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Simon N, Moirand R, Dematteis M, Bordet R, Deplanque D, Rolland B. Full-Profile Pharmacokinetic Study of High Dose Baclofen in Subjects With Alcohol Use Disorder. Front Psychiatry 2018; 9:385. [PMID: 30190685 PMCID: PMC6115517 DOI: 10.3389/fpsyt.2018.00385] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/31/2018] [Indexed: 12/20/2022] Open
Abstract
Baclofen a gamma amino-butyric acid type B (GABA-B) receptor agonist, which has raised some interest for the treatment of alcohol use disorder (AUD), occasionally at dose up to 300 mg/d. We conducted the first full-profile pharmacokinetic study on baclofen in AUD subjects, up to the oral daily dose of 300 mg. Sixty subjects treated for AUD with marketed baclofen were enrolled in a prospective phase-1 study. Participants were divided into four dose groups (1: <60 mg/d; 2: 60-120 mg/d; 3: >120 mg/d-180 mg/d; and 4: >180 mg/d), and they underwent a full-profile pharmacokinetic analysis of baclofen, using a nonlinear mixed effects modeling. The influence of different clinical and biological covariates was assessed in an upward modeling. Fifty-seven participants completed the study (522 observed concentrations collected). Racemic baclofen showed a linear pharmacokinetic profile, corresponding to a one-compartment model, with no influencing clinical or biological factor. The pharmacokinetic parameters of baclofen were (bootstrap 95% confidence intervals): absorption constant (Ka) 1.64 1/h (1.34-2), clearance (Cl/F) 11.6 L/h (10.8-12.3) and volume of distribution (Vd/F) 72.8 L (66.5-80.4) leading to a half-life of 4.4 h. The interindividual variability (IIV) was 44% (19-65), 21% (16-27), and 22% (11-36) for Ka, Cl/F, and Vd/F, respectively. The residual variability was 24% (21-26). No serious adverse event was reported. Registration: EudraCT #2013-003412-46.
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Affiliation(s)
- Nicolas Simon
- Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, Service de Pharmacologie Clinique, CAP-TV, Marseille, France
| | - Romain Moirand
- Univ Rennes, INSERM, INRA, CHU Rennes, Institut NUMECAN (Nutrition Metabolisms and Cancer), CIC 1414, Unité d'Addictologie, Rennes, France
| | - Maurice Dematteis
- UFR de Médecine, Université Grenoble Alpes, Grenoble, France
- Service d'Addictologie, CHU Grenoble Alpes, Grenoble, France
| | - Régis Bordet
- Inserm U1171, Université de Lille, Lille, France
| | - Dominique Deplanque
- Inserm U1171, Université de Lille, Lille, France
- Inserm CIC1403, CHU Lille, Université de Lille, Lille, France
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), Pôle MOPHA, CH Le VInatier, Bron, France
- Université de Lyon, Inserm U1028, CNRS UMR5292, UCBL, CRNL, Bron, France
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Palpacuer C, Duprez R, Huneau A, Locher C, Boussageon R, Laviolle B, Naudet F. Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta-analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate. Addiction 2018; 113:220-237. [PMID: 28940866 DOI: 10.1111/add.13974] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 05/16/2017] [Accepted: 07/28/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders (AUDs) is an emerging concept. Our objective was to explore the comparative effectiveness of drugs used in this indication. DESIGN Systematic review with direct and network meta-analysis of double-blind randomized controlled trials (RCTs) assessing the efficacy of nalmefene, naltrexone, acamprosate, baclofen or topiramate in non-abstinent adults diagnosed with alcohol dependence or AUDs. Two independent reviewers selected published and unpublished studies on Medline, the Cochrane Library, Embase, ClinicalTrials.gov, contacted pharmaceutical companies, the European Medicines Agency and the Food and Drug Administration, and extracted data. SETTING Thirty-two RCTs. PARTICIPANTS A total of 6036 patients. MEASUREMENTS The primary outcome was total alcohol consumption (TAC). Other consumption outcomes and health outcomes were considered as secondary outcomes. FINDINGS No study provided direct comparisons between drugs. A risk of incomplete outcome data was identified in 26 studies (81%) and risk of selective outcome reporting in 17 (53%). Nalmefene [standardized mean difference (SMD) = -0.19, 95% confidence interval (CI) = -0.29, -0.10; I2 = 0%], baclofen (SMD = -1.00, 95% CI = -1.80, -0.19; one study) and topiramate (SMD = -0.77, 95% CI = -1.12, -0.42; I2 = 0%) showed superiority over placebo on TAC. No efficacy was observed for naltrexone or acamprosate. Similar results were observed for other consumption outcomes, except for baclofen (the favourable outcome on TAC was not reproduced). The number of withdrawals for safety reasons increased under nalmefene and naltrexone. No treatment demonstrated any harm reduction (no study was powered to explore health outcomes). Indirect comparisons suggested that topiramate was superior to nalmefene, naltrexone and acamprosate on consumption outcomes, but its safety profile is known to be poor. CONCLUSIONS There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.
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Affiliation(s)
| | - Renan Duprez
- Fondation Saint Jean de Dieu, Centre Hospitalier Dinan/St Brieuc, Dinan, France
| | | | - Clara Locher
- Inserm, CIC 1414 Clinical Investigation Centre, Rennes, France.,Rennes University Hospital, Department of Biological and Clinical Pharmacology and Pharmacovigilance, Rennes, France.,Rennes 1 University, Laboratory of Experimental and Clinical Pharmacology, Rennes, France
| | - Rémy Boussageon
- Département de Médecine Générale, Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
| | - Bruno Laviolle
- Inserm, CIC 1414 Clinical Investigation Centre, Rennes, France.,Rennes University Hospital, Department of Biological and Clinical Pharmacology and Pharmacovigilance, Rennes, France.,Rennes 1 University, Laboratory of Experimental and Clinical Pharmacology, Rennes, France
| | - Florian Naudet
- Inserm, CIC 1414 Clinical Investigation Centre, Rennes, France.,Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Palo Alto, CA, USA
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Rolland B, Simon N, Franchitto N. Safety Challenges of Using High Dose Baclofen for Alcohol Use Disorder: A Focused Review. Front Psychiatry 2018; 9:367. [PMID: 30186187 PMCID: PMC6113385 DOI: 10.3389/fpsyt.2018.00367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/24/2018] [Indexed: 01/13/2023] Open
Abstract
Since the early 2000s, the gamma-aminobutyric acid type B (GABA-B) receptor agonist baclofen has been extensively used for treating alcohol use disorder (AUD). In some countries, like France, Australia, or Germany, baclofen has been used at patient-tailored dose regimens, which can reach 300 mgpd or even more in some patients. The GABA-B-related pharmacology of baclofen expose patients to a specific profile of neuropsychiatric adverse drug reactions (ADRs), primarily some frequent sedative symptoms whose risk of occurrence and severity are both related to the absolute baclofen dosing and the kinetics of dose variations. Other frequent neuropsychiatric ADRs can occur, i.e., tinnitus, insomnia, or dizziness. More rarely, other serious ADRs have been reported, like seizures, manic symptoms, or sleep apnea. However, real-life AUD patients are also exposed to other sedative drugs, like alcohol of course, but also benzodiazepines, other drugs of abuse, or other sedative medications. Consequently, the occurrence of neuropsychiatric safety issues in these patients is essentially the result of a complex multifactorial exposure, in which baclofen causality is rarely obvious by itself. As a result, the decision of initiating baclofen, as well as the daily dose management should be patient-tailored, according the medical history but also the immediate clinical situation of the patient. The overall safety profile of baclofen, as well as the clinical context in which baclofen is used, have many similarities with the use of opiate substitution medications for opiate use disorder. This empirical statement has many implications on how baclofen should be managed and dosing should be adjusted. Moreover, this constant patient-tailored adjustment can be difficult to adapt in the design of clinical trials, which may explain inconsistent findings in baclofen-related literature on AUD.
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Affiliation(s)
- Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), Pôle MOPHA, CH Le Vinatier, Bron, France.,Univ Lyon, Inserm U1028, CNRS UMR5292, UCBL, CRNL, Lyon, France
| | - Nicolas Simon
- APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, Service de Pharmacologie Clinique, CAP-TV, Aix Marseille Univ, Marseille, France
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Antonelli M, Ferrulli A, Sestito L, Vassallo GA, Tarli C, Mosoni C, Rando MM, Mirijello A, Gasbarrini A, Addolorato G. Alcohol addiction - the safety of available approved treatment options. Expert Opin Drug Saf 2017; 17:169-177. [PMID: 29120249 DOI: 10.1080/14740338.2018.1404025] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Alcohol Use Disorders (AUD) is a leading cause of mortality and morbidity worldwide. At present disulfiram, naltrexone and acamprosate are approved for the treatment of AUD in U.S. and Europe. Nalmefene is approved in Europe and sodium oxybate is approved in Italy and Austria only. Baclofen received a 'temporary recommendation for use' in France. AREAS COVERED The safety of the above mentioned medications on liver, digestive system, kidney function, nervous system, pregnancy and lactation and their possible side effects are described and discussed. EXPERT OPINION Mechanism of action and metabolism of these drugs as well as patients' clinical characteristics can affect the safety of treatment. All approved medications are valid tools for the treatment of AUD in patients without advanced liver disease. For some drugs, attention should be paid to patients with renal failure and medications may be used with caution, adjusting the dosage according to kidney function. In patients with AUD and advanced liver disease, at present only baclofen has been formally tested in randomized controlled trials showing its safety in this population.
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Affiliation(s)
- Mariangela Antonelli
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Anna Ferrulli
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy.,b Department of Endocrinology and Metabolic Disease , IRCCS Policlinico San Donato , Milan , Italy
| | - Luisa Sestito
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Gabriele A Vassallo
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Claudia Tarli
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Carolina Mosoni
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Maria M Rando
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Antonio Mirijello
- c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
| | - Antonio Gasbarrini
- d Department of Internal Medicine, Gastroenterology and Hepatology , Università Cattolica del Sacro Cuore , Rome , Italy
| | - Giovanni Addolorato
- a Alcohol Use Disorders Unit , Università Cattolica del Sacro Cuore , Rome , Italy.,d Department of Internal Medicine, Gastroenterology and Hepatology , Università Cattolica del Sacro Cuore , Rome , Italy
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Abstract
The concept of binge drinking (BD) refers to patterns of heavy episodic alcohol consumption, with BD primarily occurring among adolescents and young adults. Several official definitions of BD have been proposed, in particular by the World Health Organization, the National Institute on Alcoholism and Alcohol Abuse, and the Substance Abuse and Mental Health Services Administration. Nevertheless, none of these definitions address the psychosocial and medical consequences of the type of alcohol use seen in BD. In practice, BD can thus correspond to either hazardous or harmful use of alcohol (HUA), while the episodic nature of heavy drinking in BD means that it does not meet the criteria for 'alcohol dependence'. This diagnostic differentiation is important because it determines which type of intervention is recommended. Psychosocial, rather than pharmacological, interventions are recommended as first-line treatment for adults with HUA, while pharmacological treatment is recommended for alcohol dependence; however, HUA appears to be associated with much poorer outcomes in adolescents, which could thus warrant early use of pharmacotherapy in this patient group. For HUA, and especially in adolescents, there is currently a severe lack of data regarding the efficacy and safety of the different drugs that have been approved for adults with alcohol dependence. Various guidelines propose the use of drugs for some types of BD but that use remains off-label and empirical, which raises important safety and ethical concerns. Future research on BD should systematically assess the criteria for HUA to better differentiate its subtypes with actual consequences and better address the heterogeneity of BD in terms of both clinical profiles and outcomes. Regarding pharmacotherapy, some national guidelines have recommended nalmefene for 'mild' dependence or second-line treatment for HUA, but such recommendations are not supported by evidence. Only naltrexone has been investigated in HUA but not in adolescents. More clinical trials should be conducted among adolescents with BD and HUA criteria to determine the most appropriate use of drugs in this particularly vulnerable population of subjects.
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Rolland B, Auffret M, Labreuche J, Lapeyre-Mestre M, Dib M, Kemkem A, Grit I, Drelon M, Duhamel A, Cabe N, Vabret F, Guillin O, Baguet A, Masquelier C, Dervaux A, Deheul S, Bordet R, Carton L, Cottencin O, Jardri R, Gautier S. Phone-based safety monitoring of the first year of baclofen treatment for alcohol use disorder: the BACLOPHONE cohort study protocol. Expert Opin Drug Saf 2016; 16:125-132. [PMID: 27984918 DOI: 10.1080/14740338.2017.1270939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND In France, baclofen is frequently used off-label for alcohol use disorder (AUD). Baclofen has been associated with diverse adverse events (AEs), but the causality of these AEs has never been properly assessed. METHODS/DESIGN BACLOPHONE is a prospective multicenter cohort study conducted in the Hauts-de-France and Normandie French regions. BACLOPHONE consists of the phone-based monitoring of 792 patients during their first year of baclofen treatment for AUD. Two initial phone interviews assess the medical history, current medications, and substance use as well as complete the alcohol use identification test (AUDIT) and severity of alcohol dependence questionnaire (SADQ). Daily alcohol use and baclofen doses are noted throughout the follow-up. For every reported AE, additional phone interviews determine the seriousness of the AE, the causality of baclofen using validated causality algorithms, and the final outcome. The main objective of the study is to determine the rate of patients who stop baclofen due to an AE during the first year of treatment. DISCUSSION BACLOPHONE will provide important safety data on baclofen as a complement to the forthcoming efficacy data of randomized clinical trials.
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Affiliation(s)
- Benjamin Rolland
- a Département de Pharmacologie Médicale , INSERM U 1171, Univ Lille , Lille , France.,b Service d'Addictologie, CHU Lille , Lille , France
| | - Marine Auffret
- c Centre Régional de Pharmacovigilance, CHU Lille , Lille , France
| | - Julien Labreuche
- d Plateforme d'Aide Méthodologique , Biostatistique et Datamanagement, CHU Lille , Lille , France
| | - Maryse Lapeyre-Mestre
- e Service de Pharmacologie Clinique, CEIP-Addictovigilance, CIC 1436, CHU de ToulouseUMR-INSERM 1027 Universite Paul Sabatier - Toulouse 3 , Toulouse , France
| | - Malek Dib
- f Fédération de Recherche Clinique, CHU Lille , Lille , France
| | - Aomar Kemkem
- f Fédération de Recherche Clinique, CHU Lille , Lille , France
| | - Isabelle Grit
- f Fédération de Recherche Clinique, CHU Lille , Lille , France
| | - Marie Drelon
- g Centre d'Investigation Clinique, CHU Lille , Lille , France
| | - Alain Duhamel
- d Plateforme d'Aide Méthodologique , Biostatistique et Datamanagement, CHU Lille , Lille , France.,h CERIM, EA 2694, Univ Lille , Lille , France
| | - Nicolas Cabe
- i Service d'Addictologie, CHU de Caen , Caen , France
| | | | - Olivier Guillin
- k Centre Hospitalier du Rouvray, CHU de Rouen , Rouen , France
| | | | - Céline Masquelier
- p Centre Hospitalier Regional Universitaire de Lille Ringgold standard institution - Biostatistics CHU Lille , Lille , France
| | - Alain Dervaux
- l Service d'Addictologie, CHU d'Amiens , Amiens , France
| | - Sylvie Deheul
- m Centre d'Evaluation et d'Information sur les Pharmacodépendances, CHU Lille , Lille , France
| | - Régis Bordet
- a Département de Pharmacologie Médicale , INSERM U 1171, Univ Lille , Lille , France.,c Centre Régional de Pharmacovigilance, CHU Lille , Lille , France.,m Centre d'Evaluation et d'Information sur les Pharmacodépendances, CHU Lille , Lille , France
| | - Louise Carton
- a Département de Pharmacologie Médicale , INSERM U 1171, Univ Lille , Lille , France
| | - Olivier Cottencin
- b Service d'Addictologie, CHU Lille , Lille , France.,n SCALab UMR CNRS 9193, Univ Lille , Lille , France
| | - Renaud Jardri
- n SCALab UMR CNRS 9193, Univ Lille , Lille , France.,o Centre Universitaire de Recherche et d'Exploration, CHU Lille , Lille , France
| | - Sophie Gautier
- a Département de Pharmacologie Médicale , INSERM U 1171, Univ Lille , Lille , France.,c Centre Régional de Pharmacovigilance, CHU Lille , Lille , France
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