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Zeng S, Qing Q, Xu W, Yu S, Zheng M, Tan H, Peng J, Huang J. Personalized anesthesia and precision medicine: a comprehensive review of genetic factors, artificial intelligence, and patient-specific factors. Front Med (Lausanne) 2024; 11:1365524. [PMID: 38784235 PMCID: PMC11111965 DOI: 10.3389/fmed.2024.1365524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Precision medicine, characterized by the personalized integration of a patient's genetic blueprint and clinical history, represents a dynamic paradigm in healthcare evolution. The emerging field of personalized anesthesia is at the intersection of genetics and anesthesiology, where anesthetic care will be tailored to an individual's genetic make-up, comorbidities and patient-specific factors. Genomics and biomarkers can provide more accurate anesthetic protocols, while artificial intelligence can simplify anesthetic procedures and reduce anesthetic risks, and real-time monitoring tools can improve perioperative safety and efficacy. The aim of this paper is to present and summarize the applications of these related fields in anesthesiology by reviewing them, exploring the potential of advanced technologies in the implementation and development of personalized anesthesia, realizing the future integration of new technologies into clinical practice, and promoting multidisciplinary collaboration between anesthesiology and disciplines such as genomics and artificial intelligence.
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Affiliation(s)
- Shiyue Zeng
- Zhuzhou Clinical College, Jishou University, Jishou, China
| | - Qi Qing
- Zhuzhou Clinical College, Jishou University, Jishou, China
| | - Wei Xu
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Simeng Yu
- Zhuzhou Clinical College, Jishou University, Jishou, China
| | - Mingzhi Zheng
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Hongpei Tan
- Department of Radiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Junmin Peng
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Jing Huang
- Department of Anesthesiology, Zhuzhou Central Hospital, Zhuzhou, China
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Presto P, Sehar U, Kopel J, Reddy PH. Mechanisms of pain in aging and age-related conditions: Focus on caregivers. Ageing Res Rev 2024; 95:102249. [PMID: 38417712 DOI: 10.1016/j.arr.2024.102249] [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: 09/28/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/01/2024]
Abstract
Pain is a complex, subjective experience that can significantly impact quality of life, particularly in aging individuals, by adversely affecting physical and emotional well-being. Whereas acute pain usually serves a protective function, chronic pain is a persistent pathological condition that contributes to functional deficits, cognitive decline, and emotional disturbances in the elderly. Despite substantial progress that has been made in characterizing age-related changes in pain, complete mechanistic details of pain processing mechanisms in the aging patient remain unknown. Pain is particularly under-recognized and under-managed in the elderly, especially among patients with Alzheimer's disease (AD), Alzheimer's disease-related dementias (ADRD), and other age-related conditions. Furthermore, difficulties in assessing pain in patients with AD/ADRD and other age-related conditions may contribute to the familial caregiver burden. The purpose of this article is to discuss the mechanisms and risk factors for chronic pain development and persistence, with a particular focus on age-related changes. Our article also highlights the importance of caregivers working with aging chronic pain patients, and emphasizes the urgent need for increased legislative awareness and improved pain management in these populations to substantially alleviate caregiver burden.
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Affiliation(s)
- Peyton Presto
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Ujala Sehar
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jonathan Kopel
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - P Hemachandra Reddy
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Nutritional Sciences Department, College of Human Sciences, Texas Tech University, Lubbock, TX 79409, USA; Department of Speech, Language and Hearing Sciences, School Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Department of Public Health, School of Population and Public Health, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Neurology, Departments of School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA; Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Kraus MB, Bingham JS, Kekic A, Erickson C, Grilli CB, Seamans DP, Upjohn DP, Hentz JG, Clarke HD, Spangehl MJ. Does Preoperative Pharmacogenomic Testing of Patients Undergoing TKA Improve Postoperative Pain? A Randomized Trial. Clin Orthop Relat Res 2024; 482:291-300. [PMID: 37594401 PMCID: PMC10776165 DOI: 10.1097/corr.0000000000002767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/09/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Pharmacogenomics is an emerging and affordable tool that may improve postoperative pain control. One challenge to successful pain control is the large interindividual variability among analgesics in their efficacy and adverse drug events. Whether preoperative pharmacogenomic testing is worthwhile for patients undergoing TKA is unclear. QUESTIONS/PURPOSES (1) Are the results of preoperative pharmacogenetic testing associated with lower postoperative pain scores as measured by the Overall Benefit of Analgesic Score (OBAS)? (2) Do the results of preoperative pharmacogenomic testing lead to less total opioids given? (3) Do the results of preoperative pharmacogenomic testing lead to changes in opioid prescribing patterns? METHODS Participants of this randomized trial were enrolled from September 2018 through December 2021 if they were aged 18 to 80 years and were undergoing primary TKA under general anesthesia. Patients were excluded if they had chronic kidney disease, a history of chronic pain or narcotic use before surgery, or if they were undergoing robotic surgery. Preoperatively, patients completed pharmacogenomic testing (RightMed, OneOME) and a questionnaire and were randomly assigned to the experimental group or control group. Of 99 patients screened, 23 were excluded, one before randomization; 11 allocated patients in each group did not receive their allocated interventions for reasons such as surgery canceled, patients ultimately undergoing spinal anesthesia, and change in surgery plan. Another four patients in each group were excluded from the analysis because they were missing an OBAS report. This left 30 patients for analysis in the control group and 38 patients in the experimental group. The control and experimental groups were similar in age, gender, and race. Pharmacogenomic test results for patients in the experimental group were reviewed before surgery by a pharmacist, who recommended perioperative medications to the clinical team. A pharmacist also assessed for clinically relevant drug-gene interactions and recommended drug and dose selection according to guidelines from the Clinical Pharmacogenomics Implementation Consortium for each patient enrolled in the study. Patients were unaware of their pharmacogenomic results. Pharmacogenomic test results for patients in the control group were not reviewed before surgery; instead, standard perioperative medications were administered in adherence to our institutional care pathways. The OBAS (maximum 28 points) was the primary outcome measure, recorded 24 hours postoperatively. A two-sample t-test was used to compare the mean OBAS between groups. Secondary measures were the mean 24-hour pain score, total morphine milligram equivalent, and frequency of opioid use. Postoperatively, patients were assessed for pain with a VAS (range 0 to 10). Opioid use was recorded preoperatively, intraoperatively, in the postanesthesia care unit, and 24 hours after discharge from the postanesthesia care unit. Changes in perioperative opioid use based on pharmacogenomic testing were recorded, as were changes in prescription patterns for postoperative pain control. Preoperative characteristics were also compared between patients with and without various phenotypes ascertained from pharmacogenomic test results. RESULTS The mean OBAS did not differ between groups (mean ± SD 4.7 ± 3.7 in the control group versus 4.2 ± 2.8 in the experimental group, mean difference 0.5 [95% CI -1.1 to 2.1]; p = 0.55). Total opioids given did not differ between groups or at any single perioperative timepoint (preoperative, intraoperative, or postoperative). We found no difference in opioid prescribing pattern. After adjusting for multiple comparisons, no difference was observed between the treatment and control groups in tramadol use (41% versus 71%, proportion difference 0.29 [95% CI 0.05 to 0.53]; nominal p = 0.02; adjusted p > 0.99). CONCLUSION Routine use of pharmacogenomic testing for patients undergoing TKA did not lead to better pain control or decreased opioid consumption. Future studies might focus on at-risk populations, such as patients with chronic pain or those undergoing complex, painful surgical procedures, to test whether pharmacogenomic results might be beneficial in certain circumstances. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Molly B. Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Colby Erickson
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | | | - David P. Seamans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - David P. Upjohn
- Center for Regenerative Biotherapeutics, Mayo Clinic, Phoenix, AZ, USA
| | - Joseph G. Hentz
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Henry D. Clarke
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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Kamiya T, Hira D, Nakajima R, Shinoda K, Motomochi A, Morikochi A, Ikeda Y, Isono T, Akabane M, Ueshima S, Kakumoto M, Imai S, Morita SY, Terada T. Decreased Analgesic Effect of Tramadol in Japanese Patients with CYP2D6 Intermediate Metabolizers after Orthopedic Surgery. Biol Pharm Bull 2023; 46:907-913. [PMID: 37394642 DOI: 10.1248/bpb.b23-00030] [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: 07/04/2023]
Abstract
Tramadol is metabolized by CYP2D6 to an active metabolite, which in turn acts as an analgesic. This study aimed to investigate the impact of CYP2D6 genotype on the analgesic effect of tramadol in clinical practice. A retrospective cohort study was performed in patients treated with tramadol for postoperative pain after arthroscopic surgery for rotator cuff injury during April 2017-March 2019. The impact of CYP2D6 genotypes on the analgesic effects was assessed by the numeric rating scale (NRS) pain scoring and analyzed by the Mann-Whitney U test. Stepwise multiple linear regression analysis was performed to identify predictive factors for the area under the time-NRS curve (NRS-AUC), which was calculated using the linear trapezoidal method. Among the 85 enrolled Japanese patients, the number of phenotypes with CYP2D6 normal metabolizer (NM) and intermediate metabolizer (IM) was n = 69 (81.1%) and n = 16 (18.9%), respectively. The NRS and NRS-AUC in the IM group were significantly higher than those in the NM group until Day 7 (p < 0.05). The multiple linear regression analysis indicated that the CYP2D6 polymorphism was a prediction factor of the high NRS-AUC levels in Days 0-7 (β = 9.52, 95% CI 1.30-17.7). In IM patients, the analgesic effect of tramadol was significantly reduced one week after orthopedic surgery in clinical practice. Therefore, dose escalation of tramadol or the use of alternative analgesic medications can be recommended for IM patients.
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Affiliation(s)
- Takaki Kamiya
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital
- College of Pharmaceutical Sciences, Ritsumeikan University
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital
| | - Ryo Nakajima
- Department of Orthopedic Surgery, Shiga University of Medical Science
- Department of Orthopedic Surgery, Japan Community Health Care Organization Shiga Hospital
| | - Kazuha Shinoda
- College of Pharmaceutical Sciences, Ritsumeikan University
| | - Atsuko Motomochi
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Aya Morikochi
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Yoshito Ikeda
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Tetsuichiro Isono
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Michiya Akabane
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | | | - Mikio Kakumoto
- College of Pharmaceutical Sciences, Ritsumeikan University
| | - Shinji Imai
- Department of Orthopedic Surgery, Shiga University of Medical Science
| | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Tomohiro Terada
- Department of Pharmacy, Shiga University of Medical Science Hospital
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital
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Owonikoko SB, Suleiman JBA, Maibaka WK, Tasiu N. "What a man can do, a woman can do better": women farmers, livelihood and drug abuse in Adamawa State, northeastern Nigeria. J Ethn Subst Abuse 2023; 22:3-28. [PMID: 33511921 DOI: 10.1080/15332640.2021.1871694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Drug and substance abuse among female population is on the rise but yet to be given adequate scholarly attention. This study examines how women farmers in Adamawa State are engaging in drug and substance abuse to enhance their farming livelihood practices and the implications of their action for health and social cohesion around their communities. Using data collected from interviews and observations, the study discovered that rising female-breadwinning in the study area put a lot of pressure on women to engage in farming as owners, hired or eclectic farmers. To be able to withstand the stress of farming, some engage in the use of psychotropic stimulant substances to enhance their performance. The study also discovered that the most abused substances are cannabis and tramadol due to affordability and availability. On the other hand however, the study found out that increasing indulgence of women in substance abuse is already impacting on spousal relationship between the women indulging in substance abuse and their husbands. The study recommended that government of Adamawa State should enforce in full, the Adamawa State Unclassified (Local Substances) Abuse Law 2015 by establishing a rehabilitation center for correction and reformation of addicts in the state. Furthermore, it is also recommended that all stakeholders should give empowerment of women in the state serious attention.
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Affiliation(s)
| | | | | | - Nafisa Tasiu
- Modibbo Adama University of Technology, Yola, Nigeria.,Federal College of Education, Yola, Nigeria
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Nahid NA, Johnson JA. CYP2D6 pharmacogenetics and phenoconversion in personalized medicine. Expert Opin Drug Metab Toxicol 2022; 18:769-785. [PMID: 36597259 PMCID: PMC9891304 DOI: 10.1080/17425255.2022.2160317] [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: 10/18/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION CYP2D6 contributes to the metabolism of approximately 20-25% of drugs. However, CYP2D6 is highly polymorphic and different alleles can lead to impacts ranging from null to increase in activity. Moreover, there are commonly used drugs that potently inhibit the CYP2D6, thus causing 'phenoconversion' which can convert the genotypic normal metabolizer into phenotypic poor metabolizer. Despite growing literature on the clinical implications of non-normal CYP2D6 genotype and phenoconversion on patient-related outcomes, implementation of CYP2D6 pharmacogenetics and phenoconversion to guide prescribing is rare. This review focuses on providing the clinical importance of CYP2D6 pharmacogenetics and phenoconversion in precision medicine and summarizes the challenges and approaches to implement these into clinical practice. AREAS COVERED A literature search was performed using PubMed and clinical studies documenting the effects of CYP2D6 genotypes and/or CYP2D6 inhibitors on pharmacokinetics, pharmacodynamics or treatment outcomes of CYP2D6-metabolized drugs, and studies on implementation challenges and approaches. EXPERT OPINION Considering the extent and impact of genetic polymorphisms of CYP2D6, phenoconversion by the comedications, and contribution of CYP2D6 in drug metabolism, CYP2D6 pharmacogenetics is essential to ensure drug safety and efficacy. Utilization of proper guidelines incorporating both CYP2D6 pharmacogenetics and phenoconversion in clinical care assists in optimizing drug therapy.
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Affiliation(s)
- Noor A. Nahid
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of Florida College of Medicine, FL, USA
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Farley BJ, Awad ME, Anderson P, Esseili AS, Hruska J, Mostafa G, Saleh KJ. Opioid-Related Genetic Polymorphisms of Cytochrome P450 Enzymes after Total Joint Arthroplasty: A Focus on Drug-Drug-Gene Interaction with Commonly Coprescribed Medications. Orthop Clin North Am 2022; 53:361-375. [PMID: 36208880 DOI: 10.1016/j.ocl.2022.06.001] [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: 02/02/2023]
Abstract
Pharmacogenomic testing, together with the early detection of drug-drug-gene interactions (DDGI) before initiating opioids, can improve the selection of dosage and reduce the risk of adverse drug interactions and therapeutic failures following Total Joint Arthroplasty. The variants of CYP genes can mediate DDGI. Orthopedic surgeons should become familiar with the genetic aspect of opioid use and abuse, as well as the influence of the patient genetic makeup in opioid selection and response, and polymorphic variants in pain modulation.
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Affiliation(s)
- Brendan J Farley
- FAJR Scientific, Resident Research Partnership, 9308 Hickory Ridge Rd, Suite 301, Northville, MI, 48167, USA; Department of Orthopaedic Surgery, West Virginia University, 6040 University Town Centre Dr Drive, Morgantown, WV 26501, USA
| | - Mohamed E Awad
- FAJR Scientific, Resident Research Partnership, 9308 Hickory Ridge Rd, Suite 301, Northville, MI, 48167, USA; NorthStar Anesthesia, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA; Michigan State University College of Osteopathic Medicine, 965 Wilson Rd, East Lansing, MI 48824, USA
| | - Paige Anderson
- FAJR Scientific, Resident Research Partnership, 9308 Hickory Ridge Rd, Suite 301, Northville, MI, 48167, USA; Cedarville University, 251 N Main St, Cedarville, OH 45314, USA
| | - Ali S Esseili
- FAJR Scientific, Resident Research Partnership, 9308 Hickory Ridge Rd, Suite 301, Northville, MI, 48167, USA; University of Michigan, 4901 Evergreen Rd, Dearborn, MI 48128, USA
| | - Justin Hruska
- NorthStar Anesthesia, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA; Department of Anesthesiology, Wayne State University- Detroit Medical Center, 4201 St Antoine Street, Detroit, MI, 48201, USA
| | - Gamal Mostafa
- Wayne State University, School of Medicine, 3990 John R St, Detroit, MI 48201, USA
| | - Khaled J Saleh
- FAJR Scientific, Resident Research Partnership, 9308 Hickory Ridge Rd, Suite 301, Northville, MI, 48167, USA; Michigan State University College of Osteopathic Medicine, 965 Wilson Rd, East Lansing, MI 48824, USA; Department of Surgery, John D. Dingell VA Medical Center, 4646 John R St, Detroit, MI 48201, USA..
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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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McDonnell JM, Rigney B, Storme J, Ahern DP, Cunniffe G, Butler JS. Pharmacogenetic profiling and individualised therapy in the treatment of degenerative spinal conditions. Ir J Med Sci 2022:10.1007/s11845-022-03112-9. [PMID: 35962253 DOI: 10.1007/s11845-022-03112-9] [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: 06/11/2022] [Accepted: 07/20/2022] [Indexed: 10/15/2022]
Abstract
Patients presenting with degenerative spinal changes are often poor surgical candidates due to associated co-morbidities, frailty, or sarcopenia. Additionally, surgeries of a degenerative spine can prove difficult due to the distortion of normal surgical anatomy. Therefore, many patients are managed conservatively with a variety of modalities, including over-the-counter and prescription medications. Nevertheless, several patients do not experience adequate relief from pain with analgesic medications, precipitating multiple hospital visits, and usage of resources. As a result, back pain is regarded as a major economic burden, with total costs of associated treatment exceeding $100 billion annually. Pharmacogenetics is a relatively novel method of evaluating an individual's response to analgesic medications, through analysis of germline polymorphisms. It entails obtaining a genetic sample, often via buccal swab or peripheral blood sample, and genetic analysis achieved through either polymerase chain reaction +/- Sanger sequencing, microassays, restriction length fragment polymorphism analysis, or genetic library preparation and next generation sequencing. The potential efficacy of pharmacogenetic analysis has been highlighted across several specialities to date. However, a paucity of evidence exists regarding spine surgery populations. Nevertheless, regular prospective pharmacogenetic analysis may ultimately prove beneficial when concerning degenerative spinal cohorts due to aforementioned surgical and economic considerations. The purpose of this narrative review is to outline how metaboliser profile variants affect the pharmacokinetics of specific analgesia used to treat back pain, and to discuss the current potential and limitations of employing regular pharmacogenetic analysis for spine surgery populations with degenerative conditions.
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Affiliation(s)
- Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland.
| | - Brian Rigney
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland
| | - James Storme
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland
| | - Daniel P Ahern
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland.,School of Medicine, Trinity College, Dublin, Ireland
| | - Gráinne Cunniffe
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland
| | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Eccles St., Dublin, D07 R2WY, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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11
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Baldo BA. Current research in pathophysiology of opioid-induced respiratory depression, neonatal opioid withdrawal syndrome, and neonatal antidepressant exposure syndrome. Curr Res Toxicol 2022; 3:100078. [PMID: 35734228 PMCID: PMC9207297 DOI: 10.1016/j.crtox.2022.100078] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/20/2022] [Accepted: 06/01/2022] [Indexed: 01/29/2023] Open
Abstract
Respiratory depression (RD) is the primary cause of death due to opioids. Opioids bind to mu (µ)-opioid receptors (MORs) encoded by the MOR gene Oprm1, widely expressed in the central and peripheral nervous systems including centers that modulate breathing. Respiratory centers are located throughout the brainstem. Experiments with Oprm1-deleted knockout (KO) mice undertaken to determine which sites are necessary for the induction of opioid-induced respiratory depression (OIRD) showed that the pre-Bötzinger complex (preBötC) and the pontine Kölliker-Fuse nucleus (KF) contribute equally to OIRD but RD was not totally eliminated. Morphine showed a differential influence on preBötC and KF neurons - low doses attenuated RD following deletion of MORs from preBötC neurons and an increase in apneas after high doses whereas deletion of MORs from KF neurons but not the preBötC attenuated RD at both high and low doses. In other KO mice studies, morphine administration after deletion of Oprm1 from both the preBötC and the KF/PBN neurons, led to the conclusion that both respiratory centres contribute to OIRD but the preBötC predominates. MOR-mediated post-synaptic activation of GIRK potassium channels has been implicated as a cause of OIRD. A complementary mechanism in the preBötC involving KCNQ potassium channels independent of MOR signaling has been described. Recent experiments in rats showing that morphine depresses normal, but not gasping breathing, cast doubt on the belief that eupnea, sighs, and gasps, are under the control of preBötC neurons. Methadone, administered to alleviate symptoms of neonatal opioid withdrawal syndrome (NOWES), desensitized rats to OIRD. Protection lost between postnatal days 1 and 2 coincides with the preBötC becoming the dominant generator of respiratory rhythm. Neonatal antidepressant exposure syndrome (NADES) and serotonin toxicity (ST) show similarities including RD. Enzyme CYP2D6 involved in opioid detoxification is polymorphic. Individuals of different CYP2D6 genotype may show increased, decreased, or no enzyme activity, contributing to the variability of patient responses to different opioids and OIRD.
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Key Words
- AAV, adeno-associated virus
- CDC, Centers for Disease control and prevention
- CTAP, MOR agonist (D-Phe-Cys-Tyr-D-Trp-Arg-Thr-Pen-Thr-NH2)
- DAMGO, synthetic specific MOR agonist [D-Ala2, N-MePhe4, Gly-ol]-enkephalin
- DRG, dorsal respiratory group
- FDA, Food and Drug Administration
- GIRK, G protein-gated inwardly-rectifying potassium (K+)
- GPCR, G protein-coupled receptor
- KCNQ, voltage-gated potassium (Kv) channels in the KCNQ (Kv7) family
- KF, Kölliker-Fuse nucleus
- Kölliker-Fuse nucleus and opioid-induced respiratory depression
- MOR, mu opioid receptor
- NADES, neonatal antidepressant exposure syndrome
- NAS, neonatal abstinence syndrome
- NIH, National Institutes of Health
- NK-1R, neurokinin-1 receptor
- NOWES, neonatal opioid withdrawal syndrome
- Neonatal opioid withdrawal syndrome
- Neural mediation of opioid-induced respiratory depression
- OAD, opioid analgesic drug
- OIRD, opioid-induced respiratory depression
- PBL, lateral parabrachial
- PBN, parabrachial nucleus
- PRG, pontine respiratory group
- Pathophysiology of opioid-induced respiratory depression
- Pre-Bötzinger complex and opioid-induced respiratory depression
- RD, respiratory depression
- TACR1, tachykinin receptor 1
- VRG, ventral respiratory group
- preBötC, pre-Bötzinger complex
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Affiliation(s)
- Brian A. Baldo
- Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia
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12
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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 PMCID: PMC8249478 DOI: 10.1002/cpt.2149] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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, TN, USA
| | - Andrew A. Monte
- University of Colorado School of Medicine, Department of Emergency Medicine & Colorado Center for Personalized Medicine, Aurora, CO, USA
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Kelly E. Caudle
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Evan D. Kharasch
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kanas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Henry M. Dunnenberger
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - J. Steven Leeder
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City, Kanas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - John T. Callaghan
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Caroline Flora Samer
- Clinical Pharmacology and Toxicology Department, Geneva University Hospitals, Switzerland
| | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Cyrine E. Haidar
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Sara L. Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University Medical Center, Nashville, TN, 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, CT, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Daniel J. Müller
- Campbell Family Mental Health Research Institute of CAMH, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Cynthia A. Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, 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
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
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13
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El Desoky ES. Therapeutic Dilemma in personalized medicine. Curr Rev Clin Exp Pharmacol 2021; 17:94-102. [PMID: 34455947 DOI: 10.2174/1574884716666210525153454] [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: 10/24/2020] [Revised: 02/24/2021] [Accepted: 03/03/2021] [Indexed: 11/22/2022]
Abstract
The practice of medicine depends over a long time on identifying therapies that target an entire population. The increase in scientific knowledge over the years has led to the gradual change towards individualization and personalization of drug therapy. The hope of this change is to achieve a better clinical response to given medications and reduction of their adverse effects. Tailoring of medicine on the road of personalized medicine considers molecular and genetic mapping of the individual. However, many factors still impede the smooth application of personalized medicine and represent challenges or limitations in its achievement. In this article, we put some clinical examples that show dilemmas in the application of personalized medicine such as opioids in pain control, fluoropyrimidines in malignancy, clopidogrel as antiplatelet therapy and oral hypoglycemic drugs in Type2 diabetes in adults. Shaping the future of medicine through the application of personalized medicine for a particular patient needs to put into consideration many factors such as patient's genetic makeup and life style, pathology of the disease and dynamic changes in its course as well as interactions between administered drugs and their effects on metabolizing enzymes. We hope in the coming years, the personalized medicine will foster changes in health care system in the way not only to treat patients but also to prevent diseases.
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Affiliation(s)
- Ehab S El Desoky
- Pharmacology department. Faculty of Medicine, Assiut University, Assiut. Egypt
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14
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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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15
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Abstract
Abstract
Aims
As an analgesic that acts upon the central nervous system (CNS), tramadol has gained popularity in treating moderate to severe pain. Recently, it has been increasingly reported as a drug of misuse with intentional overdoses or intoxications. This review focuses on tramadol intoxication in humans and its effects on different systems.
Subject and method
This narrative review provides a comprehensive view of the pharmacokinetics, mechanism of action, and incidence of tramadol toxicity with an in-depth look at its side effects. In addition, the main approaches to the management of tramadol poisoning are described.
Results
Tramadol poisoning can affect multiple organ systems: gastrointestinal, central nervous system (seizure, CNS depression, low-grade coma, anxiety, and over time anoxic brain damage), cardiovascular system (palpitation, mild hypertension to life-threatening complications such as cardiopulmonary arrest), respiratory system, renal system (renal failure with higher doses of tramadol intoxication), musculoskeletal system (rhabdomyolysis), endocrine system (hypoglycemia), as well as, cause serotonin syndrome. Seizure, a serious nervous disturbance, is more common in tramadol intoxication than with other opioids. Fatal tramadol intoxications are uncommon, except in ingestion cases concurrent with other medications, particularly CNS depressants, most commonly benzodiazepines, and ethanol.
Conclusion
With the increasing popularity of tramadol, physicians must be aware of its adverse effects, substantial abuse potential, and drug interactions, to weigh its risk–benefit ratio for pain management. Alternative therapies might be considered in patients with a previous overdose history to reduce risks for adverse outcomes.
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16
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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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17
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Rollinson V, Turner R, Pirmohamed M. Pharmacogenomics for Primary Care: An Overview. Genes (Basel) 2020; 11:E1337. [PMID: 33198260 PMCID: PMC7696803 DOI: 10.3390/genes11111337] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022] Open
Abstract
Most of the prescribing and dispensing of medicines happens in primary care. Pharmacogenomics (PGx) is the study and clinical application of the role of genetic variation on drug response. Mounting evidence suggests PGx can improve the safety and/or efficacy of several medications commonly prescribed in primary care. However, implementation of PGx has generally been limited to a relatively few academic hospital centres, with little adoption in primary care. Despite this, many primary healthcare providers are optimistic about the role of PGx in their future practice. The increasing prevalence of direct-to-consumer genetic testing and primary care PGx studies herald the plausible gradual introduction of PGx into primary care and highlight the changes needed for optimal translation. In this article, the potential utility of PGx in primary care will be explored and on-going barriers to implementation discussed. The evidence base of several drug-gene pairs relevant to primary care will be outlined with a focus on antidepressants, codeine and tramadol, statins, clopidogrel, warfarin, metoprolol and allopurinol. This review is intended to provide both a general introduction to PGx with a more in-depth overview of elements relevant to primary care.
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18
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Babayeva M, Loewy Z. Repurposing Drugs for COVID-19: Pharmacokinetics and Pharmacogenomics of Chloroquine and Hydroxychloroquine. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:531-542. [PMID: 33122936 PMCID: PMC7591012 DOI: 10.2147/pgpm.s275964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/06/2020] [Indexed: 12/27/2022]
Abstract
Background A new coronavirus SARS-CoV-2 has been identified as the etiological agent of the severe acute respiratory syndrome, COVID-19, the source and cause of the 2019–20 coronavirus pandemic. Hydroxychloroquine and chloroquine have gathered extraordinary attention as therapeutic candidates against SARS-CoV-2 infections. While there is growing scientific data on the therapeutic effect, there is also concern for toxicity of the medications. The therapy of COVID-19 by hydroxychloroquine and chloroquine is off-label. Studies to analyze the personalized effect and safety are lacking. Methods A review of the literature was performed using Medline/PubMed/Embase database. A variety of keywords were employed in keyword/title/abstract searches. The electronic search was followed by extensive hand searching using reference lists from the identified articles. Results A total of 126 results were obtained after screening all sources. Mechanisms underlying variability in drug concentrations and therapeutic response with chloroquine and hydroxychloroquine in mediating beneficial and adverse effects of chloroquine and hydroxychloroquine were reviewed and analyzed. Pharmacogenomic studies from various disease states were evaluated to elucidate the role of genetic variation in drug response and toxicity. Conclusion Knowledge of the pharmacokinetics and pharmacogenomics of chloroquine and hydroxychloroquine is necessary for effective and safe dosing and to avoid treatment failure and severe complications.
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Affiliation(s)
| | - Zvi Loewy
- Touro College of Pharmacy, New York, NY, USA.,New York Medical College, Valhalla, NY, USA
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19
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Packiasabapathy S, Rangasamy V, Horn N, Hendrickson M, Renschler J, Sadhasivam S. Personalized pediatric anesthesia and pain management: problem-based review. Pharmacogenomics 2020; 21:55-73. [PMID: 31849281 DOI: 10.2217/pgs-2019-0108] [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
Pharmacogenetics, the genetic influence on the interpersonal variability in drug response, has enabled tailored pharmacotherapy and emerging 'personalized medicine.' Although oncology spearheaded the clinical implementation of personalized medicine, other specialties are rapidly catching up. In anesthesia, classical examples of genetically mediated idiosyncratic reactions have been long known (e.g., malignant hyperthermia and prolonged apnea after succinylcholine). The last two decades have witnessed an expanding body of pharmacogenetic evidence in anesthesia. This review highlights some of the prominent pharmacogenetic associations studied in anesthesia and pain management, with special focus on pediatric anesthesia.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Nicole Horn
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Michele Hendrickson
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Janelle Renschler
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
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20
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Patel JN, Hamadeh IS. Pharmacogenomics-guided opioid management. BMJ Support Palliat Care 2020; 10:374-378. [PMID: 32826269 DOI: 10.1136/bmjspcare-2020-002589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Jai N Patel
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Issam S Hamadeh
- Department of Cancer Pharmacology & Pharmacogenomics, Levine Cancer Institute, Charlotte, North Carolina, USA
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21
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Bugada D, Lorini LF, Fumagalli R, Allegri M. Genetics and Opioids: Towards More Appropriate Prescription in Cancer Pain. Cancers (Basel) 2020; 12:cancers12071951. [PMID: 32708424 PMCID: PMC7409018 DOI: 10.3390/cancers12071951] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/16/2020] [Indexed: 12/26/2022] Open
Abstract
Opioids are extensively used in patients with cancer pain; despite their efficacy, several patients can experience ineffective analgesia and/or side effects. Pharmacogenetics is a new approach to drug prescription based on the “personalized-medicine” concept, i.e., the ability of tailoring treatments to each individual’s genetic/genomic profile. Pharmacogenetics aims to identify specific genetic variants that influence pharmacokinetics and pharmacodynamics of drugs, better determining their effectiveness/safety profile. Opioid response is a complex scenario, but some gene variants have shown a correlation with pain sensitivity, as well as with opioid metabolism and clinical efficacy/adverse events. Although questions remain unanswered, some of these gene variants may already be used to identify specific patients’ phenotypes that are more prone to experience better clinical response (i.e., better analgesia and/or less adverse events). Once adopted, this approach to opioid prescription may improve a patient’s outcome. This review summarizes the available data on genetic variants and opioid response: we will focus on basic pharmacogenetic and its impact in the clinical scenario discussing how they may lead to more appropriate opioid prescription in cancer patients.
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Affiliation(s)
- Dario Bugada
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy;
- Italian Pain Group;
- Correspondence:
| | - Luca F. Lorini
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy;
- Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Massimo Allegri
- Italian Pain Group;
- Pain Therapy Service—Fondazione Policlinico Monza, 20900 Monza, Italy
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22
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Layne KA, Dargan PI, Dines AM, Leaper C, Yates C, Hovda KE, Heyerdahl F, Archer JRH, Giraudon I, Wood DM. Acute toxicity related to misuse (nonmedical use) of tramadol: Experience of the European Drug Emergencies Network Plus. Br J Clin Pharmacol 2020; 87:1668-1675. [PMID: 32503085 DOI: 10.1111/bcp.14408] [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: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 01/09/2023] Open
Abstract
Following the development of the tramadol crisis currently affecting countries in the Middle East, and Africa, there has been increasing international interest in the regulation of tramadol. This study investigates the misuse of tramadol in patients presenting to emergency departments across Europe. Data from 32 emergency departments in 21 countries were extracted from the Euro-DEN Plus database for the 4-year period from 1 January 2014 to 31 December 2017. Of the reported 24,957 emergency department presentations, tramadol misuse was reported in 105 (0.4% presentations). Tramadol misuse was most common in Bratislava (Slovakia; n = 11, 7.5% of all presentations to this centre), Riga (Latvia; n = 4, 4.9%) and Munich (Germany; n = 17, 2.9%). On arrival, 14 (13.3%) of presentations were in coma/Glasgow coma score ≤ 8 and 9 of these had a respiratory rate <12 breaths/min. These presentations potentially pose a significant burden on emergency departments with a large proportion requiring admission to hospital for ongoing care.
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Affiliation(s)
- Kerry A Layne
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Craig Leaper
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, UK
| | - Christopher Yates
- Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Mallorca, Spain
| | - Knut Erik Hovda
- The Norwegian CBRNe Centre of Medicine, Oslo University Hospital, Oslo, Norway
| | - Fridtjof Heyerdahl
- Prehospital Division, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Isabelle Giraudon
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK
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23
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Raj K, Chawla P, Singh S. Neurobehavioral Consequences Associated with Long Term Tramadol Utilization and Pathological Mechanisms. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:758-768. [DOI: 10.2174/1871527318666191112124435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/17/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023]
Abstract
:
Tramadol is a synthetic analog of codeine used to treat pain of moderate to severe intensity
and is reported to have neurotoxic potential. At therapeutic dose, tramadol does not cause major side
effects in comparison to other opioid analgesics, and is useful for the management of neurological
problems like anxiety and depression. Long term utilization of tramadol is associated with various neurological
disorders like seizures, serotonin syndrome, Alzheimer’s disease and Parkinson’s disease.
Tramadol produces seizures through inhibition of nitric oxide, serotonin reuptake and inhibitory effects
on GABA receptors. Extensive tramadol intake alters redox balance through elevating lipid peroxidation
and free radical leading to neurotoxicity and produces neurobehavioral deficits. During Alzheimer’s
disease progression, low level of intracellular signalling molecules like cGMP, cAMP, PKC
and PKA affect both learning and memory. Pharmacologically tramadol produces actions similar to Selective
Serotonin Reuptake Inhibitors (SSRIs), increasing the concentration of serotonin, which causes
serotonin syndrome. In addition, tramadol also inhibits GABAA receptors in the CNS has been evidenced
to interfere with dopamine synthesis and release, responsible for motor symptoms. The reduced
level of dopamine may produce bradykinesia and tremors which are chief motor abnormalities in Parkinson’s
Disease (PD).
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Affiliation(s)
- Khadga Raj
- Neuroscience Division, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab 142001, India
| | - Pooja Chawla
- Department of Pharmaceutical Chemistry, ISF College of Pharmacy, Moga, Punjab 142001, India
| | - Shamsher Singh
- Neuroscience Division, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab 142001, India
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Ito S. Opioids in Breast Milk: Pharmacokinetic Principles and Clinical Implications. J Clin Pharmacol 2019; 58 Suppl 10:S151-S163. [PMID: 30248201 DOI: 10.1002/jcph.1113] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/01/2018] [Indexed: 12/14/2022]
Abstract
Safety of maternal drug therapy during breastfeeding may be assessed from estimated levels of drug exposure of the infant through milk. Pharmacokinetic (PK) principles predict that the lower the clearance is, the higher the infant dose via milk will be. Drugs with low clearance (<1 mL/[kg·min]) are likely to cause an infant exposure level greater than 10% of the weight-adjusted maternal dose even if the milk-to-plasma concentration ratio is 1. Most drugs cause relatively low-level exposure below 10% of the weight-adjusted maternal dose, but opioids require caution because of their potential for severe adverse effects. Furthermore, substantial individual variations of drug clearance exist in both mother and infant, potentially causing drug accumulation over time in some infants even if an estimated dose of the drug through milk is small. Such PK differences among individuals are known not only for codeine and tramadol through pharmacogenetic variants of CYP2D6 but also for non-CYP2D6 substrate opioids including oxycodone, indicating difficulties of eliminating PK uncertainty by simply replacing an opioid with another. Overall, opioid use for pain management during labor and delivery and subsequent short-term use for 2-3 days are compatible with breastfeeding. In contrast, newly initiated and prolonged maternal opioid therapy must follow a close monitoring program of the opioid-naive infants. Until more safety data become available, treatment duration of newly initiated opioids in the postpartum period should be limited to 2-3 days in unsupervised outpatient settings. Opioid addiction treatment with methadone and buprenorphine during pregnancy may continue into breastfeeding, but infant conditions must be monitored.
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Affiliation(s)
- Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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25
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Kaye AD, Garcia AJ, Hall OM, Jeha GM, Cramer KD, Granier AL, Kallurkar A, Cornett EM, Urman RD. Update on the pharmacogenomics of pain management. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2019; 12:125-143. [PMID: 31308726 PMCID: PMC6613192 DOI: 10.2147/pgpm.s179152] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/09/2019] [Indexed: 12/30/2022]
Abstract
Pharmacogenomics is the study of genetic variants that impact drug effects through changes in a drug’s pharmacokinetics and pharmacodynamics. Pharmacogenomics is being integrated into clinical pain management practice because variants in individual genes can be predictive of how a patient may respond to a drug treatment. Pain is subjective and is considered challenging to treat. Furthermore, pain patients do not respond to treatments in the same way, which makes it hard to issue a consistent treatment regimen for all pain conditions. Pharmacogenomics would bring consistency to the subjective nature of pain and could revolutionize the field of pain management by providing personalized medical care tailored to each patient based on their gene variants. Additionally, pharmacogenomics offers a solution to the opioid crisis by identifying potentially opioid-vulnerable patients who could be recommended a nonopioid treatment for their pain condition. The integration of pharmacogenomics into clinical practice creates better and safer healthcare practices for patients. In this article, we provide a comprehensive history of pharmacogenomics and pain management, and focus on up to date information on the pharmacogenomics of pain management, describing genes involved in pain, genes that may reduce or guard against pain and discuss specific pain management drugs and their genetic correlations.
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Affiliation(s)
- Alan David Kaye
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Andrew Jesse Garcia
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - O Morgan Hall
- Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - George M Jeha
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Kelsey D Cramer
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Amanda L Granier
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, New Orleans, LA, USA
| | - Anusha Kallurkar
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
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A Single Site Population Study to Investigate CYP2D6 Phenotype of Patients with Persistent Non-Malignant Pain. ACTA ACUST UNITED AC 2019; 55:medicina55060220. [PMID: 31141989 PMCID: PMC6631257 DOI: 10.3390/medicina55060220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/17/2019] [Accepted: 05/23/2019] [Indexed: 01/08/2023]
Abstract
Background and Objectives: Codeine requires biotransformation by the CYP2D6 enzyme, encoded by the polymorphic CYP2D6 gene, to morphine for therapeutic efficacy. CYP2D6 phenotypes of poor, intermediate, and ultra-rapid metabolisers are at risk of codeine non-response and adverse drug reactions due to altered CYP2D6 function. The aim of this study was to determine whether genotype, inferred phenotype, and urinary and oral fluid codeine O-demethylation metabolites could predict codeine non-response following a short course of codeine. Materials and Methods: There were 131 Caucasians with persistent pain enrolled. Baseline assessments were recorded, prohibited medications ceased, and DNA sampling completed before commencing codeine 30 mg QDS for 5 days. Day 4 urine samples were collected 1–2 h post morning dose for codeine O-demethylation metabolites analysis. Final pain assessments were conducted on day 5. Results: None of the poor, intermediate, ultra-rapid metabolisers and only 24.5% of normal metabolisers responded to codeine. A simple scoring system to predict analgesic response from day 4 urinary metabolites was devised with overall prediction success of 79% (sensitivity 0.8, specificity 0.78) for morphine and 79% (sensitivity 0.76, specificity 0.83) for morphine:creatinine ratio. Conclusions: In conclusion, this study provides tentative evidence that day 4 urinary codeine O-demethylation metabolites could predict non-response following a short course of codeine and could be utilised in the clinical assessment of codeine response at the point of care to improve analgesic efficacy and safety in codeine therapy. We offer a scoring system to predict codeine response from urinary morphine and urinary morphine:creatinine ratio collected on the morning of day 4 of codeine 30 mg QDS, but this requires validation before it could be considered for use to assess codeine response in clinical practice.
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Alizadeh R, Aghsaie Fard Z. Renal impairment and analgesia: From effectiveness to adverse effects. J Cell Physiol 2019; 234:17205-17211. [PMID: 30916404 DOI: 10.1002/jcp.28506] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/23/2022]
Abstract
Kidney pain is one of the clinically significant features of renal dysfunction. Mild to severe pain is seen in the lower back area. Painkillers are mostly recommended in these cases to relieve the symptom. Yet, several analgesics are associated with side effects that can worsen the state of the disease. This review is based on the studies conducted in these aspects analgesics used to treat kidney pain and their effectiveness, renal consequences of postoperative analgesia, and pharmacogenetics of these palliatives are briefly summarized in this paper.
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Affiliation(s)
- Reza Alizadeh
- Department of Anesthesiology and Intensive Care, AJA University of Medical Sciences, Tehran, Iran
| | - Ziba Aghsaie Fard
- Department of Internal Medicine, School of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
PURPOSE OF REVIEW The current review will discuss the current literature on genetics of pain and analgesia, with special emphasis on perioperative setting. We will also discuss pharmacogenetics-based management guidelines, current clinical status and future perspectives. RECENT FINDINGS Recent literature suggests that the interindividual variability in pain and postoperative analgesic response is at least in part because of one's genetic make-up. Some of the well characterized polymorphisms that are associated with surgical pain and opioid-related postoperative adverse outcomes are described in catechol-O-methyl transferase, CYP2D6 and μ-opioid receptor (OPRM1), ATP-binding cassette subfamily B member 1, ABCC3, organic cation transporter 1 genes. Clinical Pharmacogenetics Implementation Consortium has put forth recommendations on CYP2D6 genotype-based opioid selection and dosing. The list of drug-gene pairs studied continue to expand. SUMMARY Pharmacogenetic approach marks the dawn of personalized pain medicine both in perioperative and chronic pain settings.
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30
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Smith DM, Weitzel KW, Elsey AR, Langaee T, Gong Y, Wake DT, Duong BQ, Hagen M, Harle CA, Mercado E, Nagoshi Y, Newsom K, Wright A, Rosenberg EI, Starostik P, Clare-Salzler MJ, Schmidt SO, Fillingim RB, Johnson JA, Cavallari LH. CYP2D6-guided opioid therapy improves pain control in CYP2D6 intermediate and poor metabolizers: a pragmatic clinical trial. Genet Med 2019; 21:1842-1850. [PMID: 30670877 PMCID: PMC6650382 DOI: 10.1038/s41436-018-0431-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/20/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE CYP2D6 bioactivates codeine and tramadol, with intermediate and poor metabolizers (IMs and PMs) expected to have impaired analgesia. This pragmatic proof-of-concept trial tested the effects of CYP2D6-guided opioid prescribing on pain control. METHODS Participants with chronic pain (94% on an opioid) from seven clinics were enrolled into CYP2D6-guided (n = 235) or usual care (n = 135) arms using a cluster design. CYP2D6 phenotypes were assigned based on genotype and CYP2D6 inhibitor use, with recommendations for opioid prescribing made in the CYP2D6-guided arm. Pain was assessed at baseline and 3 months using PROMIS® measures. RESULTS On stepwise multiple linear regression, the primary outcome of composite pain intensity (composite of current pain and worst and average pain in the past week) among IM/PMs initially prescribed tramadol/codeine (n = 45) had greater improvement in the CYP2D6-guided versus usual care arm (-1.01 ± 1.59 vs. -0.40 ± 1.20; adj P = 0.016); 24% of CYP2D6-guided versus 0% of usual care participants reported ≥30% (clinically meaningful) reduction in the composite outcome. In contrast, among normal metabolizers prescribed tramadol or codeine at baseline, there was no difference in the change in composite pain intensity at 3 months between CYP2D6-guided (-0.61 ± 1.39) and usual care (-0.54 ± 1.69) groups (adj P = 0.540). CONCLUSION These data support the potential benefits of CYP2D6-guided pain management.
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Affiliation(s)
- D Max Smith
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Clinical and Translational Science Institute, 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, College of Pharmacy, 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, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Benjamin Q Duong
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Melanie Hagen
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christopher A Harle
- Department of Health Policy and Management, Indiana University, Indianapolis, IN, USA
| | - Elvira Mercado
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ying Nagoshi
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kimberly Newsom
- University of Florida Health Pathology Laboratories, Gainesville, FL, USA
| | - Ashleigh Wright
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Eric I Rosenberg
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Petr Starostik
- University of Florida Health Pathology Laboratories, Gainesville, FL, USA.,Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Siegfried O Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Roger B Fillingim
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA.,Department of Community Dentistry and Behavioral Science, College of Dentistry, Gainesville, FL, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA. .,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA. .,Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA.
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31
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Lam YWF. Principles of Pharmacogenomics. Pharmacogenomics 2019. [DOI: 10.1016/b978-0-12-812626-4.00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Zhou S, Skaar DJ, Jacobson PA, Huang RS. Pharmacogenomics of Medications Commonly Used in the Intensive Care Unit. Front Pharmacol 2018; 9:1436. [PMID: 30564130 PMCID: PMC6289166 DOI: 10.3389/fphar.2018.01436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022] Open
Abstract
In the intensive care unit (ICU) setting, where highly variable and insufficient drug efficacies, as well as frequent and unpredictable adverse drug reactions (ADRs) occur, pharmacogenomics (PGx) offers an opportunity to improve health outcomes. However, PGx has not been fully evaluated in the ICU, partly due to lack of knowledge of how genetic markers may affect drug therapy. To fill in this gap, we conducted a review to summarize the PGx information for the medications commonly encountered in the ICU.
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Affiliation(s)
- Shuqin Zhou
- Department of Emergency and Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Debra J Skaar
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - R Stephanie Huang
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
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Palmer GM, Anderson BJ, Linscott DK, Paech MJ, Allegaert K. Tramadol, breast feeding and safety in the newborn. Arch Dis Child 2018; 103:1110-1113. [PMID: 29599166 DOI: 10.1136/archdischild-2017-313786] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Greta M Palmer
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital; University of Melbourne and Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Brian J Anderson
- Department of Anaesthesiology, Faculty of Medicine and Health Science, University of Auckland, Auckland, New Zealand
| | - David K Linscott
- Department of Anaesthesia, Christchurch Hospital; University of Otago, Christchurch, New Zealand
| | - Michael J Paech
- The University of Western Australia, Perth, Western Australia, Australia.,Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery and Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Packiasabapathy S, Sadhasivam S. Gender, genetics, and analgesia: understanding the differences in response to pain relief. J Pain Res 2018; 11:2729-2739. [PMID: 30519077 PMCID: PMC6235329 DOI: 10.2147/jpr.s94650] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Genetic variations and gender contribute significantly to the large interpatient variations in opioid-related serious adverse effects and differences in pain relief with other analgesics. Opioids are the most commonly used analgesics to relieve moderate-to-severe postoperative pain. Narrow therapeutic index and unexplained large interpatient variations in opioid-related serious adverse effects and analgesia negatively affect optimal perioperative outcomes. In surgical, experimental, chronic, and neuropathic pain models, females have been reported to have more pain than males. This review focuses on literature evidence of differences in pain relief due to multiple genetic variations and gender of the patient.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA,
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA,
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35
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Patel JN, Wiebe LA, Dunnenberger HM, McLeod HL. Value of Supportive Care Pharmacogenomics in Oncology Practice. Oncologist 2018; 23:956-964. [PMID: 29622698 PMCID: PMC6156181 DOI: 10.1634/theoncologist.2017-0599] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/21/2018] [Indexed: 12/14/2022] Open
Abstract
Genomic medicine provides opportunities to personalize cancer therapy for an individual patient. Although novel targeted therapies prolong survival, most patients with cancer continue to suffer from burdensome symptoms including pain, depression, neuropathy, nausea and vomiting, and infections, which significantly impair quality of life. Suboptimal management of these symptoms can negatively affect response to cancer treatment and overall prognosis. The effect of genetic variation on drug response-otherwise known as pharmacogenomics-is well documented and directly influences an individual patient's response to antiemetics, opioids, neuromodulators, antidepressants, antifungals, and more. The growing body of pharmacogenomic data can now guide clinicians to select the safest and most effective supportive medications for an individual patient with cancer from the very first prescription. This review outlines a theoretical patient case and the implications of using pharmacogenetic test results to personalize supportive care throughout the cancer care continuum. IMPLICATIONS FOR PRACTICE Integration of palliative medicine into the cancer care continuum has resulted in increased quality of life and survival for patients with many cancer types. However, suboptimal management of symptoms such as pain, neuropathy, depression, and nausea and vomiting continues to place a heavy burden on patients with cancer. As demonstrated in this theoretical case, pharmacogenomics can have a major effect on clinical response to medications used to treat these conditions. Recognizing the value of supportive care pharmacogenomics in oncology and application into routine practice offers an objective choice for the safest and most effective treatment compared with the traditional trial and error method.
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Affiliation(s)
- Jai N Patel
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Lauren A Wiebe
- NorthShore University Health System, Evanston, Illinois, USA
| | | | - Howard L McLeod
- The DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, Florida, USA
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Impact of CYP genotype and inflammatory markers on the plasma concentrations of tramadol and its demethylated metabolites and drug tolerability in cancer patients. Eur J Clin Pharmacol 2018; 74:1461-1469. [PMID: 30051214 DOI: 10.1007/s00228-018-2527-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/16/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE Clinical responses to oral tramadol show a large variation in cancer patients. This study aimed to evaluate the impacts of cytochrome P450 (CYP) genotype and serum inflammatory markers on the plasma concentrations of tramadol and its demethylated metabolites and drug tolerability in cancer patients. METHODS The predose plasma concentrations of tramadol and its demethylated metabolites were determined at day 4 or later in 70 Japanese cancer patients treated with oral tramadol. The CYP genotypes, serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels, and the duration of tramadol treatment were evaluated. RESULTS The CYP2D6 genotype did not affect the plasma tramadol concentration. The plasma concentration of O-desmethyltramadol and its ratio to tramadol were lower in the CYP2D6 intermediate and poor metabolizer (IM + PM) group than in the normal metabolizer (NM) group (P = 0.002 and P = 0.023). The plasma concentration of N-desmethyltramadol and its ratio to tramadol were higher in the CYP2D6 IM + PM group than in the NM group (P = 0.001 and P = 0.001). The CYP2B6*6 and CYP3A5*3 alleles had no effect on the plasma concentrations of tramadol and its demethylated metabolites. The serum IL-6 and CRP levels were inversely correlated with the plasma concentration ratios of N-desmethyltramadol to tramadol and of N,O-didesmethyltramadol to O-desmethyltramadol. The serum IL-6 level was associated with the treatment duration of oral tramadol. CONCLUSIONS The CYP2D6 genotype but not the CYP2B6 and CYP3A5 genotypes affected the plasma concentrations of O- and N-desmethyltramadol through alteration of the tramadol metabolic pathway. The serum IL-6 level was associated with N-demethylation activity and tramadol tolerability.
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Rodieux F, Vutskits L, Posfay-Barbe KM, Habre W, Piguet V, Desmeules JA, Samer CF. When the Safe Alternative Is Not That Safe: Tramadol Prescribing in Children. Front Pharmacol 2018; 9:148. [PMID: 29556194 PMCID: PMC5844975 DOI: 10.3389/fphar.2018.00148] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023] Open
Abstract
Children represent a vulnerable population in which management of nociceptive pain is complex. Drug responses in children differ from adults due to age-related differences. Moreover, therapeutic choices are limited by the lack of indication for a number of analgesic drugs due to the challenge of conducting clinical trials in children. Furthermore the assessment of efficacy as well as tolerance may be complicated by children's inability to communicate properly. According to the World Health Organization, weak opioids such as tramadol and codeine, may be used in addition to paracetamol and ibuprofen for moderate nociceptive pain in both children and adults. However, codeine prescription has been restricted for the last 5 years in children because of the risk of fatal overdoses linked to the variable activity of cytochrome P450 (CYP) 2D6 which bioactivates codeine. Even though tramadol has been considered a safe alternative to codeine, it is well established that tramadol pharmacodynamic opioid effects, efficacy and safety, are also largely influenced by CYP2D6 activity. For this reason, the US Food and Drug Administration recently released a boxed warning regarding the use of tramadol in children. To provide safe and effective tramadol prescription in children, a personalized approach, with dose adaptation according to CYP2D6 activity, would certainly be the safest method. We therefore recommend this approach in children requiring chronic or recurrent nociceptive pain treatment with tramadol. In case of acute inpatients nociceptive pain management, prescribing tramadol at the minimal effective dose, in a child appropriate dosage form and after clear instructions are given to the parents, remains reasonable based on current data. In all other situations, morphine should be preferred for moderate to severe nociceptive pain conditions.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,Department of Basic Neuroscience, Faculty of Medicine, University of GenevaGeneva, Switzerland.,Division of Anesthesiology, Unit for Pediatric Anesthesia, Children's Hospitals of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Klara M Posfay-Barbe
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Children's Hospital of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Walid Habre
- Division of Anesthesiology, Unit for Pediatric Anesthesia, Children's Hospitals of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,Anesthesiological Investigations Unit, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Valérie Piguet
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of LausanneGeneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
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Faria J, Barbosa J, Moreira R, Queirós O, Carvalho F, Dinis-Oliveira RJ. Comparative pharmacology and toxicology of tramadol and tapentadol. Eur J Pain 2018; 22:827-844. [PMID: 29369473 DOI: 10.1002/ejp.1196] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2018] [Indexed: 12/18/2022]
Abstract
Moderate-to-severe pain represents a heavy burden in patients' quality of life, and ultimately in the society and in healthcare costs. The aim of this review was to summarize data on tramadol and tapentadol adverse effects, toxicity, potential advantages and limitations according to the context of clinical use. We compared data on the pharmacological and toxicological profiles of tramadol and tapentadol, after an extensive literature search in the US National Library of Medicine (PubMed). Tramadol is a prodrug that acts through noradrenaline and serotonin reuptake inhibition, with a weak opioid component added by its metabolite O-desmethyltramadol. Tapentadol does not require metabolic activation and acts mainly through noradrenaline reuptake inhibition and has a strong opioid activity. Such features confer tapentadol potential advantages, namely lower serotonergic, dependence and abuse potential, more linear pharmacokinetics, greater gastrointestinal tolerability and applicability in the treatment of chronic and neuropathic pain. Although more studies are needed to provide clear guidance on the opioid of choice, tapentadol shows some advantages, as it does not require CYP450 system activation and has minimal serotonergic effects. In addition, it leads to less side effects and lower abuse liability. However, in vivo and in vitro studies have shown that tramadol and tapentadol cause similar toxicological damage. In this context, it is important to underline that the choice of opioid should be individually balanced and a tailored decision, based on previous experience and on the patient's profile, type of pain and context of treatment. SIGNIFICANCE This review underlines the need for a careful prescription of tramadol and tapentadol. Although both are widely prescribed synthetic opioid analgesics, their toxic effects and potential dependence are not completely understood yet. In particular, concerning tapentadol, further research is needed to better assess its toxic effects.
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Affiliation(s)
- J Faria
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - J Barbosa
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - R Moreira
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal
| | - O Queirós
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal
| | - F Carvalho
- Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal
| | - R J Dinis-Oliveira
- Department of Sciences, IINFACTS, Institute of Research and Advanced Training in Health Sciences and Technologies, University Institute of Health Sciences (IUCS), CESPU, CRL, Gandra, Portugal.,Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy UCIBIO-REQUIMTE, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
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Loss-of-function polymorphisms in the organic cation transporter OCT1 are associated with reduced postoperative tramadol consumption. Pain 2017; 157:2467-2475. [PMID: 27541716 DOI: 10.1097/j.pain.0000000000000662] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The organic cation transporter OCT1 (SLC22A1) mediates uptake and metabolism of the active tramadol metabolite (+)O-desmethyltramadol in the liver. In this study, the influence of OCT1 genetic polymorphisms on pharmacokinetics and analgesic efficacy of tramadol in patients recovering from surgery was analyzed in addition to the CYP2D6 genotype. Postoperative patients who received tramadol through patient-controlled analgesia were enrolled. Genotypes resulting in 0, 1, or 2 active OCT1 alleles were determined as well as CYP2D6 genotypes. The primary endpoint was the 24-hour postoperative tramadol consumption in patients with 0 vs at least 1 active OCT1 allele. Secondary endpoint was the OCT1-dependent plasma concentration (areas under the concentration-time curves) of the active tramadol metabolite (+)O-desmethyltramadol. Of 205 patients, 19, 82, and 104 carried 0, 1, and 2 active OCT1 alleles, respectively. Cumulative tramadol consumption through patient-controlled analgesia was lowest in patients with 0 active OCT1 allele compared with the group of patients with 1 or 2 active alleles (343 ± 235 vs 484 ± 276 mg; P = 0.03). Multiple regression revealed that the number of active OCT1 alleles (P = 0.014), CYP2D6 (P = 0.001), pain scores (P < 0.001), and the extent of surgery (0.034) had a significant influence on tramadol consumption. Plasma areas under the concentration-time curves of (+)O-desmethyltramadol were 111.8 (95% confidence interval: 63.4-160.1), 80.2 (65.1-95.3), and 64.5 (51.9-77.2) h·ng·mL in carriers of 0, 1, or 2 active OCT1 alleles (P = 0.03). Loss of OCT1 function resulted in reduced tramadol consumption and increased plasma concentrations of (+)O-desmethyltramadol in patients recovering from surgery. Therefore, analyzing OCT1 next to CYP2D6 genotype might further improve future genotype-dependent dose recommendations for tramadol.
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Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics. Scand J Pain 2017; 17:193-200. [DOI: 10.1016/j.sjpain.2017.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
Abstract
Abstract
Background
As pain is often a comorbid condition, many patients use opioid analgesics in combination with several other drugs. This implies a generally increased risk of drug interactions, which along with inherent pharmacogenetic variability and other factors may cause differences in therapeutic response of opioids.
Aim
To provide an overview of interactions and pharmacogenetic variability of relevance for individual differences in effect and tolerability of opioid analgesics, which physicians and other healthcare professionals should be aware of in clinical practice.
Methods
The article was based on unsystematic searches in PubMed to identify literature highlighting the clinical impact of drug interactions and pharmacogenetics as sources of variable response of opioid analgesics.
Results
Cytochrome P450 (CYP)-mediated metabolism is an important process for both clinically relevant interactions and pharmacogenetic variability of several opioids. Concomitant use of CYP inhibitors (e.g. paroxetine, fluoxetine and bupropion) or inducers (e.g. carbamazepine, phenobarbital and phenytoin) could counteract the clinical effect or trigger side effects of analgesics in the same manner as genetically determined differences in CYP2D6-mediated metabolism of many opioids. Moreover, combination treatment with drugs that inhibit or induce P-glycoprotein (ABCB1), a blood-brain barrier efflux transporter, may alter the amount (‘dose’) of opioids distributed to the brain. At the pharmacodynamic level, it is crucial to be aware of the potential risk of interaction causing serotonergic syndrome when combining opioids and serotonergic drugs, in particular antidepressants inhibiting serotonin reuptake (SSRIs and SNRIs). Regarding pharmacogenetics at the receptor level of pain treatment, the knowledge is currently scarce, but an allelic variant of the μ1 opioid receptor (OPRM1) gene has been associated with higher dosage requirement to achieve analgesia.
Conclusions and implications
Drug interactions and pharmacogenetic differences may lead to therapeutic failure or serious side effects of opioid analgesics. Many interactions involve combinations with antidepressants and antiepileptics, which are highly relevant drugs in patients suffering from pain. To prevent unfavourable drug interactions it is important that clinicians pay close attention and use electronic drug interaction checkers when treatments are initiated or discontinued. For the management of issues related to pharmacogenetic differences, blood-based CYP genotyping is available as routine test at many laboratories, and provide a valuable tool for proper choice of drugs and doses for treatment of pain and other diseases.
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Owusu Obeng A, Hamadeh I, Smith M. Review of Opioid Pharmacogenetics and Considerations for Pain Management. Pharmacotherapy 2017; 37:1105-1121. [DOI: 10.1002/phar.1986] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine; Icahn School of Medicine at Mount Sinai; New York NY
- Pharmacy Department; The Mount Sinai Hospital; New York New York
- Division of General Internal Medicine; Department of Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Michael Smith
- University of Michigan College of Pharmacy; Ann Arbor Michigan
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Matic M, de Wildt SN, Tibboel D, van Schaik RHN. Analgesia and Opioids: A Pharmacogenetics Shortlist for Implementation in Clinical Practice. Clin Chem 2017. [DOI: 10.1373/clinchem.2016.264986] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
The use of opioids to alleviate pain is complicated by the risk of severe adverse events and the large variability in dose requirements. Pharmacogenetics (PGx) could possibly be used to tailor pain medication based on an individual's genetic background. Many potential genetic markers have been described, and the importance of genetic predisposition in opioid efficacy and toxicity has been demonstrated in knockout mouse models and human twin studies. Such predictors are especially of value for neonates and young children, in whom the assessment of efficacy or side effects is complicated by the inability of the patient to communicate this properly. The current problem is determining which of the many potential candidates to focus on for clinical implementation.
CONTENT
We systematically searched publications on PGx for opioids in 5 databases, aiming to identify PGx markers with sufficient robust data and high enough occurrence for potential clinical application. The initial search yielded 4257 unique citations, eventually resulting in 852 relevant articles covering 24 genes. From these genes, we evaluated the evidence and selected the most promising 10 markers: cytochrome P450 family 2 subfamily D member 6 (CYP2D6), cytochrome P450 family 3 subfamily A member 4 (CYP3A4), cytochrome P450 family 3 subfamily A member 5 (CYP3A5), UDP glucuronosyltransferase family 2 member B7 (UGT2B7), ATP binding cassette subfamily B member 1 (ABCB1), ATP binding cassette subfamily C member 3 (ABCC3), solute carrier family 22 member 1 (SLC22A1), opioid receptor kappa 1 (OPRM1), catechol-O-methyltransferase (COMT), and potassium voltage-gated channel subfamily J member 6 (KCNJ6). Treatment guidelines based on genotype are already available only for CYP2D6.
SUMMARY
The application of PGx in the management of pain with opioids has the potential to improve therapy. We provide a shortlist of 10 genes that are the most promising markers for clinical use in this context.
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Affiliation(s)
- Maja Matic
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center–Sophia Children Hospital, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, the Netherlands
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Zhou Y, Ingelman-Sundberg M, Lauschke VM. Worldwide Distribution of Cytochrome P450 Alleles: A Meta-analysis of Population-scale Sequencing Projects. Clin Pharmacol Ther 2017; 102:688-700. [PMID: 28378927 PMCID: PMC5600063 DOI: 10.1002/cpt.690] [Citation(s) in RCA: 386] [Impact Index Per Article: 55.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/28/2017] [Accepted: 03/11/2017] [Indexed: 12/23/2022]
Abstract
Genetic polymorphisms in cytochrome P450 (CYP) genes can result in altered metabolic activity toward a plethora of clinically important medications. Thus, single nucleotide variants and copy number variations in CYP genes are major determinants of drug pharmacokinetics and toxicity and constitute pharmacogenetic biomarkers for drug dosing, efficacy, and safety. Strikingly, the distribution of CYP alleles differs considerably between populations with important implications for personalized drug therapy and healthcare programs. To provide a global distribution map of CYP alleles with clinical importance, we integrated whole‐genome and exome sequencing data from 56,945 unrelated individuals of five major human populations. By combining this dataset with population‐specific linkage information, we derive the frequencies of 176 CYP haplotypes, providing an extensive resource for major genetic determinants of drug metabolism. Furthermore, we aggregated this dataset into spectra of predicted functional variability in the respective populations and discuss the implications for population‐adjusted pharmacological treatment strategies.
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Affiliation(s)
- Y Zhou
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Karolinska Institutet, Stockholm, Sweden
| | - M Ingelman-Sundberg
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Karolinska Institutet, Stockholm, Sweden
| | - V M Lauschke
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Karolinska Institutet, Stockholm, Sweden
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Patel JN, Villadolid J. Cancer Drug Delivery. PHARMACEUTICAL SCIENCES 2017. [DOI: 10.4018/978-1-5225-1762-7.ch008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Advancements in cancer drug delivery have led to the development of personalized oncology care through molecularly-driven targeted therapies. Understanding molecular and cellular mechanisms which drive tumor progression and resistance is critical in managing new treatment strategies which have shifted from empiric to biomarker-directed therapy selection. Biomarker-directed therapies have improved clinical outcomes in multiple malignancies as monotherapy and in combination with other treatment modalities, however the changing scope of treatment options presents new opportunities and challenges for research. Furthermore, pharmacogenetics may provide a rationale method of personalizing anticancer drug dosing and supportive care management for oncology patients. This chapter reviews biomarker classifications and pharmacogenetics in anticancer therapy and supportive care. Examples of biomarker-directed therapies and clinical assays, in addition to future directions of molecular profiling in oncology therapy management are discussed.
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Tverdohleb T, Dinc B, Knezevic I, Candido KD, Knezevic NN. The role of cytochrome P450 pharmacogenomics in chronic non-cancer pain patients. Expert Opin Drug Metab Toxicol 2016; 12:1303-1311. [PMID: 27388970 DOI: 10.1080/17425255.2016.1209482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pharmacogenomics is the field that studies an individualized treatment approach for patients' medication regimen that can impact drug safety, productivity, and personalized health care. Pharmacogenomics characterizes the genetic differences in metabolic pathways which can affect a patient's individual responses to drug treatments. Areas covered: The various responses to pharmacological agents are mainly determined by the different types of genetic variants of the CYP450. CYP2D6 polymorphism is well known for its variation in the metabolism of drugs from many therapeutic arenas, including some analgesic drugs such as codeine, hydromorphone, oxycodone and tramadol. Allele combinations determine the phenotypic expression, characterized as either: extensive metabolizer, intermediate metabolizer, ultra-rapid metabolizer and poor metabolizer. Expert opinion: The Human Genome Project (HGP) revolutionized the future of medicine and the way health care providers approach individualized patient treatment, and chronic pain management is one of those areas. The key findings in the literature appear to be related to the CYP2D6 expression and its high polymorphism influencing the metabolism of opioid medications, and the impact of that on the patient's therapeutic outcome thus exemplifying the importance of genetic testing for CYP2D6 in the process of physician therapeutic decision making.
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Affiliation(s)
- Tatiana Tverdohleb
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA
| | - Bora Dinc
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA
| | - Ivana Knezevic
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA
| | - Kenneth D Candido
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA.,b Department of Anesthesiology, College of Medicine , University of Illinois , Chicago , IL , USA.,c Department of Surgery, College of Medicine , University of Illinois , Chicago , IL , USA
| | - Nebojsa Nick Knezevic
- a Department of Anesthesiology , Advocate Illinois Masonic Medical Center , Chicago , IL , USA.,b Department of Anesthesiology, College of Medicine , University of Illinois , Chicago , IL , USA.,c Department of Surgery, College of Medicine , University of Illinois , Chicago , IL , USA
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Andersen RL, Johnson DJ, Patel JN. Personalizing supportive care in oncology patients using pharmacogenetic-driven treatment pathways. Pharmacogenomics 2016; 17:417-34. [PMID: 26871520 DOI: 10.2217/pgs.15.178] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cancer patients frequently suffer from disease- and treatment-related pain, nausea and depression, which severely reduces patients' quality of life. It is critical that clinicians are aware of drug-gene interactions and recognize the utility of applying pharmacogenetic information to personalize and improve supportive care. Pharmacogenetic-based algorithms may enhance clinical outcomes by allowing the clinician to select the 'least genetically vulnerable' drug. This review summarizes clinically relevant drug-gene interactions and presents pharmacogenetic-driven treatment pathways for depression, nausea/vomiting and pain. Ideally, this review provides a resource for clinicians to consult when selecting pharmacotherapy for a patient who presents with limited pharmacogenetic test results, with the hope of better controlling burdensome symptoms and improving the quality of life for cancer patients.
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Affiliation(s)
- Rebecca L Andersen
- Wingate University School of Pharmacy, 515 N Main St, Wingate, NC 28174, USA
| | - Daniel J Johnson
- University of North Carolina Eshelman School of Pharmacy, CB #7355, Chapel Hill, NC 27599, USA
| | - Jai N Patel
- University of North Carolina Eshelman School of Pharmacy, CB #7355, Chapel Hill, NC 27599, USA.,Levine Cancer Institute, Carolinas HealthCare System, 1021 Morehead Medical Drive, Charlotte, NC 28204, USA
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Abstract
Practitioners are highly likely to encounter patients with concurrent use of nicotine products and opioid analgesics. Smokers present with more severe and extended chronic pain outcomes and have a higher frequency of prescription opioid use. Current tobacco smoking is a strong predictor of risk for nonmedical use of prescription opioids. Opioid and nicotinic-cholinergic neurotransmitter systems interact in important ways to modulate opioid and nicotine effects: dopamine release induced by nicotine is dependent on facilitation by the opioid system, and the nicotinic-acetylcholine system modulates self-administration of several classes of abused drugs-including opioids. Nicotine can serve as a prime for the use of other drugs, which in the case of the opioid system may be bidirectional. Opioids and compounds in tobacco, including nicotine, are metabolized by the cytochrome P450 enzyme system, but the metabolism of opioids and tobacco products can be complicated. Accordingly, drug interactions are possible but not always clear. Because of these issues, asking about nicotine use in patients taking opioids for pain is recommended. When assessing patient tobacco use, practitioners should also obtain information on products other than cigarettes, such as cigars, pipes, smokeless tobacco, and electronic nicotine delivery systems (ENDS, or e-cigarettes). There are multiple forms of behavioral therapy and pharmacotherapy available to assist patients with smoking cessation, and opioid agonist maintenance and pain clinics represent underutilized opportunities for nicotine intervention programs.
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Allegaert K, Holford N, Anderson BJ, Holford S, Stuber F, Rochette A, Trocóniz IF, Beier H, de Hoon JN, Pedersen RS, Stamer U. Tramadol and o-desmethyl tramadol clearance maturation and disposition in humans: a pooled pharmacokinetic study. Clin Pharmacokinet 2015; 54:167-78. [PMID: 25258277 DOI: 10.1007/s40262-014-0191-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES We aimed to study the impact of size, maturation and cytochrome P450 2D6 (CYP2D6) genotype activity score as predictors of intravenous tramadol disposition. METHODS Tramadol and O-desmethyl tramadol (M1) observations in 295 human subjects (postmenstrual age 25 weeks to 84.8 years, weight 0.5-186 kg) were pooled. A population pharmacokinetic analysis was performed using a two-compartment model for tramadol and two additional M1 compartments. Covariate analysis included weight, age, sex, disease characteristics (healthy subject or patient) and CYP2D6 genotype activity. A sigmoid maturation model was used to describe age-related changes in tramadol clearance (CLPO), M1 formation clearance (CLPM) and M1 elimination clearance (CLMO). A phenotype-based mixture model was used to identify CLPM polymorphism. RESULTS Differences in clearances were largely accounted for by maturation and size. The time to reach 50 % of adult clearance (TM50) values was used to describe maturation. CLPM (TM50 39.8 weeks) and CLPO (TM50 39.1 weeks) displayed fast maturation, while CLMO matured slower, similar to glomerular filtration rate (TM50 47 weeks). The phenotype-based mixture model identified a slow and a faster metabolizer group. Slow metabolizers comprised 9.8 % of subjects with 19.4 % of faster metabolizer CLPM. Low CYP2D6 genotype activity was associated with lower (25 %) than faster metabolizer CLPM, but only 32 % of those with low genotype activity were in the slow metabolizer group. CONCLUSIONS Maturation and size are key predictors of variability. A two-group polymorphism was identified based on phenotypic M1 formation clearance. Maturation of tramadol elimination occurs early (50 % of adult value at term gestation).
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit and Center for Clinical Pharmacology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium,
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Haufroid V, Hantson P. CYP2D6 genetic polymorphisms and their relevance for poisoning due to amfetamines, opioid analgesics and antidepressants. Clin Toxicol (Phila) 2015; 53:501-10. [DOI: 10.3109/15563650.2015.1049355] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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