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Aapro M, Fogli S, Morlion B, Danesi R. Opioid metabolism and drug-drug interaction in cancer. Oncologist 2024:oyae094. [PMID: 38780124 DOI: 10.1093/oncolo/oyae094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024] Open
Abstract
Concomitant use of multiple drugs in most patients with cancer may result in drug-drug interactions (DDIs), potentially causing serious adverse effects. These patients often experience unrelieved cancer-related pain (CRP) during and after cancer treatment, which can lead to a reduced quality of life. Opioids can be used as part of a multimodal pain management strategy when non-opioid analgesics are not providing adequate pain relief, not tolerated, or are contraindicated. However, due to their narrow therapeutic window, opioids are more susceptible to adverse events when a DDI occurs. Clinically relevant DDIs with opioids are usually pharmacokinetic, mainly occurring via metabolism by cytochrome P450 (CYP). This article aims to provide an overview of potential DDIs with opioids often used in the treatment of moderate-to-severe CRP and commonly used anticancer drugs such as chemotherapeutics, tyrosine kinase inhibitors (TKIs), or biologics. A DDI-checker tool was used to contextualize the tool-informed DDI assessment outcomes with clinical implications and practice. The findings were compared to observations from a literature search conducted in Embase and PubMed to identify clinical evidence for these potential DDIs. The limited results mainly included case studies and retrospective reviews. Some potential DDIs on the DDI-checker were aligned with literature findings, while others were contradictory. In conclusion, while DDI-checkers are useful tools in identifying potential DDIs, it is necessary to incorporate literature verification and comprehensive clinical assessment of the patient before implementing tool-informed decisions in clinical practice.
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Affiliation(s)
- Matti Aapro
- Genolier Cancer Centre, Clinique de Genolier, 1272 Genolier, Switzerland
| | - Stefano Fogli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa PI, Italy
| | - Bart Morlion
- Department of Cardiovascular Sciences, Section Anesthesiology and Algology, University of Leuven, 3000 Leuven, Belgium
| | - Romano Danesi
- Department of Oncology and Hemato-Oncology, University of Milano, 20122 Milano MI, Italy
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2
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Richards J, Miksys S, Novalen M, Tyndale RF. CYP2D in the brain impacts oral hydrocodone analgesia in vivo. Neuropharmacology 2022; 221:109291. [PMID: 36241086 PMCID: PMC11323711 DOI: 10.1016/j.neuropharm.2022.109291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/26/2022] [Accepted: 10/08/2022] [Indexed: 11/08/2022]
Abstract
Cytochrome P450 2D (CYP2D) metabolises many centrally-acting substrates including opioids. Hydrocodone, an opioid and CYP2D substrate, is metabolised to hydromorphone, an active metabolite. CYP2D in the brain is active in vivo and can alter drug response however, it is unknown whether metabolism by CYP2D in the brain alters oral hydrocodone induced analgesia. Propranolol, a selective CYP2D mechanism-based inhibitor, or vehicle, was administered into the right cerebral ventricle of male rats, (HAN Wistars, Envigo), 24 h before testing for analgesia from oral hydrocodone (or hydromorphone, a non-CYP2D substrate). Hydrocodone and its CYP2D-mediated metabolites were simultaneously quantified using a novel LC-MS/MS assay. After propranolol vs vehicle pretreatment, there was significantly higher analgesia from oral hydrocodone, and a significantly lower brain CYP2D metabolic ratio (an in vivo phenotype of brain CYP2D activity that was derived from the molar sum of hydromorphone and its metabolites divided by hydrocodone). The brain CYP2D metabolic ratio correlated significantly with analgesia. There was no pretreatment effect on plasma hydrocodone concentrations, elimination rates, or metabolic ratio (an in vivo phenotype for hepatic CYP2D activity). The liver CYP2D metabolic ratio did not correlate with analgesia. Propranolol pretreatment had no impact on analgesia from oral hydromorphone. These data suggest that inhibited CYP2D activity in brain, causing reduced metabolism of brain hydrocodone, resulted in higher analgesia from oral hydrocodone, despite hydrocodone having a lower μ-opioid receptor affinity than hydromorphone. Thus, variation in CYP2D in the brain may be an important source of interindividual differences in response to CYP2D substrates, including oral hydrocodone.
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Affiliation(s)
- Janielle Richards
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Miksys
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Maria Novalen
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Rachel F Tyndale
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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3
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Langman LJ, Gaskins J, Korte E, Maluf C, Wooderchak-Donahue WL, McMillin GA, Jannetto PJ, Hartley B, Malkani A, Yakkanti M, Jortani SA. Endogenous and iatrogenic sources of variability in response to opioid therapy in Post-Surgical and injured orthopedic patients. Clin Chim Acta 2021; 522:105-113. [PMID: 34384754 DOI: 10.1016/j.cca.2021.08.004] [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: 07/03/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hydrocodone is the most prescribed opioid in the US. The objective was to evaluate associations between genetic, intrinsic, and extrinsic patient factors, plasma hydrocodone and metabolites, common side effects, and pain scores in a cohort of orthopedic surgery patients. METHODS Data for each patient was collected by review of the electronic hospital record (EHR), and patient interview. Patients were recruited from those with trauma or undergoing scheduled elective surgery for total knee replacement or total hip at the University of Louisville Hospital, Baptist East Hospital, and Jewish Hospital, Louisville, KY. Plasma opiate concentrations and a targeted genotyping panel was performed. RESULTS There were statistically significant correlations with daily (p < 0.001) and total dose (p = 0.002) of hydrocodone in hospital and duration of opioid therapy. The length of opioid administration was significantly shorter in CYP2D6 EM/UM versus CYP2D6 PM/IM patients (p = 0.018). Subjects with the OPRM1 c.118G variant were also on opioids longer (p = 0.022). The effect of co-administration of a CYP2D6 inhibitor had a significant effect on the length of opioid therapy (P < 0.001). And not surprisingly the effect of the inhibitor adjusted CYP2D6 phenotype was greater in both the hospital stay period and days of opioid use post hospital discharge (p < 0.001). CONCLUSIONS Based on this study, patients should be evaluated for the use of inhibitors of CYP2D6, during hydrocodone therapy can alter the phenotype of the patient (phenocopy) and increase the probability that the patient will be on opioids for longer periods of time.
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Affiliation(s)
- Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States of America.
| | - Jeremy Gaskins
- Departments of Bioinformatics and Biostatistics, University of Louisville School of Medicine, Louisville, KY, United States of America
| | - Erik Korte
- Departments of Pathology, and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, United States of America
| | - Cynthia Maluf
- Departments of Pathology, and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, United States of America
| | | | - Gwendolyn A McMillin
- Department of Pathology, University of Utah, ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, United States of America
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States of America
| | - Brandi Hartley
- Departments of Orthopedic Surgery, University of Louisville School of Medicine, Louisville, KY, United States of America
| | - Arthur Malkani
- Departments of Orthopedic Surgery, University of Louisville School of Medicine, Louisville, KY, United States of America
| | | | - Saeed A Jortani
- Departments of Pathology, and Laboratory Medicine, University of Louisville School of Medicine, Louisville, KY, United States of America
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4
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Connors NJ, Mazer-Amirshahi M, Motov S, Kim HK. Relative addictive potential of opioid analgesic agents. Pain Manag 2020; 11:201-215. [PMID: 33300384 DOI: 10.2217/pmt-2020-0048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Opioid overdoses and deaths continue to be a problem in the USA with a significant portion related to prescribed opioid analgesic agents. The role of pharmacogentic factors in opioid addiction is an active area of research. While all opioid analgesic agents have some addictive potential, it is clear that there are some with greater addictive potential. Oxycodone is the most widely abused opioid analgesic and it appears to predispose to chronic use with high likability by users. Fentanyl and hydromorphone are both very lipophilic allowing rapid penetration into the CNS, but are not rated as highly as other agents. Providers should consider the risk of addiction with the opioids they prescribe and give those with a lower addictive potential.
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Affiliation(s)
- Nicholas J Connors
- HCA Healthcare, Trident Medical Center, Charleston, SC 29406, USA.,Palmetto Poison Center, Columbia, SC 29201, USA
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, USA
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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5
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Cornett EM, Carroll Turpin MA, Pinner A, Thakur P, Sekaran TSG, Siddaiah H, Rivas J, Yates A, Huang GJ, Senthil A, Khurmi N, Miller JL, Stark CW, Urman RD, Kaye AD. Pharmacogenomics of Pain Management: The Impact of Specific Biological Polymorphisms on Drugs and Metabolism. Curr Oncol Rep 2020; 22:18. [PMID: 32030524 DOI: 10.1007/s11912-020-0865-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pain is multifactorial and complex, often with a genetic component. Pharmacogenomics is a relative new field, which allows for the development of a truly unique and personalized therapeutic approach in the treatment of pain. RECENT FINDINGS Until recently, drug mechanisms in humans were determined by testing that drug in a population and calculating response averages. However, some patients will inevitably fall outside of those averages, and it is nearly impossible to predict who those outliers might be. Pharmacogenetics considers a patient's unique genetic information and allows for anticipation of that individual's response to medication. Pharmacogenomic testing is steadily making progress in the management of pain by being able to identify individual differences in the perception of pain and susceptibility and sensitivity to drugs based on genetic markers. This has a huge potential to increase efficacy and reduce the incidence of iatrogenic drug dependence and addiction. The streamlining of relevant polymorphisms of genes encoding receptors, transporters, and drug-metabolizing enzymes influencing the pain phenotype can be an important guide to develop safe new strategies and approaches to personalized pain management. Additionally, some challenges still prevail and preclude adoption of pharmacogenomic testing universally. These include lack of knowledge about pharmacogenomic testing, inadequate standardization of the process of data handling, questionable benefits about the clinical and financial aspects of pharmacogenomic testing-guided therapy, discrepancies in clinical evidence supporting these tests, and doubtful reimbursement of the tests by health insurance agencies.
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Affiliation(s)
- Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Michelle A Carroll Turpin
- Department of Biomedical Sciences, College of Medicine, University of Houston, Health 2 Building, Room 8037, Houston, TX, USA
| | - Allison Pinner
- Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Pankaj Thakur
- Department of Anesthesiology, Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | | | - Harish Siddaiah
- Department of Anesthesiology, Ochsner LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Jasmine Rivas
- Department of Family Medicine, ECU Vidant Medical Center, 101 Heart Drive, Greenville, NC, 27834, USA
| | - Anna Yates
- LSU Health Shreveport School of Medicine, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - G Jason Huang
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Anitha Senthil
- Department of Anesthesiology, Lahey Hospital & Medical Center, 41Mall Road, Burlington, MA, 01805, USA
| | - Narjeet Khurmi
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Jenna L Miller
- LSU Health Sciences Center New Orleans, 1901 Perdido Street, New Orleans, LA, 70112, USA
| | - Cain W Stark
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI, 53226, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Alan David Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, 1501 Kings Hwy, Shreveport, LA, 71103, USA
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6
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Hosseinnejad K, Yin T, Gaskins JT, Stauble ME, Wu Y, Jannetto P, Langman LL, Jortani SA. Lack of Influence by CYP3A4 and CYP3A5 Genotypes on Pain Relief by Hydrocodone in Postoperative Cesarean Section Pain Management. J Appl Lab Med 2019; 3:954-964. [DOI: 10.1373/jalm.2018.026070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 07/13/2018] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Genetic polymorphisms of cytochrome P450 are contributors to variability in individual response to drugs. Within the P450 family, CYP2D6 is responsible for metabolizing hydrocodone, a widely prescribed opioid for pain management. Alternatively, CYP3A4 and CYP3A5 can form norhydrocodone and dihydrocodeine. We have previously found that in a postcesarean section cohort, the rate of hydromorphone formation was dependent on the genotype of CYP2D6 and that plasma hydromorphone, not hydrocodone, was predictive of pain relief.
Method
Blood was obtained from a postcesarean cohort that were surveyed for pain response and common side effects. Plasma samples were genotyped for CYP3A4/5, and their hydrocodone concentrations were measured by LC-MS. R statistical software was used to check for differences in the outcomes due to CYP3A4/5 and CYP2D6, and a multivariate regression model was fit to determine factors associated with pain score.
Results
Two-way ANOVA between CYP3A4/A5 and CYP2D6 phenotypes revealed that the former variants did not have a statistical significance on the outcomes, and only CYP2D6 phenotypes had a significant effect on total dosage (P = 0.041). Furthermore, a 3-way ANOVA analysis showed that CYP2D6 (P = 0.036) had a predictive effect on plasma hydromorphone concentrations, and CYP3A4/A5 did not have any effect on the measured outcomes.
Conclusions
With respect to total dosages in a cesarean section population, these results confirm that CYP2D6 phenotypes are predictors for plasma hydromorphone concentration and pain relief, but CYP3A4/A5 phenotypes have no influence on pain relief or on side effects.
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Affiliation(s)
| | - Tyler Yin
- Department of Pathology, University of Louisville, Louisville, KY
| | - Jeremy T Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - M Elaine Stauble
- Department of General Obstetrics, Gynecology, and Women's Health, University of Louisville, Louisville, KY
| | - Yanhong Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Paul Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Loralie L Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Saeed A Jortani
- Department of Pathology, University of Louisville, Louisville, KY
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7
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Jacob JC, Poklis JL, Akbarali HI, Henderson G, Dewey WL. Ethanol Reversal of Tolerance to the Antinociceptive Effects of Oxycodone and Hydrocodone. J Pharmacol Exp Ther 2017; 362:45-52. [PMID: 28442580 PMCID: PMC5454589 DOI: 10.1124/jpet.117.241083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/20/2017] [Indexed: 01/09/2023] Open
Abstract
This study compared the development of tolerance to two orally bioavailable prescription opioids, oxycodone and hydrocodone, to that of morphine, and the reversal of this tolerance by ethanol. Oxycodone (s.c.) was significantly more potent in the mouse tail-withdrawal assay than either morphine or hydrocodone. Oxycodone was also significantly more potent in this assay than hydrocodone when administered orally. Tolerance was seen following chronic subcutaneous administration of each of the three drugs and by the chronic administration of oral oxycodone, but not following the chronic oral administration of hydrocodone. Ethanol (1 g/kg i.p.) significantly reversed the tolerance to the subcutaneous administration of each of the three opioids that developed when given 30 minutes prior to challenge doses. It took twice as much ethanol, when given orally, to reverse the tolerance to oxycodone. We investigated whether the observed tolerance to oxycodone and its reversal by ethanol were due to biodispositional changes or reflected a true neuronal tolerance. As expected, a relationship between brain oxycodone concentrations and activity in the tail-immersion test existed following administration of acute oral oxycodone. Following chronic treatment, brain oxycodone concentrations were significantly lower than acute concentrations. Oral ethanol (2 g/kg) reversed the tolerance to chronic oxycodone, but did not alter brain concentrations of either acute or chronic oxycodone. These studies show that there is a metabolic component of tolerance to oxycodone; however, the reversal of that tolerance by ethanol is not due to an alteration of the biodisposition of oxycodone, but rather is neuronal in nature.
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Affiliation(s)
- Joanna C Jacob
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia- (J.C.J., J.L.P., H.I.A., W.L.D.); and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom (G.H.)
| | - Justin L Poklis
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia- (J.C.J., J.L.P., H.I.A., W.L.D.); and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom (G.H.)
| | - Hamid I Akbarali
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia- (J.C.J., J.L.P., H.I.A., W.L.D.); and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom (G.H.)
| | - Graeme Henderson
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia- (J.C.J., J.L.P., H.I.A., W.L.D.); and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom (G.H.)
| | - William L Dewey
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia- (J.C.J., J.L.P., H.I.A., W.L.D.); and School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom (G.H.)
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8
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Toyama S, Shimoyama N, Shimoyama M. The analgesic effect of orexin-A in a murine model of chemotherapy-induced neuropathic pain. Neuropeptides 2017; 61:95-100. [PMID: 28041630 DOI: 10.1016/j.npep.2016.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/18/2016] [Accepted: 12/19/2016] [Indexed: 11/26/2022]
Abstract
Orexins are neuropeptides that are localized to neurons in the lateral and dorsal hypothalamus but its receptors are distributed to many different regions of the central nervous system. Orexins are implicated in a variety of physiological functions including sleep regulation, energy homeostats, and stress reactions. Furthermore, orexins administered exogenously have been shown to have analgesic effects in animal models. A type of intractable pain in patients is pain due to chemotherapy-induced peripheral neuropathy (CIPN). Several chemotherapeutic agents used for the treatment of malignant diseases induce dose-limiting neuropathic pain that compromises patients' quality of life. Here, we examined the analgesic effect of orexin-A in a murine model of CIPN, and compared it with the effect of duloxetine, the only drug recommended for the treatment of CIPN pain in patients. CIPN was induced in male BALB/c mice by repeated intraperitoneal injection of oxaliplatin, a platinum chemotherapeutic agent used for the treatment of advanced colorectal cancer. Neuropathic mechanical allodynia was assessed by the von Frey test, and the effect on acute thermal pain was assessed by the tail flick test. Intracerebroventricularly administered orexin-A dose-dependently attenuated oxaliplatin-induced mechanical allodynia and increased tail flick latencies. Oxaliplatin-induced mechanical allodynia was completely reversed by orexin-A at a low dose that did not increase tail flick latency. Duloxetine only partially reversed mechanical allodynia and had no effect on tail flick latency. The analgesic effect of orexin-A on oxaliplatin-induced mechanical allodynia was completely antagonized by prior intraperitoneal injection of SB-408124 (orexin type-1 receptor antagonist), but not by prior intraperitoneal injection of TCS-OX2-29 (orexin type-2 receptor antagonist). Our findings suggest that orexin-A is more potent than duloxetine in relieving pain CIPN pain and its analgesic effect is mediated by orexin type-1 receptors. Orexin type-1 receptor agonists may have potential therapeutic roles in the treatment of CIPN pain in patients.
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Affiliation(s)
- Satoshi Toyama
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan.
| | - Naohito Shimoyama
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan.
| | - Megumi Shimoyama
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan.
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9
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Feasibility and Utility of the Individualized Hydrocodone Therapy Based on Phenotype, Pharmacogenetics, and Pharmacokinetic Dosing. Clin J Pain 2016; 32:1105-1106. [DOI: 10.1097/ajp.0000000000000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Feasibility and Utility of the Individualized Hydrocodone Therapy Based on Phenotype, Pharmacogenetics, and Pharmacokinetic Dosing. Clin J Pain 2016; 32:1106-1107. [PMID: 27824618 DOI: 10.1097/ajp.0000000000000382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Navani D, Yoburn BC. Comment Re: Kapil et al. 2015. Clin Ther 2016; 38:229-30. [DOI: 10.1016/j.clinthera.2015.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/29/2015] [Indexed: 11/16/2022]
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12
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Gudin JA, Nalamachu SR. An overview of prodrug technology and its application for developing abuse-deterrent opioids. Postgrad Med 2015; 128:97-105. [PMID: 26615852 DOI: 10.1080/00325481.2016.1126186] [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: 10/22/2022]
Abstract
The Centers for Disease Control and Prevention has classified prescription drug abuse and overdose deaths as an epidemic. Prescription drug overdose is now the leading cause of injury death, with rates that have more than doubled since 1999. This crisis has developed concurrently with the increased prescribing and availability analgesic drugs, especially opioids, resulting from an effort on the part of clinicians to address a critical need for improved pain assessment and treatment. Clinicians have recognized that oftentimes, opioid analgesics are one of the few remaining options for patients who suffer with severe pain. A 2015 fact sheet issued by the Office of National Drug Policy stated: "While we must ensure better access to prescription medications to alleviate suffering, it is also vital that we do all we can to reduce the diversion and abuse of pharmaceuticals." The US Food and Drug Administration has issued guidance that encourages the research and development of abuse-deterrent formulation of opioids which have the potential to curtail abuse. Included among the recommended formulations for development of abuse-deterrent opioids are prodrugs. Prodrugs are chemically modified versions of pharmacological agents that must undergo a biochemical conversion following administration, often by enzymatic cleavage, to free the active drug. Prodrugs may be inherently abuse-deterrent because they are inactive or significantly less active until conversion to the active drug. This requirement for conversion in the GI tract can modify the pharmacokinetic profile and eliminate or reduce the euphoria when abusers change the route of administration. Abusers often attempt to extract the active drug for injection or insufflation. Prodrugs can be designed to be resistant to crushing or dissolving. In this article, we review the concept of prodrugs and introduce and examine the potential of abuse-deterrent opioid prodrugs.
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Affiliation(s)
- Jeffrey A Gudin
- a Pain Management and Palliative Care, Englewood Hospital and Medical Center , Englewood , NJ , USA.,b Department of Anesthesiology, Icahn School of Medicine at Mt. Sinai , New York , NY , USA
| | - Srinivas R Nalamachu
- c International Clinical Research Institute , Overland Park , KS , USA.,d Temple University School of Medicine , Philadelphia , PA , USA
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13
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Verplaetse R, Henion J. Quantitative determination of opioids in whole blood using fully automated dried blood spot desorption coupled to on-line SPE-LC-MS/MS. Drug Test Anal 2015; 8:30-8. [DOI: 10.1002/dta.1927] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | - Jack Henion
- Q Solutions; 19 Brown Rd Ithaca NY 14850 USA
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14
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Stolbach A, Paziana K, Heverling H, Pham P. A Review of the Toxicity of HIV Medications II: Interactions with Drugs and Complementary and Alternative Medicine Products. J Med Toxicol 2015; 11:326-41. [PMID: 26036354 PMCID: PMC4547966 DOI: 10.1007/s13181-015-0465-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
For many patients today, HIV has become a chronic disease. For those patients who have access to and adhere to lifelong antiretroviral (ARV) therapy, the potential for drug-drug interactions has become a real and life-threatening concern. It is known that most ARV drug interactions occur through the cytochrome P450 (CYP) pathway. Medications for comorbid medical conditions, holistic supplements, and illicit drugs can be affected by CYP inhibitors and inducers and have the potential to cause harm and toxicity. Protease inhibitors (PIs) tend to inhibit CYP3A4, while most non-nucleoside reverse transcriptase inhibitors (NNRTIs) tend to induce the enzyme. As such, failure to adjust the dose of co-administered medications, such as statins and steroids, may lead to serious complications including rhabdomyolysis and hypercortisolism, respectively. Similarly, gastric acid blockers can decrease several ARV absorption, and warfarin doses may need to be adjusted to maintain therapeutic concentrations. Illicit drugs such as methylenedioxymethamphetamine (MDMA, "ecstasy") in combination with PIs lead to increased toxicity, while the concomitant administration of sedative drugs such as midazolam and alprazolam in patients taking PIs can result in prolonged sedation, delayed recovery, and increased length of stay. Even supplements like St. John's Wort can alter PI concentrations. In theory, any drug that is metabolized by CYP has potential for a pharmacokinetic drug-drug interaction with all PIs, cobicistat, and most NNRTIs. When adding a new medication to an ARV regimen, use of a drug-drug interaction software and/or consultation with a clinical pharmacist/pharmacologist or HIV specialist is recommended.
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Affiliation(s)
- Andrew Stolbach
- />Department of Emergency Medicine, Johns Hopkins Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287 USA
| | - Karolina Paziana
- />Department of Emergency Medicine, Johns Hopkins Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287 USA
| | - Harry Heverling
- />Department of Emergency Medicine, Johns Hopkins Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287 USA
| | - Paul Pham
- />Division of Infectious Diseases, Johns Hopkins University School of Medicine, 1830 East Monument Street, 4th floor, Baltimore, MD 21205 USA
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15
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Cone EJ, DePriest AZ, Heltsley R, Black DL, Mitchell JM, LoDico C, Flegel R. Prescription Opioids. IV: Disposition of Hydrocodone in Oral Fluid and Blood Following Single-Dose Administration. J Anal Toxicol 2015; 39:510-8. [PMID: 25962610 DOI: 10.1093/jat/bkv050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The Substance Abuse and Mental Health Services Administration (SAMHSA) is currently evaluating hydrocodone (HC) for inclusion in the Mandatory Guidelines for Federal Workplace Drug Testing Programs. This study evaluated the time course of HC, norhydrocodone (NHC), dihydrocodeine (DHC) and hydromorphone (HM) in paired oral fluid and whole blood specimens by liquid chromatography-tandem mass spectrometry (limit of quantitation = 1 ng/mL of oral fluid, 5 ng/mL of blood) over a 52-h period. A single dose of HC bitartrate, 20 mg, was administered to 12 subjects. Analyte prevalence was as follows: oral fluid, HC > NHC > DHC; and blood, HC > NHC. HM was not detected in any specimen. HC was frequently detected within 15 min in oral fluid and 30 min in blood. Mean oral fluid to blood (OF : BL) ratios and correlations were 3.2 for HC (r = 0.73) and 0.7 for NHC (r = 0.42). The period of detection for oral fluid exceeded blood at all evaluated thresholds. At a 1-ng/mL threshold for oral fluid, mean detection time was 30 h for HC and 18 h for NHC and DHC. This description of HC and metabolite disposition in oral fluid following single-dose administration provides valuable interpretive guidance of HC test results.
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Affiliation(s)
- Edward J Cone
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anne Z DePriest
- Aegis Sciences Corporation, 515 Great Circle Road, Nashville, TN 37228, USA University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | - Rebecca Heltsley
- Aegis Sciences Corporation, 515 Great Circle Road, Nashville, TN 37228, USA
| | - David L Black
- Aegis Sciences Corporation, 515 Great Circle Road, Nashville, TN 37228, USA Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN, USA
| | | | - Charles LoDico
- Division of Workplace Programs, Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
| | - Ron Flegel
- Division of Workplace Programs, Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
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16
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Farr SJ, Robinson CY, Rubino CM. Effects of food and alcohol on the pharmacokinetics of an oral, extended-release formulation of hydrocodone in healthy volunteers. Clin Pharmacol 2015; 7:1-9. [PMID: 25653563 PMCID: PMC4307648 DOI: 10.2147/cpaa.s70831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the pharmacokinetics, bioavailability, and safety of oral extended-release hydrocodone (HC-ER) when administered with food or alcohol. METHODS Two single-center, open-label, randomized, crossover studies were conducted in healthy volunteers. In a two-period food-interaction study, 12 subjects received HC-ER 20 mg after an overnight fast and a high-fat meal. In a three-period alcohol-interaction study, 30 naltrexone-blocked subjects received HC-ER 50 mg with a 0%, 20%, or 40% alcohol/orange juice solution after an overnight fast. Pharmacokinetic parameters were derived from plasma concentrations of hydrocodone and its metabolites. RESULTS Exposure to hydrocodone after HC-ER 20 mg was similar in the fed and fasted states, as assessed by area under the plasma concentration versus time curve from time of dosing to time of last detectable concentration (AUC0-t; 316.14 versus 311.94 ng · h/mL); relative bioavailability (Frel) was 101.74%. Differences (fed versus fasted) in hydrocodone mean maximum plasma concentration (Cmax; 28.86 versus 22.74 ng/mL) and median time to Cmax (tmax; 6 versus 8 hours) were not clinically significant. Administration of 20% alcohol with HC-ER 50 mg did not increase systemic exposure relative to 0% alcohol (AUC0-t 878 versus 832 ng · h/mL; Frel 105%) or result in clinically meaningful changes in Cmax (51.8 versus 46.3 ng/mL) or tmax (5.44 versus 6.16 hours). Administration with 40% alcohol increased AUC0-t (1,008 ng · h/mL versus 832 ng · h/mL; Frel 120%) and Cmax (109 versus 46.3 ng/mL), and shortened tmax (2.43 versus 6.16 hours). Adverse events occurred in 10.0%, 24.1%, and 66.7% of subjects after 0%, 20%, and 40% alcohol, respectively. CONCLUSION HC-ER can be administered without regard to meals. While there was no evidence of "dose-dumping" (an unintended, rapid release in a short time period of all or most of the hydrocodone from HC-ER), even with 40% alcohol, as with all opioids, alcohol should not be ingested while using HC-ER.
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Affiliation(s)
| | | | - Christopher M Rubino
- Institute for Clinical Pharmacodynamics, Latham, NY, USA
- School of Pharmacy and Pharmaceutical Sciences, The State University of New York, University at Buffalo, Buffalo, NY, USA
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17
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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