorities to write clear guidelines.
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Affiliation(s)
- Danielle Johnson
- Institute of Translational Medicine, Department of Biostatistics, University of Liverpool, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK.
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Ardudwy, Normal Site, Bangor LL57 2PZ, UK
| | - Munir Pirmohamed
- MRC Centre for Drug Safety Science and Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Andrea Jorgensen
- Institute of Translational Medicine, Department of Biostatistics, University of Liverpool, Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
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21
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22
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Leuppi-Taegtmeyer A, Duthaler U, Hammann F, Schmid Y, Dickenmann M, Amico P, Jehle AW, Kalbermatter S, Lenherr C, Meyer zu Schwabedissen HE, Haschke M, Liechti ME, Krähenbühl S. Pharmacokinetics of oxycodone/naloxone and its metabolites in patients with end-stage renal disease during and between haemodialysis sessions. Nephrol Dial Transplant 2018; 34:692-702. [DOI: 10.1093/ndt/gfy285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Anne Leuppi-Taegtmeyer
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Urs Duthaler
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Felix Hammann
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Yasmin Schmid
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael Dickenmann
- Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Department of Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Patricia Amico
- Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Department of Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Andreas W Jehle
- Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
- Department of Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Stefan Kalbermatter
- Nephrology and Dialysis, Medical University Clinic and Kantonsspital Baselland, Liestal, Switzerland
| | - Christoph Lenherr
- Nephrology and Dialysis, Medical University Clinic and Kantonsspital Baselland, Liestal, Switzerland
| | | | - Manuel Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stephan Krähenbühl
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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23
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Opioid analgesic drugs and serotonin toxicity (syndrome): mechanisms, animal models, and links to clinical effects. Arch Toxicol 2018; 92:2457-2473. [DOI: 10.1007/s00204-018-2244-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/13/2018] [Indexed: 12/11/2022]
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24
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Mosley SA, Hicks JK, Portman DG, Donovan KA, Gopalan P, Schmit J, Starr J, Silver N, Gong Y, Langaee T, Clare-Salzler M, Starostik P, Chang YD, Rajasekhara S, Smith JE, Soares HP, George TJ, McLeod HL, Cavallari LH. Design and rational for the precision medicine guided treatment for cancer pain pragmatic clinical trial. Contemp Clin Trials 2018; 68:7-13. [PMID: 29535047 PMCID: PMC5899651 DOI: 10.1016/j.cct.2018.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/05/2018] [Accepted: 03/05/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Pain is one of the most burdensome symptoms associated with cancer and its treatment, and opioids are the cornerstone of pain management. Opioid therapy is empirically selected, and patients often require adjustments in therapy to effectively alleviate pain or ameliorate adverse drug effects that interfere with quality of life. There are data suggesting CYP2D6 genotype may contribute to inter-patient variability in response to opioids through its effects on opioid metabolism. Therefore, we aim to determine if CYP2D6 genotype-guided opioid prescribing results in greater reductions in pain and symptom severity and interference with daily living compared to a conventional prescribing approach in patients with cancer. METHODS Patients with solid tumors with metastasis and a self-reported pain score ≥ 4/10 are eligible for enrollment and randomized to a genotype-guided or conventional pain management strategy. For patients in the genotype-guided arm, CYP2D6 genotype information is integrated into opioid prescribing decisions. Patients are asked to complete questionnaires regarding their pain, symptoms, and quality of life at baseline and 2, 4, 6, and 8 weeks after enrollment. The primary endpoint is differential change in pain severity by treatment strategy (genotype-guided versus conventional pain management). Secondary endpoints include change in pain and symptom interference with daily living. CONCLUSION Pharmacogenetic-guided opioid selection for cancer pain management has potential clinical utility, but current evidence is limited to retrospective and observational studies. Precision Medicine Guided Treatment for Cancer Pain is a pragmatic clinical trial that seeks to determine the utility of CYP2D6 genotype-guided opioid prescribing in patients with cancer.
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Affiliation(s)
- Scott A Mosley
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - J Kevin Hicks
- DeBartolo Family Personalized Medicine Institute, Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Diane G Portman
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kristine A Donovan
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Priya Gopalan
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jessica Schmit
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jason Starr
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Natalie Silver
- Department of Otolaryngology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA
| | - Michael Clare-Salzler
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA; Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Petr Starostik
- Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Young D Chang
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sahana Rajasekhara
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Joshua E Smith
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Heloisa P Soares
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute, Department of Individualized Cancer Management, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Center for Pharmacogenomics, University of Florida, Gainesville, FL, USA; Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA.
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25
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Cajanus K, Neuvonen M, Koskela O, Kaunisto MA, Neuvonen PJ, Niemi M, Kalso E. Analgesic Plasma Concentrations of Oxycodone After Surgery for Breast Cancer-Which Factors Matter? Clin Pharmacol Ther 2017. [PMID: 28643329 DOI: 10.1002/cpt.771] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We investigated factors affecting analgesic oxycodone concentrations after breast cancer surgery in 1,000 women. Preoperatively, we studied heat and cold pain sensitivities and anxiety scores. Postoperatively, rest and motion pain intensities were measured and intravenous oxycodone was administered until satisfactory analgesia. At this point, the mean oxycodone concentration (variation coefficient) was 33.3 ng/mL (66%) and it was 21.7 ng/mL (69%) when the patient requested oxycodone again. At both time points, the concentrations varied >100-fold between individuals. The analgesic oxycodone concentration was increased by 21.3% per motion pain intensity score on a 0-10 scale and by 22.3% if axillary clearance was performed instead of sentinel node biopsy (P < 0.001). Forty-seven women who were older and less anxious than others (P < 0.01) required no oxycodone. Anxiety, age, chronic pain, or preoperative pain sensitivity were not independently associated with the analgesic oxycodone concentration. CYP2D6 and CYP3A genotypes did not affect analgesic concentration or duration of analgesia.
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Affiliation(s)
- Kristiina Cajanus
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Neuvonen
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Finland
| | - Outi Koskela
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Finland
| | - Mari A Kaunisto
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Finland
| | - Pertti J Neuvonen
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Finland
| | - Mikko Niemi
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, Finland
| | - Eija Kalso
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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26
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St Sauver JL, Olson JE, Roger VL, Nicholson WT, Black JL, Takahashi PY, Caraballo PJ, Bell EJ, Jacobson DJ, Larson NB, Bielinski SJ. CYP2D6 phenotypes are associated with adverse outcomes related to opioid medications. Pharmgenomics Pers Med 2017. [PMID: 28769582 DOI: 10.2147/pgpm.s136341.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Variation in the CYP2D6 gene may affect response to opioids in both poor and ultrarapid metabolizers, but data demonstrating such associations have been mixed, and the impact of variants on toxicity-related symptoms (e.g., nausea) is unclear. Therefore, we examined the association between CYP2D6 phenotype and poor pain control or other adverse symptoms related to the use of opioids in a sample of primary care patients. MATERIALS AND METHODS We identified all patients in the Mayo Clinic RIGHT Protocol who were prescribed an opioid medication between July 01, 2013 and June 30, 2015, and categorized patients into three phenotypes: poor, intermediate to extensive, or ultrarapid CYP2D6 metabolizers. We reviewed the electronic health record of these patients for indications of poor pain control or adverse symptoms related to medication use. Associations between phenotype and outcomes were assessed using Chi-square tests and logistic regression. RESULTS Overall, 257 (25% of RIGHT Protocol participants) patients received at least one opioid prescription; of these, 40 (15%) were poor metabolizers, 146 (57%) were intermediate to extensive metabolizers, and 71 (28%) were ultrarapid metabolizers. We removed patients that were prescribed a CYP2D6 inhibitor medication (n=38). After adjusting for age and sex, patients with a poor or ultrarapid phenotype were 2.7 times more likely to experience either poor pain control or an adverse symptom related to the prescription compared to patients with an intermediate to extensive phenotype (odds ratio: 2.68; 95% CI: 1.39, 5.17; p=0.003). CONCLUSION Our results suggest that >30% of patients with a poor or ultrarapid CYP2D6 phenotype may experience an adverse outcome after being prescribed codeine, tramadol, oxycodone, or hydrocodone. These medications are frequently prescribed for pain relief, and ~39% of the US population is expected to carry one of these phenotypes, suggesting that the population-level impact of these gene-drug interactions could be substantial.
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Affiliation(s)
- Jennifer L St Sauver
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Janet E Olson
- Department of Health Sciences Research.,Center for Individualized Medicine
| | - Veronique L Roger
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester.,Department of Cardiovascular Diseases
| | | | - John L Black
- Center for Individualized Medicine.,Department of Laboratory Medicine and Pathology
| | - Paul Y Takahashi
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro J Caraballo
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Bell
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Debra J Jacobson
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
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St Sauver JL, Olson JE, Roger VL, Nicholson WT, Black JL, Takahashi PY, Caraballo PJ, Bell EJ, Jacobson DJ, Larson NB, Bielinski SJ. CYP2D6 phenotypes are associated with adverse outcomes related to opioid medications. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2017; 10:217-227. [PMID: 28769582 PMCID: PMC5533497 DOI: 10.2147/pgpm.s136341] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Variation in the CYP2D6 gene may affect response to opioids in both poor and ultrarapid metabolizers, but data demonstrating such associations have been mixed, and the impact of variants on toxicity-related symptoms (e.g., nausea) is unclear. Therefore, we examined the association between CYP2D6 phenotype and poor pain control or other adverse symptoms related to the use of opioids in a sample of primary care patients. Materials and methods We identified all patients in the Mayo Clinic RIGHT Protocol who were prescribed an opioid medication between July 01, 2013 and June 30, 2015, and categorized patients into three phenotypes: poor, intermediate to extensive, or ultrarapid CYP2D6 metabolizers. We reviewed the electronic health record of these patients for indications of poor pain control or adverse symptoms related to medication use. Associations between phenotype and outcomes were assessed using Chi-square tests and logistic regression. Results Overall, 257 (25% of RIGHT Protocol participants) patients received at least one opioid prescription; of these, 40 (15%) were poor metabolizers, 146 (57%) were intermediate to extensive metabolizers, and 71 (28%) were ultrarapid metabolizers. We removed patients that were prescribed a CYP2D6 inhibitor medication (n=38). After adjusting for age and sex, patients with a poor or ultrarapid phenotype were 2.7 times more likely to experience either poor pain control or an adverse symptom related to the prescription compared to patients with an intermediate to extensive phenotype (odds ratio: 2.68; 95% CI: 1.39, 5.17; p=0.003). Conclusion Our results suggest that >30% of patients with a poor or ultrarapid CYP2D6 phenotype may experience an adverse outcome after being prescribed codeine, tramadol, oxycodone, or hydrocodone. These medications are frequently prescribed for pain relief, and ~39% of the US population is expected to carry one of these phenotypes, suggesting that the population-level impact of these gene–drug interactions could be substantial.
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Affiliation(s)
- Jennifer L St Sauver
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Janet E Olson
- Department of Health Sciences Research.,Center for Individualized Medicine
| | - Veronique L Roger
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester.,Department of Cardiovascular Diseases
| | | | - John L Black
- Center for Individualized Medicine.,Department of Laboratory Medicine and Pathology
| | - Paul Y Takahashi
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro J Caraballo
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Bell
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
| | - Debra J Jacobson
- Department of Health Sciences Research.,Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester
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Balyan R, Mecoli M, Venkatasubramanian R, Chidambaran V, Kamos N, Clay S, Moore DL, Mavi J, Glover CD, Szmuk P, Vinks A, Sadhasivam S. CYP2D6 pharmacogenetic and oxycodone pharmacokinetic association study in pediatric surgical patients. Pharmacogenomics 2017; 18:337-348. [PMID: 28244808 DOI: 10.2217/pgs-2016-0183] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Oxycodone is partly metabolized to the active metabolite oxymorphone by hepatic CYP2D6 in the liver. Significant genetic variability in CYP2D6 activity affects oxymorphone formation. This study aimed to associate CYP2D6 genotype and oxycodone's metabolism. METHODS 30 children were administered oral oxycodone postoperatively. Plasma levels of oxycodone and oxymorphone, and CYP2D6 genotype were analyzed. CYP2D6 genotype and oxycodone metabolism phenotype were determined based on CYP2D6 total activity score (TAS) and metabolism phenotype: poor metabolizer (PM), intermediate metabolizer (IM), extensive metabolizer (EM) or ultrarapid metabolizer (UM). RESULTS Compared with PM/IM subjects, significantly greater oxymorphone exposure was seen in EM subjects (p = 0.02 for Cmax, p = 0.016 for AUC0-6 and p = 0.026 for AUC0-24). Similarly, higher TAS value was found to be associated with greater oxymorphone exposure. Higher conversion of oxycodone to oxymorphone was observed in EM subjects compared with PM/IM subjects (p = 0.0007 for Cmax, p = 0.001 for AUC0-6 and p = 0.004 for AUC0-24). CONCLUSION CYP2D6 phenotypes explain metabolism of oxycodone in children, and oxymorphone exposure is higher in CYP2D6 EM phenotype. Further studies are needed to predict the occurrence of adverse event and tailor oxycodone dose for a specific CYP2D6 phenotype.
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Affiliation(s)
- Rajiv Balyan
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Marc Mecoli
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Raja Venkatasubramanian
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Nichole Kamos
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Smokey Clay
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - David L Moore
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Jagroop Mavi
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Chris D Glover
- Department of Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
| | - Peter Szmuk
- Department of Anesthesiology & Pain Management, University of Texas Southwestern & Children's Medical Center, Dallas, TX 75390, USA.,Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Alexander Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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Abstract
OBJECTIVES Genetic variants in pharmacokinetic genes can alter the effectiveness and increase the risks of using analgesics to treat pain. The purpose of this retrospective study is to describe the clinical experiences that led to pharmacogenetic testing of pediatric pain management program patients for alterations in the CYP2D6, CYP2C19, and CYP2C9 genes and correlate the analgesic efficacy and adverse analgesic effects with the gene-specific findings and Metabolic Reserve (MR) index. MATERIALS AND METHODS Nineteen patients were referred for pharmacogenetic testing between February 2010 and December 2013 due to analgesic ineffectiveness or adverse analgesic effects. CYP2D6, CYP2C19, and CYP2C9 functional status was inferred from genotyping; and MR calculated. Data from the available inpatient and outpatient medical records from January 2007 to May 2014 for these patients were reviewed and extracted to characterize patient analgesic response phenotype. RESULTS Significant CYP2D6 genetic variants were identified in 16 of the 19 (84%) patients: 4 were ultra-rapid metabolizers, 8 were deficient, 3 were poor metabolizers, and 1 was CYP2D6 null metabolizer. Of the 3 patients with functional CYP2D6 status, 2 were CYP2C19 null metabolizers. The MR scores ranged from 3.0 to 7.0, with a bimodal distribution with high frequencies corresponding to 4.0/4.5 and 7.0. DISCUSSION Clinical evaluation of analgesic ineffectiveness and adverse effects led to the high likelihood of identifying patients with CYP2D6, CYP2C19, and CYP2C9 alleles associated with alterations in analgesic metabolism. Further research is needed to integrate pharmacogenetic and clinical information into anticipatory guidance for pharmacogenetic testing and analgesic prescribing to children with pain.
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Pergolizzi JV, Seow-Choen F, Wexner SD, Zampogna G, Raffa RB, Taylor R. Perspectives on Intravenous Oxycodone for Control of Postoperative Pain. Pain Pract 2016; 16:924-34. [PMID: 26393529 DOI: 10.1111/papr.12345] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 06/19/2015] [Indexed: 02/05/2023]
Abstract
Intravenous (IV) analgesia has particular advantages in the immediate postoperative period. For example, IV administration results in a faster onset of pain relief and results in more predictable pharmacokinetics than does administration by other routes. It also allows for convenient dosing before or during surgery, permitting the initiation of effective analgesia in the early phase of the postoperative period. In addition, when patients are able to tolerate oral intake, they can be switched from IV to oral dosing based on maintaining the predictable analgesia established by the IV route. IV morphine is widely used for the control of postoperative pain, but there is a trend toward the use of oxycodone. Oxycodone (which may be mediated partly through kappa- as well as mu-opioid receptors) offers several potential advantages. Published studies comparing IV oxycodone to other IV opioids for postsurgical pain report that oxycodone is a safe and effective analgesic. Some studies show that IV oxycodone may be associated with greater pain control, fewer or less severe adverse events, and faster onset of action, although the results are not consistent across all studies. Oxycodone has been reported to be safe in the geriatric and other special populations when adequate clinical adjustments are made. Thus, the clinical reports and oxycodone's pharmacologic profile make intravenous oxycodone a potentially important "new" old drug for postoperative pain control.
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Affiliation(s)
- Joseph V Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
- Department of Pharmacology, Temple University School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, U.S.A
| | | | - Robert B Raffa
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, Pennsylvania, U.S.A
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Gaudette F, Sirhan-Daneau A, St-Onge M, Turgeon J, Michaud V. Development of a sensitive method for the determination of oxycodone and its major metabolites noroxycodone and oxymorphone in human plasma by liquid chromatography–tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1008:174-180. [DOI: 10.1016/j.jchromb.2015.11.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 11/18/2015] [Accepted: 11/19/2015] [Indexed: 11/29/2022]
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Martini CH, Proto P, Olofsen E, van Velzen M, Aarts L, Dahan A, Niesters M. A randomized controlled trial and novel mathematical analysis of the analgesic effect of oxycodone versus paracetamol orodispersible tablets. Eur J Pain 2015; 19:295-304. [PMID: 24947675 DOI: 10.1002/ejp.546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND For effective treatment of acute pain, a rapid onset of action is important. Here we quantify the antinociceptive profile of an orodispersible oxycodone tablet (OOT) in a randomized, double-blind, active comparator (paracetamol orodispersible tablet, POT), crossover study design in a population of healthy volunteers. METHODS Twelve female volunteers were randomized to receive 20 mg OOT and 500 mg POT sublingually on two occasions. The electrical pain threshold (EPTh), electrical pain tolerance (EPTol) and pressure pain threshold (PPT) were obtained at regular intervals for 5 h. Time-response data were analysed with a longitudinal pharmacodynamic model characterized by rate constants for analgesia onset (kON ), offset (kOFF ), potency parameter (EFF) and validated with a bootstrap analysis. Values are the median (95% CI) as derived from the bootstrap analysis. RESULTS OOT produced a rapid increase in response values. For electrical pain analgesia onset, t½kON , 44 (25-67) versus analgesia offset, t½kOFF , 156 (63-552) min, p < 0.01. For pressure pain, t½kON equalled t½kOFF : 30 (16-48) min. OOT was most potent on EPTol: EFF 0.95 (0.39-1.71), p < 0.01, with similar potencies on EPTh, 0.43 (0.19-0.87) and PPT, 0.40 (0.21-0.67). Paracetamol displayed 14% of the analgesic efficacy of oxycodone. CONCLUSIONS The analgesic effect of orodispersible oxycodone was successfully quantified using a mathematical model of analgesia evolution. This method allows quantification of a variety of responses times from sparse data sets. Response times as defined by a 30% increase in response thresholds varied significantly among end points: EPTol 15 min, PPTh 18 min and EPTh 41 min.
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Affiliation(s)
- C H Martini
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands
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Baber M, Bapat P, Nichol G, Koren G. The pharmacogenetics of opioid therapy in the management of postpartum pain: a systematic review. Pharmacogenomics 2015; 17:75-93. [PMID: 26652709 DOI: 10.2217/pgs.15.157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIMS Opioids are commonly prescribed for postpartum pain. Yet, providing adequate pain relief, while ensuring that the mother and her breastfeeding infant are protected from adverse events can be challenging. The objective of this systematic review was to identify the role of opioid pharmacogenetics in analgesia and adverse events among patients being treated for postpartum pain, along with their breastfeeding infants. METHODS A comprehensive search of the literature was conducted in seven databases on June 3-4, 2015. Two reviewers independently screened studies for eligibility, extracted data and evaluated study quality using the Newcastle-Ottawa Scale. RESULTS Among the 2082 papers retrieved from the search, 17 were included in the review. These 17 papers consisted of various study designs, opioids, polymorphisms and patient outcomes. This systematic review reveals that CYP2D6, OPRM1 A118G, UGT2B7 C802T and ABCB1 G2677AT may contribute to postpartum analgesia or adverse events. CONCLUSION These findings may assist in personalizing care for patients receiving opioids during the postpartum period.
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Affiliation(s)
- Marta Baber
- Division of Clinical Pharmacology & Toxicology, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.,Department of Pharmacology & Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Priya Bapat
- Division of Clinical Pharmacology & Toxicology, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.,Department of Pharmacology & Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Gail Nichol
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, Ontario, M5S 3M2, Canada
| | - Gideon Koren
- Department of Pharmacology & Toxicology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
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Brosen K. Pharmacogenetics of drug oxidation via cytochrome P450 (CYP) in the populations of Denmark, Faroe Islands and Greenland. Drug Metab Pers Ther 2015; 30:147-63. [PMID: 25719307 DOI: 10.1515/dmdi-2014-0029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 12/09/2014] [Indexed: 11/15/2022]
Abstract
Denmark, the Faroe Islands and Greenland are three population-wise small countries on the northern part of the Northern Hemisphere, and studies carried out here on the genetic control over drug metabolism via cytochrome P450 have led to several important discoveries. Thus, CYP2D6 catalyzes the 2-hydroxylation, and CYP2C19 in part catalyzes the N-demethylation of imipramine. The phenomenon of phenocopy with regard to CYP2D6 was first described when Danish patients changed phenotype from extensive to poor metabolizers during treatment with quinidine. It was a Danish extensive metabolizer patient that became a poor metabolizer during paroxetine treatment, and this was due to the potent inhibition of CYP2D6 by paroxetine, which is also is metabolized by this enzyme. Fluoxetine and norfluoxetine are also potent inhibitors of CYP2D6, and fluvoxamine is a potent inhibitor of both CYP1A2 and CYP2C19. The bioactivation of proguanil to cycloguanil is impaired in CYP2C19 poor metabolizers. The O-demethylation of codeine and tramadol to their respective my-opioid active metabolites, morphine and (+)-O-desmethyltramadol was markedly impaired in CYP2D6 poor metabolizers compared to extensive metabolizers, and this impairs the hypoalgesic effect of the two drugs in the poor metabolizers. The frequency of CYP2D6 poor metabolizers is 2%-3% in Greenlanders and nearly 15% in the Faroese population. The frequency of CYP2C19 poor metabolizers in East Greenlanders is approximately 10%. A study in Danish mono and dizygotic twins showed that the non-polymorphic 3-N-demethylation of caffeine catalyzed by CYP1A2 is subject to approximately 70% genetic control.
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35
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36
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Nielsen LM, Olesen AE, Branford R, Christrup LL, Sato H, Drewes AM. Association Between Human Pain-Related Genotypes and Variability in Opioid Analgesia: An Updated Review. Pain Pract 2014; 15:580-94. [DOI: 10.1111/papr.12232] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 06/04/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Lecia M. Nielsen
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Aalborg Denmark
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Anne E. Olesen
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Aalborg Denmark
| | - Ruth Branford
- Department of Palliative Medicine; Royal Marsden Hospital; London UK
| | - Lona L. Christrup
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Hiroe Sato
- Interstitial Lung Disease Unit; Royal Brompton Hospital & National Heart and Lung Institute; Imperial College London; London UK
| | - Asbjørn M. Drewes
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Aalborg Denmark
- Department of Clinical Medicine; Aalborg University; Aalborg Denmark
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Winchester WJ, Gore K, Glatt S, Petit W, Gardiner JC, Conlon K, Postlethwaite M, Saintot PP, Roberts S, Gosset JR, Matsuura T, Andrews MD, Glossop PA, Palmer MJ, Clear N, Collins S, Beaumont K, Reynolds DS. Inhibition of TRPM8 channels reduces pain in the cold pressor test in humans. J Pharmacol Exp Ther 2014; 351:259-69. [PMID: 25125580 DOI: 10.1124/jpet.114.216010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The transient receptor potential (subfamily M, member 8; TRPM8) is a nonselective cation channel localized in primary sensory neurons, and is a candidate for cold thermosensing, mediation of cold pain, and bladder overactivity. Studies with TRPM8 knockout mice and selective TRPM8 channel blockers demonstrate a lack of cold sensitivity and reduced cold pain in various rodent models. Furthermore, TRPM8 blockers significantly lower body temperature. We have identified a moderately potent (IC50 = 103 nM), selective TRPM8 antagonist, PF-05105679 [(R)-3-[(1-(4-fluorophenyl)ethyl)(quinolin-3-ylcarbonyl)amino]methylbenzoic acid]. It demonstrated activity in vivo in the guinea pig bladder ice water and menthol challenge tests with an IC50 of 200 nM and reduced core body temperature in the rat (at concentrations >1219 nM). PF-05105679 was suitable for acute administration to humans and was evaluated for effects on core body temperature and experimentally induced cold pain, using the cold pressor test. Unbound plasma concentrations greater than the IC50 were achieved with 600- and 900-mg doses. The compound displayed a significant inhibition of pain in the cold pressor test, with efficacy equivalent to oxycodone (20 mg) at 1.5 hours postdose. No effect on core body temperature was observed. An unexpected adverse event (hot feeling) was reported, predominantly periorally, in 23 and 36% of volunteers (600- and 900-mg dose, respectively), which in two volunteers was nontolerable. In conclusion, this study supports a role for TRPM8 in acute cold pain signaling at doses that do not cause hypothermia.
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Affiliation(s)
- Wendy J Winchester
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Katrina Gore
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Sophie Glatt
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Wendy Petit
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Jennifer C Gardiner
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Kelly Conlon
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Michael Postlethwaite
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Pierre-Philippe Saintot
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Sonia Roberts
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - James R Gosset
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Tomomi Matsuura
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Mark D Andrews
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Paul A Glossop
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Michael J Palmer
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Nicola Clear
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Susie Collins
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - Kevin Beaumont
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
| | - David S Reynolds
- Pfizer Limited, Neusentis Research Unit, Granta Park, Cambridge, United Kingdom (W.J.W., K.G., S.G., D.S.R.); Genito-Urinary Research Unit (W.J.W., J.C.G., K.C., M.P., P.-P.S., D.S.R.), Research Statistics (K.G., S.C.), Drug Safety, Research and Development (S.R.), Pharmacokinetics, Dynamics and Metabolism (J.R.G., T.M., K.B.), and Worldwide Medicinal Chemistry (M.D.A., P.A.G., M.J.P.), Pfizer Global Research and Development, Sandwich, Kent, United Kingdom; Pfizer Clinical Research Unit, Lenniksebaan, Brussels, Belgium (W.P.); and PharmaTherapeutics Pharmaceutical Sciences, Pfizer Limited, Sandwich, United Kingdom (N.C.)
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Möller J, Laflamme L, Söderberg Löfdal K. CYP2D6-Inhibiting Drugs and the Increased Risk of Fall-Related Injuries Due to Newly Initiated Opioid Treatment - A Swedish, Register-Based Case-Crossover Study. Basic Clin Pharmacol Toxicol 2014; 116:134-9. [DOI: 10.1111/bcpt.12289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Jette Möller
- Department of Public Health Sciences; Karolinska Institutet; Stockholm Sweden
| | - Lucie Laflamme
- Department of Public Health Sciences; Karolinska Institutet; Stockholm Sweden
| | - Karin Söderberg Löfdal
- Department of Clinical Pharmacology; Karolinska University Hospital Huddinge; Stockholm Sweden
- Division of Clinical Pharmacology; Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
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Söderberg Löfdal KC, Andersson ML, Gustafsson LL. Cytochrome P450-mediated changes in oxycodone pharmacokinetics/pharmacodynamics and their clinical implications. Drugs 2014; 73:533-43. [PMID: 23605691 DOI: 10.1007/s40265-013-0036-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In recent years the use of the opioid oxycodone has increased markedly and replacing morphine as the first-line choice of opioid in several countries. There are formulations for oral immediate, oral extended release and intravenous use. The bioavailability is higher than for morphine and less variable. Oxycodone is primarily metabolized in the liver by the cytochrome P450 (CYP) enzymes with CYP3A as the major metabolic pathway and CYP2D6 as the minor metabolic pathway to noroxycodone, oxymorphone and noroxymorphone. Oxycodone exerts its analgesic effect via the µ-opioid receptor. The metabolism of CYP2D6 substrates varies to a large degree between individuals as a result of allele functionality. Poor metabolizers (PM) have two non-functional alleles, extensive metabolizers (EM) are homozygous with two functional alleles or heterozygous with one functional allele and ultrarapid metabolizers (UM) have more than two functional alleles. There are pronounced interethnic differences in the allele distribution. On the basis of studies performed thus far, oxycodone concentrations in comparison with EM are similar in PM and reduced in UM. The pharmacokinetics in UM are insufficiently investigated. Simultaneous inhibition of both CYP3A and CYP2D6 results in increased oxycodone concentrations and such a combination should be avoided. A similar effect is to be expected with use of a CYP3A inhibitor in CYP2D6 PM. Concomitant use of enzyme inducers such as rifampicin, St John's wort and carbamazepine should be avoided because of the risk of subtherapeutic concentrations of oxycodone. When the dosage of morphine may result in unpredictable bioavailability, like in patients with severe hepatic cirrhosis, oxycodone might be beneficial because it has higher and less variability in bioavailability between patients than morphine.
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Affiliation(s)
- Karin C Söderberg Löfdal
- Department of Clinical Pharmacology, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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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: 458] [Impact Index Per Article: 45.8] [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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Zahari Z, Ismail R. Influence of Cytochrome P450, Family 2, Subfamily D, Polypeptide 6 (CYP2D6) Polymorphisms on Pain Sensitivity and Clinical Response to Weak Opioid Analgesics. Drug Metab Pharmacokinet 2014; 29:29-43. [DOI: 10.2133/dmpk.dmpk-13-rv-032] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Prows CA, Zhang X, Huth MM, Zhang K, Saldaña SN, Daraiseh NM, Esslinger HR, Freeman E, Greinwald JH, Martin LJ, Sadhasivam S. Codeine-related adverse drug reactions in children following tonsillectomy: a prospective study. Laryngoscope 2013; 124:1242-50. [PMID: 24122716 DOI: 10.1002/lary.24455] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/13/2013] [Accepted: 09/26/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To prospectively determine factors associated with codeine's adverse drug reactions (ADRs) at home in a large homogenous population of children undergoing outpatient tonsillectomy. STUDY DESIGN Prospective, genotype blinded, observational study with a single group and repeated ADR measures documented by parents at home. METHODS A total of 249 children 6 to 15 years of age scheduled for tonsillectomy were enrolled. The primary outcome was number of daily codeine-related ADRs. We examined the number and type of ADR by race and by days and further modeled factors potentially associated with ADR risk in a subcohort of white children. Sedation following a dose of codeine was a secondary outcome measure. Parents recorded their children's daily ADRs and sedation scores during postoperative days (POD) 0 to 3 at home. RESULTS Diaries were returned for 134 children, who were given codeine. A total of 106 (79%) reported at least one ADR. The most common ADRs were nausea, lightheadedness/dizziness for white children and nausea, and vomiting for African American children. In a subcohort of white children ≤ 45 kg, increased ADR risk was associated with the presence of one or more full function CYP2D6 alleles (P < 0.001), POD (P < 0.001), and sex (P = 0.027). Increased pain intensity (P = 0.009) and PODs 0 and 1 (P = 0.001) contributed to a higher sedation risk. Neither obstructive apnea nor predicted CYP2D6 phenotype were associated with sedation risk. CONCLUSIONS Our results provide evidence that multiple factors are associated with codeine-related ADRs and support the FDA recommendation to avoid codeine's routine use following tonsillectomy in children.
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Affiliation(s)
- Cynthia A Prows
- Division of Human Genetics, University of Cincinnati, Cincinnati, Ohio; Division of Pharmacy, University of Cincinnati, Cincinnati, Ohio
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Pedersen RS, Damkier P, Christensen MMH, Brosen K. A cytochrome P450 phenotyping cocktail causing unexpected adverse reactions in female volunteers. Eur J Clin Pharmacol 2013; 69:1997-9. [PMID: 23917460 DOI: 10.1007/s00228-013-1561-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/04/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND A four-drug cytochrome P450 (CYP) phenotyping cocktail was developed to rapidly and safely determine CYP2D6, CYP2C19, CYP2C9 and CYP1A2 enzyme activity and phenotype. METHODS The cocktail consisted of the single CYP phenotyping probes of 50 mg tramadol (CYP2D6), 20 mg omeprazole (CYP2C19), 25 mg losartan (CYP2C9) and 200 mg caffeine (CYP1A2) and was administered as a single oral dose. For enzyme activity measurements, urine was collected as 8 h post-administration and blood was sampled at 4 h. The enzyme activity was determined by metabolic ratios of molar concentrations of the drugs and their enzyme catalyzed metabolites and was correlated to the relevant genotypes. RESULTS In a pilot study in 12 healthy male volunteers the CYP genotype-phenotype correlation and robustness of the cocktail was successfully determined without detection of any adverse drug reactions. In the subsequent population study, four female volunteers experienced unexpected and unacceptable moderate and severe adverse reactions (ARs) of headache, dizziness, nausea, vomiting, blue fingers, nails and lips and difficulties in urinating, which led to the study being prematurely terminated after inclusion of only 22 subjects (15 males, 7 females) [corrected]. CONCLUSION Attention must be paid to adverse reactions when designing new combinations of phenotype cocktails regardless of the doses and drugs involved. We specifically warn against the combination of tramadol, omeprazole, losartan and caffeine.
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Affiliation(s)
- Rasmus Steen Pedersen
- Institute of Public Health, Clinical Pharmacology, University of Southern Denmark, J.B. Winslowsvej 19, 5000, Odense, Denmark,
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Sadhasivam S, Chidambaran V. Pharmacogenomics of opioids and perioperative pain management. Pharmacogenomics 2013; 13:1719-40. [PMID: 23171337 DOI: 10.2217/pgs.12.152] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Inadequate pain relief and adverse effects from analgesics remain common in children and adults during the perioperative period. Opioids are the most commonly used analgesics in children and adults to treat perioperative pain. Narrow therapeutic index and a large interpatient variability in response to opioids are clinically significant, with inadequate pain relief at one end of the spectrum and serious side effects, such as respiratory depression and excessive sedation due to relative overdosing, at the other end. Personalizing analgesia during the perioperative period attempts to maximize pain relief while minimizing adverse events from therapy. While various factors influence response to treatment among surgical patients, age, sex, race and pharmacogenetic differences appear to play major roles in predicting outcome. Genetic factors include a subset of genes that modulate the proteins involved in pain perception, pain pathway, analgesic metabolism (pharmacokinetics), transport and receptor signaling (pharmacodynamics). While results from adult genetic studies can provide direction for pediatric studies, they have limited direct applicability, as children's genetic predispositions to analgesic response may be influenced by developmental and behavioral components, altered sensitivity to analgesics and variation in gene-expression patterns. We have reviewed the available evidence on improving and personalizing pain management with opioids and the significance of individualizing analgesia, in order to maximize analgesic effect with minimal adverse effects with opioids. While the early evidence on individual genotype associations with pain, analgesia and opioid adverse outcome are promising, the large amount of conflicting data in the literature suggests that there is a need for larger and more robust studies with appropriate population stratification and consideration of nongenetic and other genetic risk factors. Although the clinical evidence and the prospect of being able to provide point-of-care genotyping to enable clinicians to deliver personalized analgesia for individual patients is still not available, positioning our research to identify all possible major genetic and nongenetic risk factors of an individual patient, advancing less expensive point-of-care genotyping technology and developing easy-to-use personalized clinical decision algorithms will help us to improve current clinical and economic outcomes associated with pain and opioid pain management.
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Affiliation(s)
- Senthilkumar Sadhasivam
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.
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Putative Association of ABCB1 2677G>T/A With Oxycodone-Induced Central Nervous System Depression in Breastfeeding Mothers. Ther Drug Monit 2013; 35:466-72. [DOI: 10.1097/ftd.0b013e318288f158] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stamer UM, Zhang L, Book M, Lehmann LE, Stuber F, Musshoff F. CYP2D6 genotype dependent oxycodone metabolism in postoperative patients. PLoS One 2013; 8:e60239. [PMID: 23555934 PMCID: PMC3610662 DOI: 10.1371/journal.pone.0060239] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/23/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The impact of polymorphic cytochrome P450 CYP2D6 enzyme on oxycodone's metabolism and clinical efficacy is currently being discussed. However, there are only spare data from postoperative settings. The hypothesis of this study is that genotype dependent CYP2D6 activity influences plasma concentrations of oxycodone and its metabolites and impacts analgesic consumption. METHODS Patients received oxycodone 0.05 mg/kg before emerging from anesthesia and patient-controlled analgesia (PCA) for the subsequent 48 postoperative hours. Blood samples were drawn at 30, 90 and 180 minutes after the initial oxycodone dose. Plasma concentrations of oxycodone and its metabolites oxymorphone, noroxycodone and noroxymorphone were analyzed by liquid chromatography-mass spectrometry with electrospray ionization. CYP2D6 genotyping was performed and 121 patients were allocated to the following genotype groups: PM (poor metabolizer: no functionally active CYP2D6 allele), HZ/IM (heterozygous subjects, intermediate metabolizers with decreased CYP2D6 activity), EM (extensive metabolizers, normal CYP2D6 activity) and UM (ultrarapid metabolizers, increased CYP2D6 activity). Primary endpoint was the genotype dependent metabolite ratio of plasma concentrations oxymorphone/oxycodone. Secondary endpoint was the genotype dependent analgesic consumption with calculation of equianalgesic doses compared to the standard non-CYP dependent opioid piritramide. RESULTS Metabolism differed between CYP2D6 genotypes. Mean (95%-CI) oxymophone/oxycodone ratios were 0.10 (0.02/0.19), 0.13 (0.11/0.16), 0.18 (0.16/0.20) and 0.28 (0.07/0.49) in PM, HZ/IM, EM and UM, respectively (p = 0.005). Oxycodone consumption up to the 12(th) hour was highest in PM (p = 0.005), resulting in lowest equianalgesic doses of piritramide versus oxycodone for PM (1.6 (1.4/1.8); EM and UM 2.2 (2.1/2.3); p<0.001). Pain scores did not differ between genotypes. CONCLUSIONS In this postoperative setting, the number of functionally active CYP2D6 alleles had an impact on oxycodone metabolism. The genotype also impacted analgesic consumption, thereby causing variation of equianalgesic doses piritramide : oxycodone. Different analgesic needs by genotypes were met by PCA technology in this postoperative cohort.
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Affiliation(s)
- Ulrike M Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, University of Bern, Bern, Switzerland.
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Klimas R, Witticke D, El Fallah S, Mikus G. Contribution of oxycodone and its metabolites to the overall analgesic effect after oxycodone administration. Expert Opin Drug Metab Toxicol 2013; 9:517-28. [PMID: 23488585 DOI: 10.1517/17425255.2013.779669] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Oxycodone (OC) is an opioid which exerts its analgesic effect through µ-receptors in the brain. It is metabolized through CYP450 enzymes and some of the metabolites show pharmacological activity. The aim of this investigation is to research the contribution of the metabolites of OC to its overall analgesic effect. A further aim was to elucidate the role of drug-drug interactions and CYP2D6 polymorphism. RESEARCH DESIGN AND METHODS The authors performed a literature search to identify published information on: blood concentrations of OC and metabolites, protein binding, blood-brain-barrier behavior and opioid receptor affinity. The authors then calculated the contribution of OC and metabolites to the overall analgesic effect. RESULTS OC itself is responsible for 83.02 and 94.76% of the analgesic effect during p.o. and i.v. administration, respectively. Oxymorphone (OM), which has a much higher affinity for the µ-receptor, only plays a minor role (15.77 and 4.52% for p.o. and i.v., respectively). Although the CYP2D6 genotype modulates OM pharmacokinetics, OC remains the major contributor to the overall analgesic effect. CONCLUSION This article's calculations demonstrate that OC itself is responsible for the analgesic effect. Although OM and noroxymorphone have much higher µ-receptor affinity than the parent drug, the metabolite concentrations at the site of action are very low. This suggests that there is a minimal analgesic effect from these metabolites.
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Affiliation(s)
- Romina Klimas
- University of Heidelberg, Department of Clinical Pharmacology and Pharmacoepidemiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Zwisler ST, Enggaard TP, Mikkelsen S, Verstuyft C, Becquemont L, Sindrup SH, Brosen K. Lack of Association ofOPRM1andABCB1Single-Nucleotide Polymorphisms to Oxycodone Response in Postoperative Pain. J Clin Pharmacol 2013; 52:234-42. [DOI: 10.1177/0091270010397729] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Olkkola KT, Kontinen VK, Saari TI, Kalso EA. Does the pharmacology of oxycodone justify its increasing use as an analgesic? Trends Pharmacol Sci 2013; 34:206-14. [PMID: 23465410 DOI: 10.1016/j.tips.2013.02.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 01/28/2013] [Accepted: 02/04/2013] [Indexed: 12/17/2022]
Abstract
Oxycodone is a semisynthetic opioid analgesic that is increasingly used for the treatment of acute, cancer, and chronic non-malignant pain. Oxycodone was synthesized in 1917 but its pharmacological properties were not thoroughly studied until recently. Oxycodone is a fairly selective μ-opioid receptor agonist, but there is a striking discrepancy between the relatively low binding potential and G protein activation by oxycodone and its analgesic efficacy. It has been claimed that this is because of active metabolites and enhanced passage to the central nervous system by active transport. We critically review studies on the basic pharmacology of oxycodone and on its pharmacokinetics and pharmacodynamics in humans. In particular, the role of pharmacogenomics and population pharmacokinetics in understanding the properties of oxycodone is discussed in detail. We compare oxycodone with morphine, the standard opioid in clinical use.
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Affiliation(s)
- Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care, Emergency Care, and Pain Medicine, University of Turku and Turku University Hospital, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520 Turku, Finland.
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Vuilleumier PH, Stamer UM, Landau R. Pharmacogenomic considerations in opioid analgesia. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2012; 5:73-87. [PMID: 23226064 PMCID: PMC3513230 DOI: 10.2147/pgpm.s23422] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Indexed: 12/25/2022]
Abstract
Translating pharmacogenetics to clinical practice has been particularly challenging in the context of pain, due to the complexity of this multifaceted phenotype and the overall subjective nature of pain perception and response to analgesia. Overall, numerous genes involved with the pharmacokinetics and dynamics of opioids response are candidate genes in the context of opioid analgesia. The clinical relevance of CYP2D6 genotyping to predict analgesic outcomes is still relatively unknown; the two extremes in CYP2D6 genotype (ultrarapid and poor metabolism) seem to predict pain response and/or adverse effects. Overall, the level of evidence linking genetic variability (CYP2D6 and CYP3A4) to oxycodone response and phenotype (altered biotransformation of oxycodone into oxymorphone and overall clearance of oxycodone and oxymorphone) is strong; however, there has been no randomized clinical trial on the benefits of genetic testing prior to oxycodone therapy. On the other hand, predicting the analgesic response to morphine based on pharmacogenetic testing is more complex; though there was hope that simple genetic testing would allow tailoring morphine doses to provide optimal analgesia, this is unlikely to occur. A variety of polymorphisms clearly influence pain perception and behavior in response to pain. However, the response to analgesics also differs depending on the pain modality and the potential for repeated noxious stimuli, the opioid prescribed, and even its route of administration.
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Affiliation(s)
- Pascal H Vuilleumier
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital Universität Bern, Switzerland
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