1
|
Ni L, Cao Z, Jiang J, Zhang W, Hu W, Zhang Q, Shen C, Chen X, Zheng L. Evaluating Drug Interactions between Ritonavir and Opioid Analgesics: Implications from Physiologically Based Pharmacokinetic Simulation. Pharmaceuticals (Basel) 2024; 17:640. [PMID: 38794210 PMCID: PMC11124264 DOI: 10.3390/ph17050640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/05/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Several commonly used opioid analgesics, such as fentanyl, sufentanil, alfentanil, and hydrocodone, are by report primarily metabolized by the CYP3A4 enzyme. The concurrent use of ritonavir, a potent CYP3A4 inhibitor, can lead to significant drug interactions. Using physiologically based pharmacokinetic (PBPK) modeling and simulation, this study examines the effects of different dosing regimens of ritonavir on the pharmacokinetics of these opioids. The findings reveal that co-administration of ritonavir significantly increases the exposure of fentanyl analogs, with over a 10-fold increase in the exposure of alfentanil and sufentanil when given with ritonavir. Conversely, the effect of ritonavir on fentanyl exposure is modest, likely due to additional metabolism pathways. Additionally, the study demonstrates that the steady-state exposure of hydrocodone and its active metabolite hydromorphone can be increased by up to 87% and 95%, respectively, with concurrent use of ritonavir. The extended-release formulation of hydrocodone is particularly affected. These insights from PBPK modeling provide valuable guidance for optimizing opioid dosing and minimizing the risk of toxicity when used in combination with ritonavir-containing prescriptions.
Collapse
Affiliation(s)
- Liang Ni
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China;
| | - Zhihai Cao
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (Z.C.); (W.Z.); (W.H.); (Q.Z.)
- School of Pharmacy, Anhui Medical University, Hefei 230032, China
| | - Jiakang Jiang
- Department of Pharmacy and Biomedical Engineering, Clinical College of Anhui Medical University, Hefei 230031, China;
| | - Wei Zhang
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (Z.C.); (W.Z.); (W.H.); (Q.Z.)
| | - Wei Hu
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (Z.C.); (W.Z.); (W.H.); (Q.Z.)
| | - Qian Zhang
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (Z.C.); (W.Z.); (W.H.); (Q.Z.)
| | - Chaozhuang Shen
- Department of Clinical Pharmacy and Pharmacy Administration, West China School of Pharmacy, Sichuan University, Chengdu 610041, China;
| | - Xijing Chen
- Clinical Pharmacokinetics Laboratory, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China;
| | - Liang Zheng
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (Z.C.); (W.Z.); (W.H.); (Q.Z.)
| |
Collapse
|
2
|
Buonanno P, Marra A, Iacovazzo C, Vargas M, Nappi S, Squillacioti F, de Siena AU, Servillo G. The PATIENT Approach: A New Bundle for the Management of Chronic Pain. J Pers Med 2023; 13:1551. [PMID: 38003866 PMCID: PMC10672627 DOI: 10.3390/jpm13111551] [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: 09/20/2023] [Revised: 10/15/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Chronic pain is one of the most challenging diseases for physicians as its etiology and manifestations can be extremely varied. Many guidelines have been published and many therapeutic options are nowadays available for the different types of pain. Given the enormous amount of information that healthcare providers must handle, it is not always simple to keep in mind all the phases and strategies to manage pain. We here present the acronym PATIENT (P: patient's perception; A: assessment; T: tailored approach; I: iterative evaluation; E: education; N: non-pharmacological approach; T: team), a bundle which can help to summarize all the steps to follow in the management of chronic pain. METHODS We performed a PubMed search with a list of terms specific for every issue of the bundle; only English articles were considered. RESULTS We analyzed the literature investigating these topics to provide an overview of the available data on each bundle's issue; their synthesis lead to an algorithm which may allow healthcare providers to undertake every step of a patient's evaluation and management. DISCUSSION Pain management is very complex; our PATIENT bundle could be a guide to clinicians to optimize a patient's evaluation and treatment.
Collapse
|
3
|
Gerhart J, Draica F, Benigno M, Atkinson J, Reimbaeva M, Francis D, Baillon-Plot N, Sidhu GS, Damle BD. Real-World Evidence of the Top 100 Prescribed Drugs in the USA and Their Potential for Drug Interactions with Nirmatrelvir; Ritonavir. AAPS J 2023; 25:73. [PMID: 37468770 DOI: 10.1208/s12248-023-00832-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/07/2023] [Indexed: 07/21/2023] Open
Abstract
Nirmatrelvir (coadministered with ritonavir as PAXLOVIDTM) reduces the risk of COVID-19-related hospitalizations and all-cause death in individuals with mild-to-moderate COVID-19 at high risk of progression to severe disease. Ritonavir is coadministered as a pharmacokinetic enhancer. However, ritonavir may cause drug-drug interactions (DDIs) due to its interactions with various drug-metabolizing enzymes and transporters, including cytochrome P450 (CYP) 3A, CYP2D6, and P-glycoprotein transporters. To better understand the extent of DDIs (or lack thereof) of nirmatrelvir; ritonavir in a clinical setting, this study used real-world evidence (RWE) from the Optum Clinformatics Data Mart database to identify the top 100 drugs most commonly prescribed to US patients at high risk of progression to severe COVID-19 disease. The top 100 drugs were identified based on total counts associated with drugs prescribed to high-risk patients (i.e., ≥ 1 medical condition associated with an increased risk of severe COVID-19) who were continuously enrolled in the database throughout 2019 and had ≥ 1 prescription claim. Each of the 100 drugs was then assessed for DDI risk based on their metabolism, excretion, and transport pathways identified from available US prescribing and medical literature sources. Seventy drugs identified were not expected to have DDIs with nirmatrelvir; ritonavir, including many cardiovascular agents, anti-infectives, antidiabetic agents, and antidepressants. Conversely, 30 drugs, including corticosteroids, narcotic analgesics, anticoagulants, statins, and sedatives/hypnotics, were expected to cause DDIs with nirmatrelvir; ritonavir. This RWE analysis is complementary to the prescribing information and other DDI management tools for guiding healthcare providers in managing DDIs.
Collapse
Affiliation(s)
- Jacqueline Gerhart
- Pfizer Inc, Global Product Development, 500 Arcola Road, Collegeville, Pennsylvania, 19426, USA.
| | - Florin Draica
- Pfizer Inc, US Medical Affairs, Hospital, New York, New York, USA
| | | | | | - Maya Reimbaeva
- Pfizer Inc, Global Biometrics and Data Management, Groton, Connecticut, USA
| | - Domenick Francis
- Pfizer Inc, US Medical Affairs, Hospital, New York, New York, USA
| | | | | | - Bharat D Damle
- Pfizer Inc, Global Product Development, New York, New York, USA
| |
Collapse
|
4
|
Myers AL, Jeske AH. Provider-directed analgesia for dental pain. Expert Rev Clin Pharmacol 2023; 16:435-451. [PMID: 37083548 DOI: 10.1080/17512433.2023.2206118] [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: 04/22/2023]
Abstract
INTRODUCTION Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry. AREAS COVERED This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain. EXPERT OPINION Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.
Collapse
Affiliation(s)
- Alan L Myers
- Department of Diagnostic & Biomedical Sciences, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Arthur H Jeske
- Office of the Dean, School of Dentistry, The University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
5
|
Utility of Therapeutic Drug Monitoring in Identifying Clinically Significant Interactions Between St. John's Wort and Prescription Drugs. Ther Drug Monit 2023; 45:35-44. [PMID: 36624575 DOI: 10.1097/ftd.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/15/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The general population widely uses herbal medicines, as they are regarded as effective and safe. St. John's wort, which is an effective herbal antidepressant, exhibits both pharmacokinetic and pharmacodynamic interactions with several drugs. The aim of this review was to highlight the clinically significant interactions of St. John's wort with drugs that require to be monitored to assess their therapeutic effect. METHODS Published literature was searched using electronic databases, such as MEDLINE, PubMed, and Elsevier ScienceDirect using terms such as "herbal medicine," "herbal toxicity," "legislation herbal medicine," "drug-herb interactions," "St. John's wort," and "St. John's wort-drug interactions." Searches were limited to the English language, and there was no restriction on the date of publication. RESULTS St. John's wort exhibits a number of pharmacokinetic and pharmacodynamic interactions with drugs. The most dangerous interactions occurred when used concurrently with the immunosuppressants, cyclosporine, and tacrolimus (treatment failure or organ rejection) or warfarin (treatment failure resulting in thromboembolic events) or antiretroviral agents (treatment failure and the emergence of new viral variants that are resistant to conventional drugs). CONCLUSIONS Patients should consult their health care providers before consuming herbal supplements, especially St. John's wort, to avoid potentially dangerous drug-herb interactions.
Collapse
|
6
|
Karballaei-Mirzahosseini H, Kaveh-Ahangaran R, Shahrami B, Rouini MR, Najafi A, Ahmadi A, Sadrai S, Mojtahedzadeh A, Najmeddin F, Mojtahedzadeh M. Pharmacokinetic study of high-dose oral rifampicin in critically Ill patients with multidrug-resistant Acinetobacter baumannii infection. Daru 2022; 30:311-322. [PMID: 36069988 PMCID: PMC9715901 DOI: 10.1007/s40199-022-00449-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022] Open
Abstract
PURPOSE Although rifampicin (RIF) is used as a synergistic agent for multidrug-resistant Acinetobacter baumannii (MDR-AB) infection, the optimal pharmacokinetic (PK) indices of this medication have not been studied in the intensive care unit (ICU) settings. This study aimed to evaluate the PK of high dose oral RIF following fasting versus fed conditions in terms of achieving the therapeutic goals in critically ill patients with MDR-AB infections. METHODS 29 critically ill patients were included in this study. Under fasting and non-fasting conditions, RIF was given at 1200 mg once daily through a nasogastric tube. Blood samples were obtained at seven time points: exactly before administration of the drug, and at 1, 2, 4, 8, 12, and 24 h after RIF ingestion. To quantify RIF in serum samples, high-performance liquid chromatography (HPLC) was used. The MONOLIX Software and the Monte Carlo simulations were employed to estimate the PK parameters and describe the population PK model. RESULTS The mean area under the curve over the last 24-h (AUC0-24) value and accuracy (mean ± standard deviation) in the fasting and fed states were 220.24 ± 119.15 and 290.55 ± 276.20 μg × h/mL, respectively. There was no significant difference among AUCs following fasting and non-fasting conditions (P > 0.05). The probability of reaching the therapeutic goals at the minimum inhibitory concentration (MIC) of 4 mg/L, was only 1.6%. CONCLUSION In critically ill patients with MDR-AB infections, neither fasting nor non-fasting administrations of high-dose oral RIF achieve the therapeutic aims. More research is needed in larger populations and with measuring the amount of protein-unbound RIF levels.
Collapse
Affiliation(s)
- Hossein Karballaei-Mirzahosseini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
| | - Romina Kaveh-Ahangaran
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
| | - Bita Shahrami
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
| | - Mohammad Reza Rouini
- Department of Pharmaceutics, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sima Sadrai
- Department of Pharmaceutics, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Farhad Najmeddin
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran.
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, 16-Azar St., Enghelab Ave., Tehran, 14176-14418, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
7
|
Yang L, Pan YL, Liu CZ, Guo DX, Zhao X. A retrospective comparative study of local anesthesia only and local anesthesia with sedation for percutaneous endoscopic lumbar discectomy. Sci Rep 2022; 12:7427. [PMID: 35523922 PMCID: PMC9076919 DOI: 10.1038/s41598-022-11393-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 04/20/2022] [Indexed: 12/28/2022] Open
Abstract
It is still an unsolved problem to achieve both immediate intraoperative feedback and satisfactory surgical experience in percutaneous endoscopic lumbar discectomy under local anesthesia for lumbar disk herniation (LDH) patients. Herein, we compared the analgesic and sedative effects of local anesthesia alone and local anesthesia with conscious sedation in LDH patients during percutaneous endoscopic lumbar discectomy. Ninety-two LDH patients were enrolled and divided into the following groups: control group (Con Group), dexmedetomidine group (Dex Group), oxycodone group (Oxy Group), and dexmedetomidine + oxycodone group (Dex + Oxy Group). Various signs, including mean arterial pressure (MAP), heart rate (HR), pulse oximeter oxygen saturation (SpO2) and Ramsay score, were compared before anesthesia (T1), working cannula establishment (T2), nucleus pulposus removal (T3), and immediately postoperation (T4). Clinical outcomes, including VAS score, operation time, hospitalization period, Macnab criteria, and SF-36 score, were also evaluated. The Dex + Oxy Group showed the most stable MAP and HR at T2 and T3 in all groups. The clinical outcomes, such as VAS, hospitalization period, Macnab criteria, and SF-36 score, have no significant differences among groups (p > 0.05). Local anesthesia combined with conscious sedation is a safe and effective method to improve the surgical experience and achieve satisfying clinical outcomes for LDH patients during percutaneous endoscopic lumbar discectomy.
Collapse
Affiliation(s)
- Liu Yang
- Department of Spinal Surgery, Zhengzhou Orthopaedic Hospital, Zhengzhou, Henan Province, China
| | - Yu-Lin Pan
- Department of Spinal Surgery, Zhengzhou Orthopaedic Hospital, Zhengzhou, Henan Province, China
| | - Chun-Zhi Liu
- Department of Spinal Surgery, Zhengzhou Orthopaedic Hospital, Zhengzhou, Henan Province, China
| | - De-Xin Guo
- Department of Spinal Surgery, Zhengzhou Orthopaedic Hospital, Zhengzhou, Henan Province, China
| | - Xin Zhao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China.
| |
Collapse
|
8
|
Sonti S, Tyagi K, Pande A, Daniel R, Sharma AL, Tyagi M. Crossroads of Drug Abuse and HIV Infection: Neurotoxicity and CNS Reservoir. Vaccines (Basel) 2022; 10:vaccines10020202. [PMID: 35214661 PMCID: PMC8875185 DOI: 10.3390/vaccines10020202] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 01/27/2023] Open
Abstract
Drug abuse is a common comorbidity in people infected with HIV. HIV-infected individuals who abuse drugs are a key population who frequently experience suboptimal outcomes along the HIV continuum of care. A modest proportion of HIV-infected individuals develop HIV-associated neurocognitive issues, the severity of which further increases with drug abuse. Moreover, the tendency of the virus to go into latency in certain cellular reservoirs again complicates the elimination of HIV and HIV-associated illnesses. Antiretroviral therapy (ART) successfully decreased the overall viral load in infected people, yet it does not effectively eliminate the virus from all latent reservoirs. Although ART increased the life expectancy of infected individuals, it showed inconsistent improvement in CNS functioning, thus decreasing the quality of life. Research efforts have been dedicated to identifying common mechanisms through which HIV and drug abuse lead to neurotoxicity and CNS dysfunction. Therefore, in order to develop an effective treatment regimen to treat neurocognitive and related symptoms in HIV-infected patients, it is crucial to understand the involved mechanisms of neurotoxicity. Eventually, those mechanisms could lead the way to design and develop novel therapeutic strategies addressing both CNS HIV reservoir and illicit drug use by HIV patients.
Collapse
Affiliation(s)
- Shilpa Sonti
- Center for Translational Medicine, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA 19107, USA; (S.S.); (A.L.S.)
| | - Kratika Tyagi
- Department of Biotechnology, Banasthali Vidyapith, Vanasthali, Jaipur 304022, Rajasthan, India;
| | - Amit Pande
- Cell Culture Laboratory, ICAR-Directorate of Coldwater Fisheries Research, Bhimtal, Nainital 263136, Uttarakhand, India;
| | - Rene Daniel
- Farber Hospitalist Service, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Adhikarimayum Lakhikumar Sharma
- Center for Translational Medicine, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA 19107, USA; (S.S.); (A.L.S.)
| | - Mudit Tyagi
- Center for Translational Medicine, Thomas Jefferson University, 1020 Locust Street, Philadelphia, PA 19107, USA; (S.S.); (A.L.S.)
- Correspondence: ; Tel.: +1-215-503-5157 or +1-703-909-9420
| |
Collapse
|
9
|
Zhu LL, Zhou Q. Awareness of Drug-Drug Interaction in Elderly Patients with Osteoarthritis and Depression [Letter]. Neuropsychiatr Dis Treat 2022; 18:705-706. [PMID: 35391946 PMCID: PMC8983053 DOI: 10.2147/ndt.s364573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ling-Ling Zhu
- Geriatric VIP Ward, Division of Nursing, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, Zhejiang Province, People's Republic of China
| | - Quan Zhou
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310009, Zhejiang Province, People's Republic of China
| |
Collapse
|
10
|
Cheng S, Siddiqui TG, Gossop M, Wyller TB, Kristoffersen ES, Lundqvist C. The patterns and burden of multimorbidity in geriatric patients with prolonged use of addictive medications. Aging Clin Exp Res 2021; 33:2857-2864. [PMID: 33599959 PMCID: PMC8531043 DOI: 10.1007/s40520-021-01791-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/11/2021] [Indexed: 01/12/2023]
Abstract
Background Multimorbidity and prolonged use of addictive medications are prevalent among older patients, and known to increase the risk of adverse drug events. Yet, the relationship between these two entities has remained understudied. Aims This study explored the association between multimorbidity burden and prolonged use of addictive medications in geriatric patients, adjusted for clinically important covariates. Furthermore, we identified comorbidity patterns in prolonged users. Methods We conducted a cross-sectional study on a consecutive sample of 246 patients, aged 65–90 years, admitted to a large public university hospital in Norway. We defined prolonged use of addictive medications as using benzodiazepines, opioids and/or z-hypnotics beyond the duration recommended by clinical guidelines (≥ 4 weeks). Multimorbidity was assessed with the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), based on diagnoses made by independent physicians. Results Compared to non-prolonged use, prolonged use was significantly more common among patients who had psychiatric (19/27, 70%), liver (19/22, 86%), upper gastrointestinal tract (21/32, 66%), musculoskeletal (52/96, 54%), or nervous system disorders (46/92, 50%). Patients with prolonged use had a higher multimorbidity burden than those without such use (CIRS-G score, mean = 7.7, SD = 2.7 versus mean = 4.6, SD = 2.2, p < 0.001). Multivariable logistic regression indicated a significant association between multimorbidity burden and prolonged addictive medication use (OR = 1.72, 95% CI 1.42–2.08). Predictive margins postestimation showed a systematic increase in the predicted CIRS-G scores when the number of addictive drug used increases. Conclusions Multimorbidity is strongly associated with prolonged use of addictive medications. Multiple substance use may aggravate disease burden of older patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01791-5.
Collapse
Affiliation(s)
- Socheat Cheng
- Division of Health Services Research and Psychiatry (AHUSKHP), Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, PO Box 1000, 1478, Lørenskog, Norway.
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway.
| | - Tahreem Ghazal Siddiqui
- Division of Health Services Research and Psychiatry (AHUSKHP), Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, PO Box 1000, 1478, Lørenskog, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
| | - Michael Gossop
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Espen Saxhaug Kristoffersen
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Christofer Lundqvist
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
11
|
A Large-Scale Observational Study on the Temporal Trends and Risk Factors of Opioid Overdose: Real-World Evidence for Better Opioids. Drugs Real World Outcomes 2021; 8:393-406. [PMID: 34037960 PMCID: PMC8324607 DOI: 10.1007/s40801-021-00253-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/25/2022] Open
Abstract
Background The USA is in the midst of an opioid overdose epidemic. To address the epidemic, we conducted a large-scale population study on opioid overdose. Objectives The primary objective of this study was to evaluate the temporal trends and risk factors of inpatient opioid overdose. Based on its patterns, the secondary objective was to examine the innate properties of opioid analgesics underlying reduced overdose effects. Methods A retrospective cross-sectional study was conducted based on a large-scale inpatient electronic health records database, Cerner Health Facts®, with (1) inclusion criteria for participants as patients admitted between 1 January, 2009 and 31 December, 2017 and (2) measurements as opioid overdose prevalence by year, demographics, and prescription opioid exposures. Results A total of 4,720,041 patients with 7,339,480 inpatient encounters were retrieved from Cerner Health Facts®. Among them, 30.2% patients were aged 65+ years, 57.0% female, 70.1% Caucasian, 42.3% single, 32.0% from the South, and 80.8% in an urban area. From 2009 to 2017, annual opioid overdose prevalence per 1000 patients significantly increased from 3.7 to 11.9 with an adjusted odds ratio (aOR): 1.16, 95% confidence interval (CI) 1.15–1.16. Compared to the major demographic counterparts, being in (1) age group: 41–50 years (overall aOR 1.36, 95% CI 1.31–1.40) or 51–64 years (overall aOR 1.35, 95% CI 1.32–1.39), (2) marital status: divorced (overall aOR 1.19, 95% CI 1.15–1.23), and (3) census region: West (overall aOR 1.32, 95% CI 1.28–1.36) were significantly associated with a higher odds of opioid overdose. Prescription opioid exposures were also associated with an increased odds of opioid overdose, such as meperidine (overall aOR 1.09, 95% CI 1.06–1.13) and tramadol (overall aOR 2.20, 95% CI 2.14–2.27). Examination on the relationships between opioid analgesic properties and their association strengths, aORs, and opioid overdose showed that lower aOR values were significantly associated with (1) high molecular weight, (2) non-interaction with multi-drug resistance protein 1 or interaction with cytochrome P450 3A4, and (3) non-interaction with the delta opioid receptor or kappa opioid receptor. Conclusions The significant increasing trends of opioid overdose at the inpatient care setting from 2009 to 2017 suggested an ongoing need for efforts to combat the opioid overdose epidemic in the USA. Risk factors associated with opioid overdose included patient demographics and prescription opioid exposures. Moreover, there are physicochemical, pharmacokinetic, and pharmacodynamic properties underlying reduced overdose effects, which can be utilized to develop better opioids. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-021-00253-8.
Collapse
|
12
|
Kinney EM, Vijapurapu S, Covvey JR, Nemecek BD. Clinical outcomes of concomitant rifamycin and opioid therapy: A systematic review. Pharmacotherapy 2021; 41:479-489. [PMID: 33748959 DOI: 10.1002/phar.2520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/07/2022]
Abstract
Opioids are one of the most prescribed classes of analgesic medications. Their narrow therapeutic index and metabolism through cytochrome p450 (CYP) enzymes can result in a drug interaction when used concomitantly with rifamycins. In clinical scenarios where concurrent therapy with an opioid and a rifamycin occurs, there is no standardized guidance for managing the interaction. The objective of this review was to examine literature which evaluates the concomitant use of opioids and rifamycins with clinically relevant CYP-inducing properties. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria was performed. PubMed, Scopus, and OVID Embase were queried for studies from database inception to January 2020 related to rifamycin and opioid medications. Only full-text, peer-reviewed, English language articles addressing clinical outcomes from concomitant rifamycin and opioid therapy were included. The review isolated 12 articles for data extraction from an original 2260 citations identified. Rifampin (11; 92%) and rifabutin (2; 17%) were the rifamycins studied along with seven different opioids. Decreased effect of opioids with concomitant rifampin therapy manifested as withdrawal in numerous patients on methadone and a decreased analgesic effect from tramadol, morphine, and, most notably, oxycodone. Only the combinations of rifampin with buccal fentanyl and rifabutin with buprenorphine and methadone were found to have no clinically measurable interaction. Available literature suggests that a decrease in opioid clinical effects is appreciated with concomitant rifamycin therapy. Further research is needed to focus on specific mitigation strategies beyond opioid agent selection, such as dosing adjustment recommendations.
Collapse
Affiliation(s)
- Eric M Kinney
- West Virginia University Medicine, J.W. Ruby Memorial Hospital, Morgantown, West Virginia, USA
| | | | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Branden D Nemecek
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh Medical Center, Mercy Hospital, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
13
|
Baburaj G, Thomas L, Rao M. Potential Drug Interactions of Repurposed COVID-19 Drugs with Lung Cancer Pharmacotherapies. Arch Med Res 2021; 52:261-269. [PMID: 33257051 PMCID: PMC7670900 DOI: 10.1016/j.arcmed.2020.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 11/03/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022]
Abstract
Lung cancer patients are at heightened risk for developing COVID-19 infection as well as complications due to multiple risk factors such as underlying malignancy, anti-cancer treatment induced immunosuppression, additional comorbidities and history of smoking. Recent literatures have reported a significant proportion of lung cancer patients coinfected with COVID-19. Chloroquine, hydroxychloroquine, lopinavir/ritonavir, ribavirin, oseltamivir, remdesivir, favipiravir, and umifenovir represent the major repurposed drugs used as potential experimental agents for COVID-19 whereas azithromycin, dexamethasone, tocilizumab, sarilumab, famotidine and ceftriaxone are some of the supporting agents that are under investigation for COVID-19 management. The rationale of this review is to identify potential drug-drug interactions (DDIs) occurring in lung cancer patients receiving lung cancer medications and repurposed COVID-19 drugs using Micromedex and additional literatures. This review has identified several potential DDIs that could occur with the concomitant treatments of COVID-19 repurposed drugs and lung cancer medications. This information may be utilized by the healthcare professionals for screening and identifying potential DDIs with adverse outcomes, based on their severity and documentation levels and consequently design prophylactic and management strategies for their prevention. Identification, reporting and management of DDIs and dissemination of related information should be a major consideration in the delivery of lung cancer care during this ongoing COVID-19 pandemic for better patient outcomes and updating guidelines for safer prescribing practices in this coinfected condition.
Collapse
Affiliation(s)
- Gayathri Baburaj
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Levin Thomas
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| |
Collapse
|
14
|
Associations between mental health disorder and management of physical chronic conditions in China: a pooled cross-sectional analysis. Sci Rep 2021; 11:5731. [PMID: 33707604 PMCID: PMC7952541 DOI: 10.1038/s41598-021-85126-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/16/2021] [Indexed: 11/25/2022] Open
Abstract
Physical non-communicable diseases (NCDs) and mental health disorders are a rapidly increasing health burden in low-and middle-income countries. This study aims to examine the relationships between mental health disorders and cascade of care in managing four common physical NCDs (hypertension, diabetes, dyslipidemia, chronic kidney disease) in China. We utilized two waves of nationally-representative China Health and Retirement Longitudinal Study (CHARLS 2011, 2015) of older adult population aged 45 and above. A series of unadjusted and adjusted mixed-effect logistic regression was applied to evaluate the association between presence of mental health disorder and physical chronic disease awareness, treatment, and control. We found that the odds of dyslipidemia (AOR 1.81, 95% CI 1.36–2.39) and kidney disease awareness (AOR 2.88, 95% CI 2.12–3.92) were higher for individuals with mental chronic conditions, compared to those without mental chronic conditions. The odds of having hypertension treatment was higher for subjects with mental health disorder, compared to those without (AOR 1.32, 95% CI 1.02–1.70). The odds of having physical chronic conditions controlled was not significantly associated with having mental chronic conditions (P > 0.05). These results indicated that adults with mental health disorder have a greater likelihood of awareness of having dyslipidemia and kidney disease, and receiving treatment for hypertension. Strategies to address the growing burden of physical-mental NCDs in China should include efforts to improve management of patients with comorbid health condition and improve access to continual high-quality treatment after the first diagnosis.
Collapse
|
15
|
Alifarsangi A, Esmaeili-Mahani S, Sheibani V, Abbasnejad M. The citrus flavanone naringenin prevents the development of morphine analgesic tolerance and conditioned place preference in male rats. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:43-51. [PMID: 33006902 DOI: 10.1080/00952990.2020.1813296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Opioids are effective analgesics in the management of chronic pain. However, their clinical use is hindered by adverse side effects such as addiction and analgesic tolerance. Naringenin is a common polyphenolic constituent of the citrus fruits and is one of the most commonly consumed flavonoids within our regular diet. However, its influences on opioid tolerance and addiction have not yet been clarified. OBJECTIVES To examine the effect of different doses of naringenin on analgesic tolerance, conditioned place preference and neuroinflammation in morphine-exposed rats. METHODS Analgesic tolerance was induced by the injection of 10 mg/kg morphine twice daily for 8 days in 70 male Wistar rats. To evaluate the effect of naringenin on the development of morphine tolerance, different doses (10, 25 and 50 mg/kg i.p.) were injected 15 min before morphine. The tail-flick test was used to assess nociceptive threshold. Conditioned place preference test was used to evaluate morphine-seeking behaviors. The lumbar spinal cord was assayed to determine glial fibrillary acidic protein (GFAP) and cyclooxygenase-2 (COX-2) levels by Western blotting. RESULTS The data showed that naringenin could significantly prevent morphine tolerance (p < .001) and conditioned place preference. In addition, chronic morphine-induced GFAP and COX-2 overexpression was significantly reversed by 50 mg/kg naringenin (p < .05 and p < .01, respectively). CONCLUSION Our results suggest that naringenin may have a potential anti-tolerant/anti-addiction property against chronic morphine misuse and that this preventive effect is associated with its anti-neuroinflammatory effects.
Collapse
Affiliation(s)
- Atena Alifarsangi
- Laboratory of Molecular Neuroscience, Kerman Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran.,Department of Biology, Faculty of Sciences, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Saeed Esmaeili-Mahani
- Laboratory of Molecular Neuroscience, Kerman Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran.,Department of Biology, Faculty of Sciences, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Vahid Sheibani
- Laboratory of Molecular Neuroscience, Kerman Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Abbasnejad
- Laboratory of Molecular Neuroscience, Kerman Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| |
Collapse
|
16
|
Fitting S, McRae M, Hauser KF. Opioid and neuroHIV Comorbidity - Current and Future Perspectives. J Neuroimmune Pharmacol 2020; 15:584-627. [PMID: 32876803 PMCID: PMC7463108 DOI: 10.1007/s11481-020-09941-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/02/2020] [Indexed: 12/14/2022]
Abstract
With the current national opioid crisis, it is critical to examine the mechanisms underlying pathophysiologic interactions between human immunodeficiency virus (HIV) and opioids in the central nervous system (CNS). Recent advances in experimental models, methodology, and our understanding of disease processes at the molecular and cellular levels reveal opioid-HIV interactions with increasing clarity. However, despite the substantial new insight, the unique impact of opioids on the severity, progression, and prognosis of neuroHIV and HIV-associated neurocognitive disorders (HAND) are not fully understood. In this review, we explore, in detail, what is currently known about mechanisms underlying opioid interactions with HIV, with emphasis on individual HIV-1-expressed gene products at the molecular, cellular and systems levels. Furthermore, we review preclinical and clinical studies with a focus on key considerations when addressing questions of whether opioid-HIV interactive pathogenesis results in unique structural or functional deficits not seen with either disease alone. These considerations include, understanding the combined consequences of HIV-1 genetic variants, host variants, and μ-opioid receptor (MOR) and HIV chemokine co-receptor interactions on the comorbidity. Lastly, we present topics that need to be considered in the future to better understand the unique contributions of opioids to the pathophysiology of neuroHIV. Graphical Abstract Blood-brain barrier and the neurovascular unit. With HIV and opiate co-exposure (represented below the dotted line), there is breakdown of tight junction proteins and increased leakage of paracellular compounds into the brain. Despite this, opiate exposure selectively increases the expression of some efflux transporters, thereby restricting brain penetration of specific drugs.
Collapse
Affiliation(s)
- Sylvia Fitting
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-3270, USA
| | - MaryPeace McRae
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Kurt F Hauser
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, 1217 East Marshall Street, Richmond, VA, 23298-0613, USA.
- Department of Anatomy and Neurobiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23298-0709, USA.
- Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 203 East Cary Street, Richmond, VA, 23298-0059, USA.
| |
Collapse
|
17
|
Desai N, Burns L, Gong Y, Zhi K, Kumar A, Summers N, Kumar S, Cory TJ. An update on drug-drug interactions between antiretroviral therapies and drugs of abuse in HIV systems. Expert Opin Drug Metab Toxicol 2020; 16:1005-1018. [PMID: 32842791 DOI: 10.1080/17425255.2020.1814737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION While considerable progress has been made in the fight against HIV/AIDS, to date there has not been a cure, and millions of people around the world are currently living with HIV/AIDS. People living with HIV/AIDS have substance abuse disorders at higher rates than non-infected individuals, which puts them at an increased risk of drug-drug interactions. AREAS COVERED Potential drug-drug interactions are reviewed for a variety of potential drugs of abuse, both licit and illicit. These drugs include alcohol, cigarettes or other nicotine delivery systems, methamphetamine, cocaine, opioids, and marijuana. Potential interactions include decreased adherence, modulation of drug transporters, or modulation of metabolic enzymes. We also review the relative incidence of the use of these drugs of abuse in People living with HIV/AIDS. EXPERT OPINION Despite considerable improvements in outcomes, disparities in outcomes between PLWHA who use drugs of abuse, vs those who do not still exist. It is of critical necessity to improve outcomes in these patients and to work with them to stop abusing drugs of abuse.
Collapse
Affiliation(s)
- Nuti Desai
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy , Memphis, TN, USA
| | - Leah Burns
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy , Memphis, TN, USA
| | - Yuqing Gong
- Department of Pharmacy Science, University of Tennessee Health Science Center College of Pharmacy , Memphis, TN, USA
| | - Kaining Zhi
- Plough Center for Sterile Drug Delivery Solutions, University of Tennessee Health Science Center , Memphis, TN, USA
| | - Asit Kumar
- Department of Pharmacy Science, University of Tennessee Health Science Center College of Pharmacy , Memphis, TN, USA
| | - Nathan Summers
- Division of Infectious Diseases, University of Tennessee Health Science Center College of Medicine , Memphis, TN, USA
| | - Santosh Kumar
- Department of Pharmacy Science, University of Tennessee Health Science Center College of Pharmacy , Memphis, TN, USA
| | - Theodore J Cory
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy , Memphis, TN, USA
| |
Collapse
|
18
|
Morici N, Cantoni S, Soriano F, Sacco A, Viola G, Esposito G, Oreglia JA, Cattaneo M, Savonitto S. Recurrent stent thrombosis in a patient with acute coronary syndrome and ischemic colitis: between life-threatening thrombosis and life-threatening bleeding. Platelets 2020; 31:820-824. [PMID: 31607192 DOI: 10.1080/09537104.2019.1678122] [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: 10/25/2022]
Abstract
Complete blood count should always be considered to tailor diagnosis and appropriate management in patients with acute ischemic heart disease. We present a challenging case of recurrent acute coronary syndrome, in the context of very high thrombotic risk due to concomitant inflammatory disease. Although no general guidelines exist for the switch between antiplatelet agents, particularly in the acute setting, in specific cases, the availability of different orally- and i.v.-acting agents and platelet function tests may allow to discriminate among multiple possible mechanisms of drug failure or side effects in the individual patient.
Collapse
Affiliation(s)
- Nuccia Morici
- Intensive Coronary Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano , Milan, Italy
| | - Silvia Cantoni
- Hematology Department, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy
| | - Francesco Soriano
- Interventional cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy
| | - Alice Sacco
- Intensive Coronary Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy
| | - Giovanna Viola
- Intensive Coronary Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy
| | - Giuseppe Esposito
- Interventional cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy.,Division of Cardiology, Università degli studi di Bari Aldo Moro , Bari, Italia.,Division of Cardiology, Policlinico Consorziale di Bari , Bari, Italia
| | - Jacopo A Oreglia
- Interventional cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , Milan, Italy
| | - Marco Cattaneo
- Dipartimento di Scienze della Salute, Università Degli Studi di Milano , Milan, Italy.,Unità di Medicina 3, ASST Santi Paolo e Carlo , Milan, Italy
| | | |
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW The present review aims to address the feasibility of opioid free anesthesia (OFA). The use of opioids to provide adequate perioperative pain management has been a central practice of anesthesia, and only recently has been challenged. Understanding the goals and challenges of OFA is essential as the approach to intraoperative analgesia and postsurgical management of pain has shifted in response to the opioid epidemic in the United States. RECENT FINDINGS OFA is an opioid sparing technique, which focuses on multimodal or balanced analgesia, relying on nonopioid adjuncts and regional anesthesia. Enhanced recovery after surgery protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery. SUMMARY The feasibility of OFA is evident. However, there are limitations of this approach that warrant discussion including the potential for adverse drug interactions with multimodal analgesics, the need for providers trained in regional anesthesia, and the management of pain expectations. Additionally, minimizing opioid use perioperatively also requires a change in current prescribing practices. Monitors that can reliably quantify nociception would be helpful in the titration of these analgesics and enable anesthesiologists to achieve the goal in providing personalized perioperative medicine.
Collapse
|
20
|
Kelty E, Hulse G, Joyce D, Preen DB. Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality. CNS Drugs 2020; 34:629-642. [PMID: 32215842 DOI: 10.1007/s40263-020-00719-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.
Collapse
Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia.
| | - Gary Hulse
- Division of Psychiatry, Medical School, The University of Western Australia, Perth, WA, Australia.,Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
| | - David Joyce
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA, 6009, Australia
| |
Collapse
|
21
|
Kim JH, Kim JY, Lee N, Yee J, Gwak HS. The impact of drug interactions on adverse effects of oral oxycodone in male geriatric patients. J Clin Pharm Ther 2020; 45:976-982. [PMID: 32068910 DOI: 10.1111/jcpt.13113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/05/2019] [Accepted: 01/06/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE With increased opioid use, drug-drug interactions (DDIs) and associated adverse events are growing among geriatric patients. However, the clinical significance of potential metabolic DDIs associated with opioid use has not been fully evaluated among geriatric patients. Particularly, cytochrome (CYP) P450 enzymes are important in drug metabolism of oxycodone and a black box warning for oxycodone reveals serious risks associated with drug-oxycodone interactions. This study focused on the use of oxycodone in geriatric patients to evaluate its adverse drug reactions (ADRs) and DDIs associated with CYP P450 enzymes. METHODS A retrospective cohort study using patients treated at Korea Veterans Hospital was performed. Data from male patients aged 65 years and older who received oxycodone were analysed. Binomial variables describing patient-related characteristics, drug-related characteristics and CYP-mediating drugs were constructed. Associations between these variables and the frequency of ADRs were determined. The odds ratio (OR) and adjusted odds ratio (AOR) were calculated from univariable and multivariable analyses, respectively. RESULTS AND DISCUSSION Among 111 patients, 32.4% experienced at least one ADR. The most common ADR was gastrointestinal-related (n = 21), followed by dizziness and drowsiness (n = 8). Use of either CYP2D6 inhibitors or CYP3A4 inhibitors increased the rate of ADRs by 20.4 and 25.4 times, respectively. In the case of patients taking both inhibitors, the adjusted OR was 48.6, and the attributable risk was 97.9%. WHAT IS NEW AND CONCLUSION This study suggests that inappropriate combinations of oxycodone with CYP2D6 inhibitors and/or CYP3A4 inhibitors may warrant treatment modification to avoid ADRs in geriatric patients. Clinicians should monitor any signs of ADRs that may reflect DDIs while a geriatric patient is taking oxycodone.
Collapse
Affiliation(s)
- Joo Hee Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea.,College of Pharmacy & Institute of Pharmaceutical Science and Technology, Ajou University, Suwon-si, Korea
| | - Ji Young Kim
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul, Korea.,Department of Pharmacy, Korea Veterans Hospital, Seoul, Korea
| | - Nari Lee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea.,Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul, Korea
| |
Collapse
|
22
|
Abstract
Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.
Collapse
|
23
|
Sum G, Koh GCH, Mercer SW, Wei LY, Majeed A, Oldenburg B, Lee JT. Patients with more comorbidities have better detection of chronic conditions, but poorer management and control: findings from six middle-income countries. BMC Public Health 2020; 20:9. [PMID: 31906907 PMCID: PMC6945654 DOI: 10.1186/s12889-019-8112-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/19/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The burden of non-communicable diseases (NCDs) is rising rapidly in middle-income countries (MICs), where NCDs are often undiagnosed, untreated and uncontrolled. How comorbidity impacts diagnosis, treatment, and control of NCDs is an emerging area of research inquiry and have important clinical implications as highlighted in the recent National Institute for Health and Care Excellence guidelines for treating patients suffering from multiple NCDs. This is the first study to examine the association between increasing numbers of comorbidities with being undiagnosed, untreated, and uncontrolled for NCDs, in 6 large MICs. METHODS Cross-sectional analysis of the World Health Organisation Study of Global Ageing and Adult Health (WHO SAGE) Wave 1 (2007-10), which consisted of adults aged ≥18 years from 6 populous MICs, including China, Ghana, India, Mexico, Russia and South Africa (overall n = 41, 557). RESULTS A higher number of comorbidities was associated with better odds of diagnosis for hypertension, angina, and arthritis, and higher odds of having treatment for hypertension and angina. However, more comorbidities were associated with increased odds of uncontrolled hypertension, angina, arthritis, and asthma. Comorbidity with concordant conditions was associated with improved diagnosis and treatment of hypertension and angina. CONCLUSION Patients with more comorbidities have better diagnosis of chronic conditions, but this does not translate into better management and control of these conditions. Patients with multiple NCDs are high users of health services and are at an increased risk of adverse health outcomes. Hence, improving their access to care is a priority for healthcare systems.
Collapse
Affiliation(s)
- Grace Sum
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Tahir Foundation Building, Singapore, 117549, Singapore.
| | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Tahir Foundation Building, Singapore, 117549, Singapore
| | - Stewart W Mercer
- Primary Care and Multimorbidity, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland
| | - Lim Yee Wei
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England
| | - Brian Oldenburg
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - John Tayu Lee
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Tahir Foundation Building, Singapore, 117549, Singapore.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England.,Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| |
Collapse
|
24
|
Hu Y, Wang R, Chen F. Bi-submodular Optimization (BSMO) for Detecting Drug-Drug Interactions (DDIs) from On-line Health Forums. JOURNAL OF HEALTHCARE INFORMATICS RESEARCH 2019; 3:19-42. [PMID: 35415422 PMCID: PMC8982730 DOI: 10.1007/s41666-018-0032-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 11/29/2022]
Abstract
Online health discussion forums as information exchange repository are used by different patient groups for sharing experience and seeking advice. Their accessibility is tremendously expanded in the last decade with the rapid growth of mobile internet. Among many popular topics, "drug-drug interactions" (DDIs) forum embeds a large number of DDIs hazards patient experienced however not published. In this paper, we intend to uncover the potential DDIs from the online forums and formulate the task as a sub-graph detection problem, such that co-mentioned drugs and symptoms are modeled as vertices, along with the occurrences are modeled as weighted edges. Therefore, a connected sub-graph consisting of both symptoms and drug vertices reveals DDIs occurrence. We then propose a novel bi-submodular function to characterize the likelihood of DDI occurrence within a connected sub-graph and apply an approximated algorithm to resolve the bi-submodular optimization (BSMO). The complexity of the algorithm is nearly linear. Our extensive experiments demonstrate the effectiveness and efficiency of the proposed approach.
Collapse
Affiliation(s)
- Yan Hu
- Department of Computer Science, State University of New York at Albany, Albany, NY 12222 USA
| | - Rui Wang
- Department of Computer Science, State University of New York at Albany, Albany, NY 12222 USA
| | - Feng Chen
- Department of Computer Science, State University of New York at Albany, Albany, NY 12222 USA
| |
Collapse
|
25
|
Affiliation(s)
- J A Jeevendra Martyn
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Shriners Hospital for Children, and Harvard Medical School - all in Boston
| | - Jianren Mao
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Shriners Hospital for Children, and Harvard Medical School - all in Boston
| | - Edward A Bittner
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Shriners Hospital for Children, and Harvard Medical School - all in Boston
| |
Collapse
|
26
|
Richeval C, Gaulier JM, Romeuf L, Allorge D, Gaillard Y. Case report: relevance of metabolite identification to detect new synthetic opioid intoxications illustrated by U-47700. Int J Legal Med 2018; 133:133-142. [PMID: 30443678 DOI: 10.1007/s00414-018-1969-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 11/09/2018] [Indexed: 01/11/2023]
Abstract
Today, new psychoactive substances (NPS) producers increasingly appear to be targeting new synthetic opioids (NSOs), and the recent emergence of NSOs is causing considerable concern in North America and in Europe. For toxicologists, NSO detection in a forensic context presents three additional difficulties to the general NPS analytical detection challenge: (i) high frequency of new products, (ii) low concentrations (in μg/L range and under) in biological samples related to their high opioid potency, and (iii) extensive metabolism. In this context, the present work aims to highlight the relevance of NSO metabolite detection in potential intoxication cases. Illustration is given with U-47700, an emerging NSO, (i) that was identified in a powder recently collected in France and in a fatality case, (ii) whose metabolites were in vitro produced using human liver microsomes and their mass spectra (MS) added in our MS/MS and HRMS libraries, and (iii) for which metabolism data were compared to those of the literature: U-47700 was identified in the powder and at 3040 μg/L in peripheral blood in the fatality case. In addition, high amounts of several U-47700 metabolites, especially N-desmethyl-U-47700, were observed in urine. Even if metabolite formation may largely depend on the enzymatic activity as well as on the length of the survival time, confrontation of these results to data found in the literature strongly suggests that this metabolite is regularly a better blood and (mainly) urine biomarker of U-47700 intake than U-47700 itself. Indeed, in this fatality and in other previous reports, N-desmethyl-U-47700 produced the main observed chromatographic signal (i) systematically in vitro and (ii) commonly in vivo, especially in urines. N,N-Didesmethyl-U-47700 is also sometimes a better biomarker of U-47700 intake than U-47700 itself. Accordingly, we suggest adding N-desmethyl-U-47700 (and N,N-didesmethyl-U-47700) in mass spectrum databases used for toxicological screening in order to reduce the risk of false-negative results in intoxication cases involving U-47700.
Collapse
Affiliation(s)
- Camille Richeval
- Unité Fonctionnelle de Toxicologie, CHU Lille, 59000, Lille, France.,EA 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, University of Lille, 59000, Lille, France
| | - Jean-Michel Gaulier
- Unité Fonctionnelle de Toxicologie, CHU Lille, 59000, Lille, France. .,EA 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, University of Lille, 59000, Lille, France.
| | | | - Delphine Allorge
- Unité Fonctionnelle de Toxicologie, CHU Lille, 59000, Lille, France.,EA 4483 - IMPECS - IMPact de l'Environnement Chimique sur la Santé humaine, University of Lille, 59000, Lille, France
| | | |
Collapse
|
27
|
Dagostino C, Allegri M, Napolioni V, D'Agnelli S, Bignami E, Mutti A, van Schaik RH. CYP2D6 genotype can help to predict effectiveness and safety during opioid treatment for chronic low back pain: results from a retrospective study in an Italian cohort. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:179-191. [PMID: 30425549 PMCID: PMC6205525 DOI: 10.2147/pgpm.s181334] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Opioids are widely used for chronic low back pain (CLBP); however, it is still unclear how to predict their effectiveness and safety. Codeine, tramadol and oxycodone are metabolized by CYP/CYP450 2D6 (CYP2D6), a highly polymorphic enzyme linked to allele-specific related differences in metabolic activity. Purpose CYP2D6 genetic polymorphisms could potentially help to predict the effectiveness and safety of opioid-based drugs in clinical practice, especially in the treatment of CLBP. Patients and methods A cohort of 224 Italian patients with CLBP treated with codeine or oxycodone was retrospectively evaluated to determine whether adverse reactions and effectiveness were related to CYP2D6 single-nucleotide polymorphisms. CYP2D6 genotyping was performed using the xTAG® CYP2D6 Kit v3 (Luminex) to determine CYP2D6 metabolizer phenotype (poor, intermediate, rapid and ultrarapid). Subjects from the cohort were categorized into two groups according to the occurrence of side effects (Case) or benefit (Control) after chronic analgesic treatment. The impact of CYP2D6 polymorphism on treatment outcome was tested at the metabolizer phenotype, diplotype and haplotype levels. Results CYP2D6 polymorphism was significantly associated with opioid treatment outcome (Omnibus P=0.018, for both global haplotype and diplotype distribution test). CYP2D6*6 and *9 carriers, alleles characterized by a reduced (*9) or absent (*6) enzymatic activity, were significantly (P<0.05) associated with therapeutic failure. CYP2D6 ultrarapid metabolizers (CYP2D6*2N patients) showed an increased risk of side effects, as would be predicted. Despite their low frequency, CYP2D6 *1/*11, *4/*6 and *41/* 2N diplotypes showed significant (P<0.05) associations of efficacy and side effects with chronic opioid treatment. Conclusion Our results showed that reduced CYP2D6 activity is correlated with lack of therapeutic effect. We found that the pharmacogenetic analysis of CYP2D6 could be helpful in foreseeing the safety and effectiveness of codeine or oxycodone treatment in CLBP.
Collapse
Affiliation(s)
- Concetta Dagostino
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy, .,Study In Multidisciplinary Pain Research (SIMPAR), Milan 20100, Italy,
| | - Massimo Allegri
- Study In Multidisciplinary Pain Research (SIMPAR), Milan 20100, Italy, .,Anesthesia and Intensive Care Department, IRCCS Multi Medica Hospital, Milan 20099, Italy.,Italian Pain Institute, Milan 20100, Italy
| | - Valerio Napolioni
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA 94305, USA
| | - Simona D'Agnelli
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy,
| | - Elena Bignami
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy,
| | - Antonio Mutti
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy,
| | - Ron Hn van Schaik
- Department of Clinical Chemistry, Erasmus MC, 3000 Rotterdam, The Netherlands
| |
Collapse
|
28
|
Pérez-Mañá C, Papaseit E, Fonseca F, Farré A, Torrens M, Farré M. Drug Interactions With New Synthetic Opioids. Front Pharmacol 2018; 9:1145. [PMID: 30364252 PMCID: PMC6193107 DOI: 10.3389/fphar.2018.01145] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/21/2018] [Indexed: 12/31/2022] Open
Abstract
Fentanyl, fentanyl analogs, and other new synthetic opioids (NSO) have burst onto the illegal drug market as new psychoactive substances (NPS). They are often sold as heroin to unsuspecting users and produce euphoria through their agonist action on μ- opioid receptors. Their high consumption, often combined with other substances, has led to multiple intoxications during recent years. In some countries, such as the United States, the consumption of opioids, whether for medical or recreational purposes, has become epidemic and is considered a public health problem. Fentanyl analogs are more potent than fentanyl which in turn is 50 times more potent than morphine. Furthermore, some fentanyl analogs have longer duration of action and therefore interactions with other substances and medicines can be more serious. This review is focused on the potentially most frequent interactions of opioid NPS taking into account the drugs present in the reported cases of poly-intoxication, including other illegal drugs of abuse and medication. Substances involved are mainly antidepressants, antihistamines, antipsychotics, benzodiazepines, analgesics, anesthetics, psychostimulants, other opioids, alcohol, and illegal drugs of abuse. The interactions can be produced due to pharmacokinetic and pharmacodynamic mechanisms. Naloxone can be used as an antidote, although required doses might be higher than for traditional opioid intoxications. It is crucial that doctors who habitually prescribe opioids, which are often misused by patients and NPS users, be aware of designer opioids' potentially life-threatening drug-drug interactions in order to prevent new cases of intoxication.
Collapse
Affiliation(s)
- Clara Pérez-Mañá
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| | - Esther Papaseit
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| | - Francina Fonseca
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Adriana Farré
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Marta Torrens
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Magi Farré
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| |
Collapse
|
29
|
|
30
|
Abstract
Our goal consisted of describing the 4-year prevalence, contributors, and interventions for long QTc's in methadone maintenance treatment. Cardiologists' diagnosis of long QTc defined case-ness in 62 patients. Long QTc categories, drawn from epidemiological reports, encompassed 440 to 469 (borderline), 470 to 499 (moderate), and 500+ milliseconds (severe). Data collection included electrocardiograms, demographic characteristics, contributors to long QTc, and interventions-plus-outcomes (defined by resolution of long QTc). Of 62 patients, 21 had 39 long QTc episodes-a 4-year case prevalence of 34%, and an annual episode incidence of 15.7 per 100. Contributing factors identified in 36 of 39 episodes consisted of medication management (n = 19), illicit drug use (n = 11), and other factors (n = 6). Long QTc reverted to normal in 38 of 39 episodes. Of 21 patients, 12 (57%) experienced one or two recurrences. Methadone maintenance treatment physicians normalized most episodes as outpatients, often in collaboration with patients' primary care physicians. One fifth of episodes required hospitalization and other specialty care. Lack of timely QTc normalization may have accounted for one sudden death.
Collapse
|