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Iversen DB, Andersen NE, Dalgård Dunvald A, Pottegård A, Stage TB. Drug metabolism and drug transport of the 100 most prescribed oral drugs. Basic Clin Pharmacol Toxicol 2022; 131:311-324. [PMID: 35972991 PMCID: PMC9804310 DOI: 10.1111/bcpt.13780] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 01/05/2023]
Abstract
Safe and effective use of drugs requires an understanding of metabolism and transport. We identified the 100 most prescribed drugs in six countries and conducted a literature search on in vitro data to assess contribution of Phase I and II enzymes and drug transporters to metabolism and transport. Eighty-nine of the 100 drugs undergo drug metabolism or are known substrates for drug transporters. Phase I enzymes are involved in metabolism of 67 drugs, while Phase II enzymes mediate metabolism of 18 drugs. CYP3A4/5 is the most important Phase I enzyme involved in metabolism of 43 drugs followed by CYP2D6 (23 drugs), CYP2C9 (23 drugs), CYP2C19 (22 drugs), CYP1A2 (14 drugs) and CYP2C8 (11 drugs). More than half of the drugs (54 drugs) are known substrates for drug transporters. P-glycoprotein (P-gp) is known to be involved in transport of 30 drugs, while breast cancer resistance protein (BCRP) facilitates transport of 11 drugs. A considerable proportion of drugs are subject to a combination of Phase I metabolism, Phase II metabolism and/or drug transport. We conclude that the majority of the most frequently prescribed drugs depend on drug metabolism or drug transport. Thus, understanding variability of drug metabolism and transport remains a priority.
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Affiliation(s)
- Ditte B. Iversen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Nanna Elman Andersen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Ann‐Cathrine Dalgård Dunvald
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Anton Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Tore B. Stage
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
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2
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Nagpal AS, Lodge DJ, Potter JS, Frazer A, Tragus R, Curtis ME, Boley AM, Eckmann M. Analgesic Effects of Oxycodone in Combination With Risperidone or Ziprasidone: Results From a Pilot Randomized Controlled Trial in Healthy Volunteers. FRONTIERS IN PAIN RESEARCH 2022; 3:752256. [PMID: 35295795 PMCID: PMC8915578 DOI: 10.3389/fpain.2022.752256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background and ObjectivesPatients taking opioids are at risk of developing dependence and possibly abuse. Given the role of the mesolimbic dopamine system in opioid reward, blocking dopamine D2 receptors should limit the abuse liability of opioid analgesics. This pilot study evaluates the analgesic efficacy of oxycodone combined with an atypical antipsychotic (dopamine D2 receptor antagonist).MethodsA randomized, double-blind, within-subjects, controlled trial in healthy volunteers was conducted at UT Health SA Pain Clinic. Fifteen volunteers with previous medical exposure to opioids were enrolled. Risperidone (2 mg) or ziprasidone (80 mg) in combination with oxycodone (5, 10, 15 mg) was administered. Pain intensity using the cold pressor test, Current Opioid Misuse Measure (COMM), Addiction Research Center Inventory (ARCI, opioid subscale), Drug likability with drug effects questionnaire (DEQ) were assessed.ResultsOxycodone produced dose dependent increases in thermal analgesia on the cold pressor test that was significant at 10 and 15 mg (t = 3.087, P = 0.017). The combination did not significantly alter thermal analgesia. There was no significant effect of the combination on the ARCI or the POMS.Discussion and ConclusionThe combination of an atypical antipsychotic with oxycodone does not alter analgesic response or increase the incidence of adverse effects when compared to oxycodone alone. Such information is critical for the development of drug combinations for the treatment of pain and provide the foundation for future studies of abuse potential in drug users.Scientific SignificanceThis intervention in chronic pain patients is unique because it utilizes FDA approved drugs in combination to reduce abuse liability. The first step, and aim of this study, is to confirm the drug combination does not interfere with analgesic efficacy. The next step is to examine the combination in recreational drug users to assess the potential to block the euphoric effects of oxycodone. Ultimately, if this combination is effective, this approach could be beneficial in management of chronic pain.
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Affiliation(s)
- Ameet S. Nagpal
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, United States
| | - Daniel J. Lodge
- Department of Pharmacology, UT Health San Antonio, San Antonio, TX, United States
| | - Jennifer S. Potter
- Department of Psychiatry, UT Health San Antonio, San Antonio, TX, United States
| | - Alan Frazer
- Department of Pharmacology, UT Health San Antonio, San Antonio, TX, United States
| | - Robin Tragus
- Department of Pediatrics, UT Health San Antonio, San Antonio, TX, United States
| | - Megan E. Curtis
- Department of Psychiatry, UT Health San Antonio, San Antonio, TX, United States
- Department of Psychology, University of Texas at San Antonio, San Antonio, TX, United States
| | - Angela M. Boley
- Department of Pharmacology, UT Health San Antonio, San Antonio, TX, United States
- *Correspondence: Angela M. Boley ; orcid.org/0000-0003-0253-1481
| | - Maxim Eckmann
- Department of Anesthesiology, UT Health San Antonio, San Antonio, TX, United States
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3
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Reizine N, Danahey K, Schierer E, Liu P, Middlestadt M, Ludwig J, Truong TM, van Wijk XMR, Yeo KTJ, Malec M, Ratain MJ, O'Donnell PH. Impact of CYP2D6 Pharmacogenomic Status on Pain Control Among Opioid-Treated Oncology Patients. Oncologist 2021; 26:e2042-e2052. [PMID: 34423496 DOI: 10.1002/onco.13953] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Several opioids have pharmacogenomic associations impacting analgesic efficacy. However, germline pharmacogenomic testing is not routinely incorporated into supportive oncology. We hypothesized that CYP2D6 profiling would correlate with opioid prescribing and hospitalizations. MATERIALS AND METHODS We analyzed 61,572 adult oncology patients from 2012 to 2018 for opioid exposures. CYP2D6 metabolizer phenotype (ultra-rapid [UM], normal metabolizer [NM], intermediate [IM], or poor [PM]), the latter two of which may cause inefficacy of codeine, tramadol, and standard-dose hydrocodone, was determined for patients genotyped for reasons unrelated to pain. The primary endpoint was number of opioid medications received during longitudinal care (IM/PMs vs. NMs). Secondary endpoint was likelihood of pain-related hospital encounters. RESULTS Most patients with cancer (n = 34,675, 56%) received multiple opioids (average 2.8 ± 1.6/patient). Hydrocodone was most commonly prescribed (62%), followed by tramadol, oxycodone, and codeine. In the CYP2D6 genotyped cohort (n = 105), IM/PMs received a similar number of opioids (3.4 ± 1.4) as NMs (3.3 ± 1.9). However, IM/PMs were significantly more likely to experience pain-related hospital encounters compared with NMs, independent of other variables (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-23.6; p = .03). IM/PMs were also more likely to be treated with later-line opioids that do not require CYP2D6 metabolism, such as morphine and hydromorphone (OR = 3.3; 95% CI, 1.1-9.8; p = .03). CONCLUSION CYP2D6 genotype may identify patients with cancer at increased risk for inadequate analgesia when treated with typical first-line opioids like codeine, tramadol, or standard-dose hydrocodone. Palliative care considerations are an integral part of optimal oncology care, and these findings justify prospective evaluation of preemptive genotyping as a strategy to improve oncology pain management. IMPLICATIONS FOR PRACTICE Genomic variation in metabolic enzymes can predispose individuals to inefficacy when receiving opioid pain medications. Patients with intermediate and/or poor CYP2D6 metabolizer status do not adequately convert codeine, tramadol, and hydrocodone into active compounds, with resulting increased risk of inadequate analgesia. This study showed that patients with cancer frequently receive CYP2D6-dependent opioids. However, patients with CYP2D6 intermediate and poor metabolizer status had increased numbers of pain-related hospitalizations and more frequently required the potent non-CYP2D6 opioids morphine and hydromorphone. This may reflect inadequate initial analgesia with the common "first-line" CYP2D6-metabolized opioids. Preemptive genotyping to guide opioid prescribing during cancer care may improve pain-related patient outcomes.
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Affiliation(s)
- Natalie Reizine
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA.,Center for Research Informatics, University of Chicago, Chicago, Illinois, USA
| | - Emily Schierer
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Ping Liu
- Department of Public Health Services, University of Chicago, Chicago, Illinois, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Jenna Ludwig
- Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Tien M Truong
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Xander M R van Wijk
- Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Kiang-Teck J Yeo
- Department of Pathology, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Monica Malec
- Section of Geriatric and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Mark J Ratain
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
| | - Peter H O'Donnell
- Section of Geriatric and Palliative Medicine, University of Chicago Medical Center and Biological Sciences, Chicago, Illinois, USA.,Center for Personalized Therapeutics, University of Chicago, Chicago, Illinois, USA
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4
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Zheng NS, Stone CA, Jiang L, Shaffer CM, Kerchberger VE, Chung CP, Feng Q, Cox NJ, Stein CM, Roden DM, Denny JC, Phillips EJ, Wei WQ. High-throughput framework for genetic analyses of adverse drug reactions using electronic health records. PLoS Genet 2021; 17:e1009593. [PMID: 34061827 PMCID: PMC8195357 DOI: 10.1371/journal.pgen.1009593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 06/11/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022] Open
Abstract
Understanding the contribution of genetic variation to drug response can improve the delivery of precision medicine. However, genome-wide association studies (GWAS) for drug response are uncommon and are often hindered by small sample sizes. We present a high-throughput framework to efficiently identify eligible patients for genetic studies of adverse drug reactions (ADRs) using “drug allergy” labels from electronic health records (EHRs). As a proof-of-concept, we conducted GWAS for ADRs to 14 common drug/drug groups with 81,739 individuals from Vanderbilt University Medical Center’s BioVU DNA Biobank. We identified 7 genetic loci associated with ADRs at P < 5 × 10−8, including known genetic associations such as CYP2D6 and OPRM1 for CYP2D6-metabolized opioid ADR. Additional expression quantitative trait loci and phenome-wide association analyses added evidence to the observed associations. Our high-throughput framework is both scalable and portable, enabling impactful pharmacogenomic research to improve precision medicine. Adverse drug reactions are a considerable burden on the healthcare system. Genetic studies can improve our understanding of the pathophysiological mechanisms of adverse drug reactions but have been hindered by small sample sizes. Drug responses are less often recorded than physiological traits and common diseases. Here, we present a high-throughput framework to efficiently identify eligible patients for genetic studies of adverse drug reactions from electronic health records. We validated our approach by conducting genome-wide association studies for adverse reactions to 14 common drug/drug groups with 81,739 individuals from Vanderbilt University Medical Centre’s BioVU DNA Biobank, identifying 7 genetic loci associated with adverse drug reactions. Our high-throughput framework can enable impactful pharmacogenomic research to help develop clinical guidelines for the delivery of the right drug to the right person.
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Affiliation(s)
- Neil S. Zheng
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Lan Jiang
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Christian M. Shaffer
- Tennessee Valley Healthcare System—Nashville Campus, Nashville, Tennessee, United States of America
| | - V. Eric Kerchberger
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Cecilia P. Chung
- Division of Rheumatology & Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Tennessee Valley Healthcare System—Nashville Campus, Nashville, Tennessee, United States of America
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - QiPing Feng
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Nancy J. Cox
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - C. Michael Stein
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Pharmacology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Dan M. Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Pharmacology, Vanderbilt University, Nashville, Tennessee, United States of America
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Joshua C. Denny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Elizabeth J. Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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5
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Luo S, Jiang R, Grzymski JJ, Lee W, Lu JT, Washington NL. Comprehensive Allele Genotyping in Critical Pharmacogenes Reduces Residual Clinical Risk in Diverse Populations. Clin Pharmacol Ther 2021; 110:759-767. [PMID: 33930192 PMCID: PMC8453755 DOI: 10.1002/cpt.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
Genomic‐guided pharmaceutical prescribing is increasingly recognized as an important clinical application of genetics. Accurate genotyping of pharmacogenomic (PGx) genes can be difficult, owing to their complex genetic architecture involving combinations of single‐nucleotide polymorphisms and structural variation. Here, we introduce the Helix PGx database, an open‐source star allele, genotype, and resulting metabolic phenotype frequency database for CYP2C9, CYP2C19, CYP2D6, and CYP4F2, based on short‐read sequencing of >86,000 unrelated individuals enrolled in the Helix DNA Discovery Project. The database is annotated using a pipeline that is clinically validated against a broad range of alleles and designed to call CYP2D6 structural variants with high (98%) accuracy. We find that CYP2D6 has greater allelic diversity than the other genes, manifest in both a long tail of low‐frequency star alleles, as well as a disproportionate fraction (36%) of all novel predicted loss‐of‐function variants identified. Across genes, we observe that many rare alleles (<0.1% frequency) in the overall cohort have 10 times higher frequency in one or more subgroups with non‐European genetic ancestry. Extending these PGx genotypes to predicted metabolic phenotypes, we demonstrate that >90% of the cohort harbors a high‐risk variant in one of the four pharmacogenes. Based on the recorded prescriptions for >30,000 individuals in the Healthy Nevada Project, combined with predicted PGx metabolic phenotypes, we anticipate that standard‐of‐care screening of these 4 pharmacogenes could impact nearly half of the general population.
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Affiliation(s)
| | | | - Joseph J Grzymski
- Desert Research Institute, Reno, Nevada, USA.,Renown Institute of Health Innovation, Reno, Nevada, USA
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6
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Bonezzi C, Fornasari D, Cricelli C, Magni A, Ventriglia G. Pharmacological Management of Adults with Chronic Non-Cancer Pain in General Practice. Pain Ther 2020; 9:17-28. [PMID: 33315207 PMCID: PMC7736454 DOI: 10.1007/s40122-020-00218-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022] Open
Abstract
Chronic pain is a public health priority that affects about 20% of the general population, causing disability and impacting productivity and quality of life. It is often managed in the primary care setting. Chronic pain management is most effective when the pain mechanism has been identified and addressed by appropriate therapy. This document provides an overview of pharmacological therapy for chronic non-cancer pain in the primary care setting, with the aim of improving treatment decisions based on the underlying pain mechanisms and pain neuroscience.
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Affiliation(s)
- Cesare Bonezzi
- ICS Maugeri IRCCS, Via Salvatore Maugeri 10, Pavia, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Università Degli Studi Di Milano, Via Vanvitelli 32, Milan, Italy.
| | - Claudio Cricelli
- SIMG (Italian College of General Practitioners and Primary Care), Via Del Sansovino 179, Florence, Italy
| | - Alberto Magni
- SIMG (Italian College of General Practitioners and Primary Care), Via Del Sansovino 179, Florence, Italy
| | - Giuseppe Ventriglia
- SIMG (Italian College of General Practitioners and Primary Care), Via Del Sansovino 179, Florence, Italy
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7
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Acute pain and side effects after tramadol in breast cancer patients: results of a prospective double-blind randomized study. Sci Rep 2020; 10:18766. [PMID: 33127945 PMCID: PMC7599328 DOI: 10.1038/s41598-020-75961-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/16/2020] [Indexed: 11/23/2022] Open
Abstract
The objective of this study was to evaluate the severity of acute pain and side effects in breast cancer patients postoperatively treated with two regimens of tramadol with paracetamol in a prospective double-blind study. Altogether 117 breast cancer patients who had axillary lymphadenectomy were randomized into two analgesic study groups and the analgesic treatment lasted 4 weeks. Stronger analgesia group received every 8 h 75/650 mg of tramadol with paracetamol, while weaker analgesia group received every 8 h 37.5/325 mg of tramadol with paracetamol. Patients with the higher dose of tramadol had less pain during the 1st and 4th week than patients with the lower dose. Frequency of nausea, vomiting, lymphedema or range of shoulder movement was not significantly different between the two groups of patients. Constipation was significantly more common in the group with stronger analgesia during the 2nd week in comparison to patients with weaker analgesia. The patients who were on 75/650 mg of tramadol with paracetamol had less pain in comparison to patients who were on 37.5/325 mg. Side effects were mild, but common in both groups of patients.
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8
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Boyle J, Stock CJ. CYP2D6 Expression in Veterans Experiencing Opioid Overdose: A Postmortem Review. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:289-293. [PMID: 32848444 PMCID: PMC7429207 DOI: 10.2147/pgpm.s261424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/20/2022]
Abstract
Purpose The purpose is to characterize the CYP2D6 genotype and predict the phenotype of decedents of opioid overdose to determine if the ultrarapid (UM) phenotype is over-represented in opioid overdose deaths. CYP2D6 is the enzyme responsible for metabolism of various opioids implicated in overdose. The UM group may be at greater risk for overdose due to the rapid metabolism of hydrocodone, oxycodone, or tramadol to more active/potent metabolites than their peers with (poor) PM, (intermediate) IM, or (extensive) EM metabolic phenotypes. Patients and Methods Blood samples obtained during autopsy following an opioid overdose from 75 US military veteran decedents prescribed hydrocodone, oxycodone, or tramadol from one VA medical center were analyzed. DNA extraction, CYP2D6 genotyping, and copy number variation (CNV) testing were performed using the iPLEX® genotyping assay and MassARRAY. Phenotype prediction was based on Clinical Pharmacogenetics Implementation Consortium (CPIC) recommendations. Toxicology results were obtained from Medical Examiner reports of the deceased. Prescription medication information was extracted from archived medical records. Results The majority of the sample had a phenotype of EM metabolizer (75%), with 7% of the total sample having a UM metabolizer phenotype. In addition to hydrocodone, oxycodone, and tramadol (found in 41% of opioid positive samples), other opioids found in toxicology tests included diacetylmorphine, fentanyl, buprenorphine, and methadone. Two or more substances, including alcohol, benzodiazepines, and other potentially sedating medications, were found in nearly half of the opioid positive toxicology samples. Conclusion In this study, 7% of veteran decedents of opioid overdose had CYP2D6 UM metabolic phenotype. The small sample size precludes a conclusion that the frequency of UM phenotype is greater than expected in North American Caucasian groups. The findings in this study do not support the hypothesis that the UM phenotype is over-represented in opioid overdose.
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Affiliation(s)
- Julia Boyle
- Department of Pharmacy, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Pharmacy Practice, Idaho State University College of Pharmacy, Meridian, ID, USA
| | - Christopher J Stock
- Department of Pharmacy, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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9
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Lopes GS, Bielinski SJ, Moyer AM, Black Iii JL, Jacobson DJ, Jiang R, Larson NB, St Sauver JL. Sex Differences in Associations Between CYP2D6 Phenotypes and Response to Opioid Analgesics. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:71-79. [PMID: 32214840 PMCID: PMC7081062 DOI: 10.2147/pgpm.s239222] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/03/2020] [Indexed: 12/15/2022]
Abstract
Background Several small studies have previously investigated associations between the cytochrome P450 2D6 (CYP2D6) metabolism and response to opioids. We used a large sample of patients to study associations between CYP2D6 phenotypes and estimated CYP2D6 enzymatic activity scores with pain control and adverse reactions related to codeine and tramadol use. We conducted additional analyses to determine whether our results were consistent among men and women. Methods We used data from 2,877 participants in the RIGHT Protocol who were prescribed codeine and/or tramadol between 01/01/2005 and 12/31/2017 and who were not prescribed CYP2D6 inhibitors within 1 year prior to the opioid prescription. CYP2D6 phenotype categories were condensed into four groups: (1) Ultra-rapid and Rapid (n = 61), (2) Normal and Intermediate to Normal (n = 1,448), (3) Intermediate and Intermediate to Poor (n = 1,175), and (4) Poor metabolizer status (n = 193). Opioid-related outcomes included indications of poor pain control or adverse reactions related to medication use. We modeled the risk of each outcome using logistic regression, adjusting for age, sex, race, and ethnicity. Results The results revealed a trend from poor to ultra-rapid and rapid CYP2D6 phenotypes in which the risk of adverse reactions incrementally increased and the risk of poor pain control incrementally decreased. This trend reached statistical significance among female (but not male) participants. Among normal and intermediate to normal metabolizers, a larger proportion of women experienced adverse reactions relative to men. Discussion We replicated and extended the findings of previous research indicating associations between CYP2D6 phenotypes and response to opioids. In addition, the observed associations were stronger in women than in men. We recommend sex differences to be factored in future research investigating associations between pharmacogenomics and response to medications.
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Affiliation(s)
- Guilherme S Lopes
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ann M Moyer
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - John Logan Black Iii
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Debra J Jacobson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ruoxiang Jiang
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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10
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Bielinski SJ, St Sauver JL, Olson JE, Larson NB, Black JL, Scherer SE, Bernard ME, Boerwinkle E, Borah BJ, Caraballo PJ, Curry TB, Doddapaneni H, Formea CM, Freimuth RR, Gibbs RA, Giri J, Hathcock MA, Hu J, Jacobson DJ, Jones LA, Kalla S, Koep TH, Korchina V, Kovar CL, Lee S, Liu H, Matey ET, McGree ME, McAllister TM, Moyer AM, Muzny DM, Nicholson WT, Oyen LJ, Qin X, Raj R, Roger VL, Rohrer Vitek CR, Ross JL, Sharp RR, Takahashi PY, Venner E, Walker K, Wang L, Wang Q, Wright JA, Wu TJ, Wang L, Weinshilboum RM. Cohort Profile: The Right Drug, Right Dose, Right Time: Using Genomic Data to Individualize Treatment Protocol (RIGHT Protocol). Int J Epidemiol 2020; 49:23-24k. [PMID: 31378813 PMCID: PMC7124480 DOI: 10.1093/ije/dyz123] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2019] [Indexed: 12/29/2022] Open
Affiliation(s)
- Suzette J Bielinski
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Janet E Olson
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nicholas B Larson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - John L Black
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Steven E Scherer
- Human Genome Sequencing Center, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | | | - Eric Boerwinkle
- Human Genome Sequencing Center, Department of Molecular and Human Genetics, Baylor College of Medicine, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Bijan J Borah
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Pedro J Caraballo
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy B Curry
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Robert R Freimuth
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Richard A Gibbs
- Human Genome Sequencing Center, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Jyothsna Giri
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew A Hathcock
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jianhong Hu
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Debra J Jacobson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Leila A Jones
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara Kalla
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Viktoriya Korchina
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Christie L Kovar
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Sandra Lee
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Hongfang Liu
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Eric T Matey
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Michaela E McGree
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Donna M Muzny
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Wayne T Nicholson
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lance J Oyen
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Xiang Qin
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Ritika Raj
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Véronique L Roger
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Richard R Sharp
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric Venner
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Kimberly Walker
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Liwei Wang
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Qiaoyan Wang
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Jessica A Wright
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Tsung-Jung Wu
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Liewei Wang
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Richard M Weinshilboum
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Clinical Pharmacology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
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Ferreira V, Velloso M, Landoni M. Bioavailability of butorphanol after intranasal administration to horses. BULGARIAN JOURNAL OF VETERINARY MEDICINE 2020. [DOI: 10.15547/bjvm.2019-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of the present study was to describe butorphanol pharmacokinetics and bioavailability following intranasal administration to horses. Six adult horses received 0.05 mg/kg butorphanol, in a randomised crossover design, by either intravenous or intranasal route. Plasma concentrations of butorphanol were measured at predetermined time points using liquid chromatography/mass spectrometry assay. After intravenous injection, mean ±SD butorphanol steady-state volume of distribution and clearance was 3.20 ± 1.77 l/kg and 3.18 ± 1.47 L/kg/h, respectively. Terminal half-lives for butorphanol after intravenous and intranasal administrations were 0.68 ± 0.17 h and 1.79 ± 1.43 h. For intranasal administration, absorption half-life and peak plasma concentration were 0.43 ± 0.33 h and 1.95 ± 1.7 ng/mL, respectively. Bioavailability was 54.45 ± 20.09%. Intranasal butorphanol administration in horses is practical, not stressful and well tolerated. Therefore, it might be a substitute to the intravenous route in adult horses
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Rocco R, Thiels CA, Ubl DS, Moyer AM, Habermann EB, Cassivi SD. Use of pharmacogenetic data to guide individualized opioid prescribing after surgery. Surgery 2019; 166:476-482. [PMID: 31320226 DOI: 10.1016/j.surg.2019.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/28/2019] [Accepted: 04/07/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Despite the current strategies aimed at avoiding opioid overprescription by implementing institutional guidelines, the use of opioids after surgical procedures remains highly variable. It is well known that opioids are activated by the cytochrome p450 CYP2D6 enzyme to exert pharmacologic effect. Individual variation in CYP2D6 activity affects drug metabolism, and genotyping can be performed to predict an individual's ability to metabolize CYP2D6 substrates. We postulate that the pharmacogenomic identification of patients with different opioid metabolism capacity may allow for the individualization of postsurgical opioid prescription. METHODS This study was generated by the unison of data from 2 prior initiatives taking place at our Institution. In the first study, patients undergoing 1 of 25 elective surgical procedures were prospectively identified as part of a quality initiative and surveyed by phone 21 to 35 days after hospital discharge to complete a 29-question survey regarding opioid utilization and pain experience. Additional chart abstraction was conducted to obtain prescribing data and pain scores during the hospitalization. The second study was the Mayo Clinic Right Drug, Right Dose, Right Time study protocol, in which 5 pharmacogenes, including CYP2D6, were genotyped for 1,000 Mayo Clinic Biobank participants. The goal of this study was to implement preemptive pharmacogenomics in an academic health care setting and to generate data for further pharmacogenomic research. Patients were classified by their predicted CYP2D6 activity based on their CYP2D6 genotype. RESULTS Of the 2,486 patients with prospective opioid utilization data, 21 had pharmacogenetic data available and were included in the analysis. These patients were classified according to their activity as opioid metabolizers, with 10 patients (48%) classified as intermediate, 4 patients (19%) as intermediate to normal, and 7 patients (33%) as normal or extensive. Compared with the intermediate to normal and intermediate phenotypes, normal or extensive patients had the highest percentages of preoperative opioid naivety and recorded pain scores throughout the surgical experience. The percentage of unused opioids for intermediate, intermediate to normal, and normal or extensive categories was 79%, 63%, and 46%, respectively. Moreover, of the 14 patients declaring the highest level of satisfaction for their pain control after discharge, 60% belonged to intermediate, 100% to intermediate to normal, and 57% to the normal or extensive group. CONCLUSION This study outlines a possible correlation between genetically controlled metabolism and opioid requirements after surgery. In this setting, an increased CYP2D6 enzymatic activity was associated to a greater opioid consumption, lesser amount of unused opioids, and a lower satisfaction level from opioid prescription.
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Affiliation(s)
- Raffaele Rocco
- Department of Surgery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN.
| | - Cornelius A Thiels
- Department of Surgery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Daniel S Ubl
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Stephen D Cassivi
- Department of Surgery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN
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13
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Pharmacogenetic Testing in Acute and Chronic Pain: A Preliminary Study. ACTA ACUST UNITED AC 2019; 55:medicina55050147. [PMID: 31100953 PMCID: PMC6572509 DOI: 10.3390/medicina55050147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/01/2019] [Accepted: 05/13/2019] [Indexed: 01/18/2023]
Abstract
Background and Objectives: Pain is one of the most common symptoms that weighs on life’s quality and health expenditure. In a reality where increasingly personalized therapies are needed, the early use of genetic tests that highlights the individual response to analgesic drugs could be a valuable help in clinical practice. The aim of this preliminary study is to observe if the therapy set to 5 patients suffering of chronic or acute pain is concordant to the Pharmacogenetic test (PGT) results. Materials and Methods: This preliminary study compares the genetic results of pharmacological effectiveness and tolerability analyzed by the genetic test Neurofarmagen Analgesia®, with the results obtained in clinical practice of 5 patients suffering from acute and chronic pain. Results: Regarding the genetic results of the 5 samples analyzed, 2 reports were found to be completely comparable with the evidences of the clinical practice, while in 3 reports the profile of tolerability and effectiveness were partially discordant. Conclusion: In light of the data not completely overlapping with results observed in clinical practice, further studies would be appropriate in order to acquire more information on the use of Neurofarmagen in routine clinical settings.
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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.
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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
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Mills RA, Eichmeyer JN, Williams LM, Muskett JA, Schmidlen TJ, Maloney KA, Lemke AA. Patient Care Situations Benefiting from Pharmacogenomic Testing. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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16
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Rodieux F, Vutskits L, Posfay-Barbe KM, Habre W, Piguet V, Desmeules JA, Samer CF. When the Safe Alternative Is Not That Safe: Tramadol Prescribing in Children. Front Pharmacol 2018; 9:148. [PMID: 29556194 PMCID: PMC5844975 DOI: 10.3389/fphar.2018.00148] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/13/2018] [Indexed: 01/10/2023] Open
Abstract
Children represent a vulnerable population in which management of nociceptive pain is complex. Drug responses in children differ from adults due to age-related differences. Moreover, therapeutic choices are limited by the lack of indication for a number of analgesic drugs due to the challenge of conducting clinical trials in children. Furthermore the assessment of efficacy as well as tolerance may be complicated by children's inability to communicate properly. According to the World Health Organization, weak opioids such as tramadol and codeine, may be used in addition to paracetamol and ibuprofen for moderate nociceptive pain in both children and adults. However, codeine prescription has been restricted for the last 5 years in children because of the risk of fatal overdoses linked to the variable activity of cytochrome P450 (CYP) 2D6 which bioactivates codeine. Even though tramadol has been considered a safe alternative to codeine, it is well established that tramadol pharmacodynamic opioid effects, efficacy and safety, are also largely influenced by CYP2D6 activity. For this reason, the US Food and Drug Administration recently released a boxed warning regarding the use of tramadol in children. To provide safe and effective tramadol prescription in children, a personalized approach, with dose adaptation according to CYP2D6 activity, would certainly be the safest method. We therefore recommend this approach in children requiring chronic or recurrent nociceptive pain treatment with tramadol. In case of acute inpatients nociceptive pain management, prescribing tramadol at the minimal effective dose, in a child appropriate dosage form and after clear instructions are given to the parents, remains reasonable based on current data. In all other situations, morphine should be preferred for moderate to severe nociceptive pain conditions.
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Affiliation(s)
- Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,Department of Basic Neuroscience, Faculty of Medicine, University of GenevaGeneva, Switzerland.,Division of Anesthesiology, Unit for Pediatric Anesthesia, Children's Hospitals of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Klara M Posfay-Barbe
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Children's Hospital of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Walid Habre
- Division of Anesthesiology, Unit for Pediatric Anesthesia, Children's Hospitals of Geneva, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,Anesthesiological Investigations Unit, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Valérie Piguet
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
| | - Jules A Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of LausanneGeneva, Switzerland
| | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of GenevaGeneva, Switzerland
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