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Schmidhammer H, Al-Khrasani M, Fürst S, Spetea M. Peripheralization Strategies Applied to Morphinans and Implications for Improved Treatment of Pain. Molecules 2023; 28:4761. [PMID: 37375318 DOI: 10.3390/molecules28124761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Opioids are considered the most effective analgesics for the treatment of moderate to severe acute and chronic pain. However, the inadequate benefit/risk ratio of currently available opioids, together with the current 'opioid crisis', warrant consideration on new opioid analgesic discovery strategies. Targeting peripheral opioid receptors as effective means of treating pain and avoiding the centrally mediated side effects represents a research area of substantial and continuous attention. Among clinically used analgesics, opioids from the class of morphinans (i.e., morphine and structurally related analogues) are of utmost clinical importance as analgesic drugs activating the mu-opioid receptor. In this review, we focus on peripheralization strategies applied to N-methylmorphinans to limit their ability to cross the blood-brain barrier, thus minimizing central exposure and the associated undesired side effects. Chemical modifications to the morphinan scaffold to increase hydrophilicity of known and new opioids, and nanocarrier-based approaches to selectively deliver opioids, such as morphine, to the peripheral tissue are discussed. The preclinical and clinical research activities have allowed for the characterization of a variety of compounds that show low central nervous system penetration, and therefore an improved side effect profile, yet maintaining the desired opioid-related antinociceptive activity. Such peripheral opioid analgesics may represent alternatives to presently available drugs for an efficient and safer pain therapy.
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Affiliation(s)
- Helmut Schmidhammer
- Department of Pharmaceutical Chemistry, Institute of Pharmacy and Center for Molecular Biosciences (CMBI), University of Innsbruck, Innrain 80-82, 6020 Innsbruck, Austria
| | - Mahmoud Al-Khrasani
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary
| | - Susanna Fürst
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Nagyvárad tér 4, H-1445 Budapest, Hungary
| | - Mariana Spetea
- Department of Pharmaceutical Chemistry, Institute of Pharmacy and Center for Molecular Biosciences (CMBI), University of Innsbruck, Innrain 80-82, 6020 Innsbruck, Austria
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2
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Gabel F, Hovhannisyan V, Andry V, Goumon Y. Central metabolism as a potential origin of sex differences in morphine antinociception but not induction of antinociceptive tolerance in mice. Br J Pharmacol 2023; 180:843-861. [PMID: 34986502 DOI: 10.1111/bph.15792] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 12/07/2021] [Accepted: 12/28/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE In rodents, morphine antinociception is influenced by sex. However, conflicting results have been reported regarding the interaction between sex and morphine antinociceptive tolerance. Morphine is metabolised in the liver and brain into morphine-3-glucuronide (M3G). Sex differences in morphine metabolism and differential metabolic adaptations during tolerance development might contribute to behavioural discrepancies. This article investigates the differences in peripheral and central morphine metabolism after acute and chronic morphine treatment in male and female mice. EXPERIMENTAL APPROACH Sex differences in morphine antinociception and tolerance were assessed using the tail-immersion test. After acute and chronic morphine treatment, morphine and M3G metabolic kinetics in the blood were evaluated using LC-MS/MS. They were also quantified in several CNS regions. Finally, the blood-brain barrier (BBB) permeability of M3G was assessed in male and female mice. KEY RESULTS This study demonstrated that female mice showed weaker morphine antinociception and faster induction of tolerance than males. Additionally, female mice showed higher levels of M3G in the blood and in several pain-related CNS regions than male mice, whereas lower levels of morphine were observed in these regions. M3G brain/blood ratios after injection of M3G indicated no sex differences in M3G BBB permeability, and these ratios were lower than those obtained after injection of morphine. CONCLUSION These differences are attributable mainly to morphine central metabolism, which differed between males and females in pain-related CNS regions, consistent with weaker morphine antinociceptive effects in females. However, the role of morphine metabolism in antinociceptive tolerance seemed limited. LINKED ARTICLES This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Affiliation(s)
- Florian Gabel
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Volodya Hovhannisyan
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Virginie Andry
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France.,SMPMS-INCI, Mass Spectrometry Facilities of the CNRS UPR3212, CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Yannick Goumon
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France.,SMPMS-INCI, Mass Spectrometry Facilities of the CNRS UPR3212, CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
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Noufal Y, Kringel D, Toennes SW, Dudziak R, Lötsch J. Pharmacological data science perspective on fatal incidents of morphine treatment. Pharmacol Ther 2023; 241:108312. [PMID: 36423714 DOI: 10.1016/j.pharmthera.2022.108312] [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: 09/16/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Abstract
Morphine prescribed for analgesia has caused drug-related deaths at an estimated incidence of 0.3% to 4%. Morphine has pharmacological properties that make it particularly difficult to assess the causality of morphine administration with a patient's death, such as its slow transfer between plasma and central nervous sites of action and the existence of the active metabolite morphine-6-glucuronide with opioid agonistic effects, Furthermore, there is no well-defined toxic dose or plasma/blood concentration for morphine. Dosing is often adjusted for adequate pain relief. Here, we summarize reported deaths associated with morphine therapy, including associated morphine exposure and modulating patient factors such as pharmacogenetics, concomitant medications, or comorbidities. In addition, we systematically analyzed published numerical information on the stability of concentrations of morphine and its relevant metabolites in biological samples collected postmortem. A medicolegal case is presented in which the causality of morphine administration with death was in dispute and pharmacokinetic modeling was applied to infer the administered dose. The results of this analytical review suggest that (i) inference from postmortem blood concentrations to the morphine dose administered has low validity and (ii) causality between a patient's death and the morphine dose administered remains a highly context-dependent and collaborative assessment among experts from different medical specialties.
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Affiliation(s)
- Yazan Noufal
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Dario Kringel
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan W Toennes
- Goethe-University, University Hospital Frankfurt, Institute of Legal Medicine, Kennedyallee 104, 60596 Frankfurt am Main, Germany
| | - Rafael Dudziak
- Goethe-University, University Hospital Frankfurt, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörn Lötsch
- Goethe-University, Institute of Clinical Pharmacology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany.
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Gabel F, Hovhannisyan V, Berkati AK, Goumon Y. Morphine-3-Glucuronide, Physiology and Behavior. Front Mol Neurosci 2022; 15:882443. [PMID: 35645730 PMCID: PMC9134088 DOI: 10.3389/fnmol.2022.882443] [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: 02/23/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Morphine remains the gold standard painkiller available to date to relieve severe pain. Morphine metabolism leads to the production of two predominant metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). This metabolism involves uridine 5′-diphospho-glucuronosyltransferases (UGTs), which catalyze the addition of a glucuronide moiety onto the C3 or C6 position of morphine. Interestingly, M3G and M6G have been shown to be biologically active. On the one hand, M6G produces potent analgesia in rodents and humans. On the other hand, M3G provokes a state of strong excitation in rodents, characterized by thermal hyperalgesia and tactile allodynia. Its coadministration with morphine or M6G also reduces the resulting analgesia. Although these behavioral effects show quite consistency in rodents, M3G effects are much more debated in humans and the identity of the receptor(s) on which M3G acts remains unclear. Indeed, M3G has little affinity for mu opioid receptor (MOR) (on which morphine binds) and its effects are retained in the presence of naloxone or naltrexone, two non-selective MOR antagonists. Paradoxically, MOR seems to be essential to M3G effects. In contrast, several studies proposed that TLR4 could mediate M3G effects since this receptor also appears to be essential to M3G-induced hyperalgesia. This review summarizes M3G’s behavioral effects and potential targets in the central nervous system, as well as the mechanisms by which it might oppose analgesia.
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Affiliation(s)
- Florian Gabel
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Volodya Hovhannisyan
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Abdel-Karim Berkati
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
| | - Yannick Goumon
- CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
- SMPMS, Mass Spectrometry Facilities of the CNRS UPR 3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
- *Correspondence: Yannick Goumon,
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Kulik K, Żyżyńska-Granica B, Kowalczyk A, Kurowski P, Gajewska M, Bujalska-Zadrożny M. Magnesium and Morphine in the Treatment of Chronic Neuropathic Pain-A Biomedical Mechanism of Action. Int J Mol Sci 2021; 22:13599. [PMID: 34948397 PMCID: PMC8707930 DOI: 10.3390/ijms222413599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 02/06/2023] Open
Abstract
The effectiveness of opioids in the treatment of neuropathic pain is limited. It was demonstrated that magnesium ions (Mg2+), physiological antagonists of N-methyl-D-aspartate receptor (NMDAR), increase opioid analgesia in chronic pain. Our study aimed to determine the molecular mechanism of this action. Early data indicate the cross-regulation of µ opioid receptor (MOR) and NMDAR in pain control. Morphine acting on MOR stimulates protein kinase C (PKC), while induction of NMDAR recruits protein kinase A (PKA), leading to a disruption of the MOR-NMDAR complex and promoting functional changes in receptors. The mechanical Randall-Selitto test was used to assess the effect of chronic Mg2+ and morphine cotreatment on streptozotocin-induced hyperalgesia in Wistar rats. The level of phosphorylated NMDAR NR1 subunit (pNR1) and phosphorylated MOR (pMOR) in the periaqueductal gray matter was determined with the Western blot method. The activity of PKA and PKC was examined by standard enzyme immunoassays. The experiments showed a reduction in hyperalgesia after coadministration of morphine (5 mg/kg intraperitoneally) and Mg2+ (40 mg/kg intraperitoneally). Mg2+ administered alone significantly decreased the level of pNR1, pMOR, and activity of both tested kinases. The results suggest that blocking NMDAR signaling by Mg2+ restores the MOR-NMDAR complex and thus enables morphine analgesia in neuropathic rats.
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Affiliation(s)
- Kamila Kulik
- Centre for Preclinical Research and Technology, Department of Pharmacodynamics, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (B.Ż.-G.); (A.K.); (P.K.); (M.B.-Z.)
| | - Barbara Żyżyńska-Granica
- Centre for Preclinical Research and Technology, Department of Pharmacodynamics, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (B.Ż.-G.); (A.K.); (P.K.); (M.B.-Z.)
- Chair and Department of Biochemistry, Medical University of Warsaw, Banacha 1 Str., 02-097 Warsaw, Poland
| | - Agnieszka Kowalczyk
- Centre for Preclinical Research and Technology, Department of Pharmacodynamics, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (B.Ż.-G.); (A.K.); (P.K.); (M.B.-Z.)
| | - Przemysław Kurowski
- Centre for Preclinical Research and Technology, Department of Pharmacodynamics, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (B.Ż.-G.); (A.K.); (P.K.); (M.B.-Z.)
| | - Małgorzata Gajewska
- Department of Physiological Sciences, Warsaw University of Life Sciences, Nowoursynowska 159 Str., 02-776 Warsaw, Poland;
| | - Magdalena Bujalska-Zadrożny
- Centre for Preclinical Research and Technology, Department of Pharmacodynamics, Medical University of Warsaw, Banacha 1b Str., 02-097 Warsaw, Poland; (B.Ż.-G.); (A.K.); (P.K.); (M.B.-Z.)
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Zhou X, Smith QR, Liu X. Brain penetrating peptides and peptide-drug conjugates to overcome the blood-brain barrier and target CNS diseases. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2021; 13:e1695. [PMID: 33470550 DOI: 10.1002/wnan.1695] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/19/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
Nearly one in six people worldwide suffer from disorders of the central nervous system (CNS). There is an urgent need for effective strategies to improve the success rates in CNS drug discovery and development. The lack of effective technologies for delivering drugs and genes to the brain due to the blood-brain barrier (BBB), a structural barrier that effectively blocks most neurotherapeutic agents from reaching the brain, has posed a formidable hurdle for CNS drug development. Brain-homing and brain-penetrating molecular transport vectors, such as brain permeable peptides or BBB shuttle peptides, have shown promise in overcoming the BBB and ferrying the drug molecules to the brain. The BBB shuttle peptides are discovered by phage display technology or derived from natural neurotropic proteins or certain viruses and harness the receptor-mediated transcytosis molecular machinery for crossing the BBB. Brain permeable peptide-drug conjugates (PDCs), composed of BBB shuttle peptides, linkers, and drug molecules, have emerged as a promising CNS drug delivery system by taking advantage of the endogenous transcytosis mechanism and tricking the brain into allowing these bioactive molecules to pass the BBB. Here, we examine the latest development of brain-penetrating peptide shuttles and brain-permeable PDCs as molecular vectors to deliver small molecule drug payloads across the BBB to reach brain parenchyma. Emerging knowledge of the contribution of the peptides and their specific receptors expressed on the brain endothelial cells, choice of drug payloads, the design of PDCs, brain entry mechanisms, and delivery efficiency to the brain are highlighted. This article is categorized under: Therapeutic Approaches and Drug Discovery > Emerging Technologies Therapeutic Approaches and Drug Discovery > Nanomedicine for Neurological Disease.
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Affiliation(s)
- Xue Zhou
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Quentin R Smith
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Amarillo, Texas, USA
| | - Xinli Liu
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, Texas, USA
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Gretler SR, Finno CJ, McKemie DS, Kass PH, Knych HK. Metabolism, pharmacokinetics and selected pharmacodynamic effects of codeine following a single oral administration to horses. Vet Anaesth Analg 2020; 47:694-704. [PMID: 32654915 PMCID: PMC7872472 DOI: 10.1016/j.vaa.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe the pharmacokinetics and selected pharmacodynamic variables of codeine and its metabolites in Thoroughbred horses following a single oral administration. STUDY DESIGN Prospective experimental study. ANIMALS A total of 12 Thoroughbred horses, nine geldings and three mares, aged 4-8 years. METHODS Horses were administered codeine (0.6 mg kg-1) orally and blood was collected before administration and at various times until 120 hours post administration. Plasma and urine samples were collected and analyzed for codeine and its metabolites by liquid chromatography-mass spectrometry, and plasma pharmacokinetics were determined. Heart rate and rhythm, step counts, packed cell volume and total plasma protein were measured before and 4 hours after administration. RESULTS Codeine was rapidly converted to the metabolites norcodeine, codeine-6-glucuronide (C6G), morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Plasma codeine concentrations were best represented using a two-compartment model. The Cmax, tmax and elimination t½ were 270.7 ± 136.0 ng mL-1, 0.438 ± 0.156 hours and 2.00 ± 0.534 hours, respectively. M3G was the main metabolite detected (Cmax 492.7 ± 35.5 ng mL-1), followed by C6G (Cmax 96.1 ± 33.8 ng mL-1) and M6G (Cmax 22.3 ± 4.96 ng mL-1). Morphine and norcodeine were the least abundant metabolites with Cmax of 3.17 ± 0.95 and 1.42 ± 0.79 ng mL-1, respectively. No significant adverse or excitatory effects were observed. CONCLUSIONS AND CLINICAL RELEVANCE Following oral administration, codeine is rapidly metabolized to morphine, M3G, M6G, C6G and norcodeine in horses. Plasma concentrations of M6G, a presumed active metabolite of morphine, were comparable to concentrations reported previously following administration of an analgesic dose of morphine to horses. Codeine was well tolerated based on pharmacodynamic variables and behavioral observations.
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Affiliation(s)
- Sophie R Gretler
- K.L. Maddy Equine Analytical Pharmacology Laboratory, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Carrie J Finno
- Department of Population Health and Reproduction, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - Daniel S McKemie
- K.L. Maddy Equine Analytical Pharmacology Laboratory, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Philip H Kass
- Department of Population Health and Reproduction, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - Heather K Knych
- K.L. Maddy Equine Analytical Pharmacology Laboratory, University of California-Davis, School of Veterinary Medicine, Davis, CA, USA; Department of Veterinary Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, CA, USA.
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Changes of Exhaled Volatile Organic Compounds in Postoperative Patients Undergoing Analgesic Treatment: A Prospective Observational Study. Metabolites 2020; 10:metabo10080321. [PMID: 32784730 PMCID: PMC7463857 DOI: 10.3390/metabo10080321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 12/26/2022] Open
Abstract
Assessment and treatment of postoperative pain can be challenging as objective examination techniques to detect and quantify pain are lacking. We aimed to investigate changes of exhaled volatile organic compounds (VOCs) in patients with postoperative pain before and after treatment with opioid analgesics. In an observational study in 20 postoperative patients, we monitored for postoperative pain, hemodynamic parameters, and catecholamines before and during treatment. VOCs in the patients were determined by direct real-time proton transfer reaction time-of-flight mass spectrometry prior (0 min) and after piritramide application (15 min as well as 30 min). Cardiovascular variables changed and norepinephrine levels decreased during treatment. The VOCs acetonitrile (<0.001), acetaldehyde (p = 0.002), benzopyran (p = 0.004), benzene (p < 0.001), hexenal (p = < 0.001), 1-butanethiol (p = 0.004), methanethiol (p < 0.001), ethanol (p = 0.003), and propanol (p = < 0.001) changed significantly over time. Patients with Numeric Rating Scale (NRS) < 4 showed a significantly lower concentration of hexenal compared to patients with NRS > 4 at the time points 15 min (45.0 vs. 385.3 ncps, p = 0.047) and 30 min (38.3 vs. 334.6 ncps, p = 0.039). Breath analysis can provide additional information for noninvasive monitoring for analgesic treatment in postoperative patients.
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Gabel F, Aubry AS, Hovhannisyan V, Chavant V, Weinsanto I, Maduna T, Darbon P, Goumon Y. Unveiling the Impact of Morphine on Tamoxifen Metabolism in Mice in vivo. Front Oncol 2020; 10:25. [PMID: 32154159 PMCID: PMC7046683 DOI: 10.3389/fonc.2020.00025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/08/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Tamoxifen is used to treat breast cancer and cancer recurrences. After administration, tamoxifen is converted into two more potent antitumor compounds, 4OH-tamoxifen and endoxifen by the CYP3A4/5 and 2D6 enzymes in human. These active compounds are inactivated by the same UDP-glucuronosyltransferase isoforms as those involved in the metabolism of morphine. Importantly, cancer-associated pain can be treated with morphine, and the common metabolic pathway of morphine and tamoxifen suggests potential clinically relevant interactions. Methods: Mouse liver microsomes were used to determine the impact of morphine on 4OH-tamoxifen metabolism in vitro. For in vivo experiments, female mice were first injected with tamoxifen alone and then with tamoxifen and morphine. Blood was collected, and LC-MS/MS was used to quantify tamoxifen, 4OH-tamoxifen, N-desmethyltamoxifen, endoxifen, 4OH-tamoxifen-glucuronide, and endoxifen-glucuronide. Results:In vitro, we found increased Km values for the production of 4OH-tamoxifen-glucuronide in the presence of morphine, suggesting an inhibitory effect on 4OH-tamoxifen glucuronidation. Conversely, in vivo morphine treatment decreased 4OH-tamoxifen levels in the blood while dramatically increasing the formation of inactive metabolites 4OH-tamoxifen-glucuronide and endoxifen-glucuronide. Conclusions: Our findings emphasize the need for caution when extrapolating results from in vitro metabolic assays to in vivo drug metabolism interactions. Importantly, morphine strongly impacts tamoxifen metabolism in mice. It suggests that tamoxifen efficiency could be reduced when both drugs are co-administered in a clinical setting, e.g., to relieve pain in breast cancer patients. Further studies are needed to assess the potential for tamoxifen-morphine metabolic interactions in humans.
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Affiliation(s)
- Florian Gabel
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France
| | - Anne-Sophie Aubry
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France
| | - Volodya Hovhannisyan
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France
| | - Virginie Chavant
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France.,Mass Spectrometry Facilities of the CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
| | - Ivan Weinsanto
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France
| | - Tando Maduna
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France
| | - Pascal Darbon
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France
| | - Yannick Goumon
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, Strasbourg, France.,Mass Spectrometry Facilities of the CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
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Morphine Dose Optimization in Critically Ill Pediatric Patients With Acute Respiratory Failure: A Population Pharmacokinetic-Pharmacogenomic Study. Crit Care Med 2020; 47:e485-e494. [PMID: 30920410 DOI: 10.1097/ccm.0000000000003741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop a pharmacokinetic-pharmacogenomic population model of morphine in critically ill children with acute respiratory failure. DESIGN Prospective pharmacokinetic-pharmacogenomic observational study. SETTING Thirteen PICUs across the United States. PATIENTS Pediatric subjects (n = 66) mechanically ventilated for acute respiratory failure, weight greater than or equal to 7 kg, receiving morphine and/or midazolam continuous infusions. INTERVENTIONS Serial blood sampling for drug quantification and a single blood collection for genomic evaluation. MEASUREMENTS AND MAIN RESULTS Concentrations of morphine, the two main metabolites, morphine-3-glucuronide and morphine-6-glucuronide, were quantified by high-performance liquid chromatography tandem mass spectrometry/mass spectroscopy. Subjects were genotyped using the Illumina HumanOmniExpress genome-wide single nucleotide polymorphism chip. Nonlinear mixed-effects modeling was performed to develop the pharmacokinetic-pharmacogenomic model. A two-compartment model with linear elimination and two individual compartments for metabolites best describe morphine disposition in this population. Our analysis demonstrates that body weight and postmenstrual age are relevant predictors of pharmacokinetic parameters of morphine and its metabolites. Furthermore, our research shows that a duration of mechanical ventilation greater than or equal to 10 days reduces metabolite formation and elimination upwards of 30%. However, due to the small sample size and relative heterogeneity of the population, no heritable factors associated with uridine diphosphate glucuronyl transferase 2B7 metabolism of morphine were identified. CONCLUSIONS The results provide a better understanding of the disposition of morphine and its metabolites in critically ill children with acute respiratory failure requiring mechanical ventilation due to nonheritable factors. It also provides the groundwork for developing additional studies to investigate the role of heritable factors.
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Qualification of impurities based on metabolite data. Regul Toxicol Pharmacol 2020; 110:104524. [DOI: 10.1016/j.yrtph.2019.104524] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/05/2019] [Accepted: 11/08/2019] [Indexed: 01/13/2023]
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12
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Midazolam Dose Optimization in Critically Ill Pediatric Patients With Acute Respiratory Failure: A Population Pharmacokinetic-Pharmacogenomic Study. Crit Care Med 2020; 47:e301-e309. [PMID: 30672747 DOI: 10.1097/ccm.0000000000003638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To develop a pharmacokinetic-pharmacogenomic population model of midazolam in critically ill children with primary respiratory failure. DESIGN Prospective pharmacokinetic-pharmacogenomic observational study. SETTING Thirteen PICUs across the United States. PATIENTS Pediatric subjects mechanically ventilated for acute respiratory failure, weight greater than or equal to 7 kg, receiving morphine and/or midazolam continuous infusions. INTERVENTIONS Serial blood sampling for drug quantification and a single blood collection for genomic evaluation. MEASUREMENTS AND MAIN RESULTS Concentrations of midazolam, the 1' (1`-hydroxymidazolam metabolite) and 4' (4`-hydroxymidazolam metabolite) hydroxyl, and the 1' and 4' glucuronide metabolites were measured. Subjects were genotyped using the Illumina HumanOmniExpress genome-wide single nucleotide polymorphism chip. Nonlinear mixed effects modeling was performed to develop the pharmacokinetic-pharmacogenomic model. Body weight, age, hepatic and renal functions, and the UGT2B7 rs62298861 polymorphism are relevant predictors of midazolam pharmacokinetic variables. The estimated midazolam clearance was 0.61 L/min/70kg. Time to reach 50% complete mature midazolam and 1`-hydroxymidazolam metabolite/4`-hydroxymidazolam metabolite clearances was 1.0 and 0.97 years postmenstrual age. The final model suggested a decrease in midazolam clearance with increase in alanine transaminase and a lower clearance of the glucuronide metabolites with a renal dysfunction. In the pharmacogenomic analysis, rs62298861 and rs28365062 in the UGT2B7 gene were in high linkage disequilibrium. Minor alleles were associated with a higher 1`-hydroxymidazolam metabolite clearance in Caucasians. In the pharmacokinetic-pharmacogenomic model, clearance was expected to increase by 10% in heterozygous and 20% in homozygous for the minor allele with respect to homozygous for the major allele. CONCLUSIONS This work leveraged available knowledge on nonheritable and heritable factors affecting midazolam pharmacokinetic in pediatric subjects with primary respiratory failure requiring mechanical ventilation, providing the basis for a future implementation of an individual-based approach to sedation.
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Mirra A, Birras J, Diez Bernal S, Spadavecchia C. Morphine plasmatic concentration in a pregnant mare and its foal after long term epidural administration. BMC Vet Res 2020; 16:19. [PMID: 31959188 PMCID: PMC6971975 DOI: 10.1186/s12917-020-2242-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/10/2020] [Indexed: 12/05/2022] Open
Abstract
Background Epidural administration of morphine has been shown to be an effective analgesic strategy in horses; however, the possible occurrence of side effects limits its usage. In order to decrease their frequency, it is important to target the minimal effective plasma concentration and avoid overdosing. As to date species-specific pharmacokinetics data are not available for epidural morphine, the dosing regimen is usually established on the basis of clinical reports and personal experience. In certain physiological conditions, like gestation, the outcome of an empirical dosing scheme can be unpredictable. The aim of this case report is to describe the pharmacological profile of morphine and its metabolites after prolonged epidural administration in a pregnant mare and her foal. Case presentation A 20 years old pregnant mare was presented to our hospital because of severe lameness, 2 months before delivery. Following an ineffective systemic pain treatment, an epidural catheter was inserted and morphine administered (initial dose 0.1 mg/kg every 8 h). Due to its efficacy in controlling pain, it was continued until end of gestation. Plasmatic concentration of morphine and its metabolites were assessed in the mare 6 weeks after starting the treatment, and in both the mare and foal during the first days after delivery. Plasmatic values similar to those previously reported in the literature following morphine short term administration through various routes and not accompanied by side effects were found in the mare, except during an excitatory period. Moreover, no evidence of dangerous drug accumulation or significant milk passage was noticed in the foal. Mild reduction of feces production with no signs of colic and two self-limiting episodes of excitement occurred during treatment in the mare. No side effects occurred during gestation and first phases of life in the foal. Conclusion Prolonged epidural administration of morphine in a pregnant mare allowed good pain control in absence of clinically relevant side effects, in both the mare and her foal. Sudden increase in morphine plasmatic concentration can occur and side effects appear; careful treatment to the lowest effective dose and continuous monitoring of the clinical condition of the treated horse should be performed.
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Affiliation(s)
- Alessandro Mirra
- Department of Clinical Veterinary Medicine, Anaesthesiology and Pain Therapy Section, Vetsuisse Faculty, University of Bern, Länggassstrasse 124, 3012, Bern, Switzerland.
| | - Jasmin Birras
- Swiss Institute for Equine Medicine (ISME), Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, and Agroscope, Bern, Switzerland
| | - Sabina Diez Bernal
- Department of Clinical Veterinary Medicine, Anaesthesiology and Pain Therapy Section, Vetsuisse Faculty, University of Bern, Länggassstrasse 124, 3012, Bern, Switzerland
| | - Claudia Spadavecchia
- Department of Clinical Veterinary Medicine, Anaesthesiology and Pain Therapy Section, Vetsuisse Faculty, University of Bern, Länggassstrasse 124, 3012, Bern, Switzerland
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14
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Ito S. Opioids in Breast Milk: Pharmacokinetic Principles and Clinical Implications. J Clin Pharmacol 2019; 58 Suppl 10:S151-S163. [PMID: 30248201 DOI: 10.1002/jcph.1113] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/01/2018] [Indexed: 12/14/2022]
Abstract
Safety of maternal drug therapy during breastfeeding may be assessed from estimated levels of drug exposure of the infant through milk. Pharmacokinetic (PK) principles predict that the lower the clearance is, the higher the infant dose via milk will be. Drugs with low clearance (<1 mL/[kg·min]) are likely to cause an infant exposure level greater than 10% of the weight-adjusted maternal dose even if the milk-to-plasma concentration ratio is 1. Most drugs cause relatively low-level exposure below 10% of the weight-adjusted maternal dose, but opioids require caution because of their potential for severe adverse effects. Furthermore, substantial individual variations of drug clearance exist in both mother and infant, potentially causing drug accumulation over time in some infants even if an estimated dose of the drug through milk is small. Such PK differences among individuals are known not only for codeine and tramadol through pharmacogenetic variants of CYP2D6 but also for non-CYP2D6 substrate opioids including oxycodone, indicating difficulties of eliminating PK uncertainty by simply replacing an opioid with another. Overall, opioid use for pain management during labor and delivery and subsequent short-term use for 2-3 days are compatible with breastfeeding. In contrast, newly initiated and prolonged maternal opioid therapy must follow a close monitoring program of the opioid-naive infants. Until more safety data become available, treatment duration of newly initiated opioids in the postpartum period should be limited to 2-3 days in unsupervised outpatient settings. Opioid addiction treatment with methadone and buprenorphine during pregnancy may continue into breastfeeding, but infant conditions must be monitored.
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Affiliation(s)
- Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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15
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Liang RJ, Lai YH, Kao YT, Yang TH, Chen YL, Wang HJ. A novel finding of nalbuphine-6-glucuronide, an active opiate metabolite, possessing potent antinociceptive effects: Synthesis and biological evaluation. Eur J Med Chem 2019; 178:544-551. [PMID: 31212133 DOI: 10.1016/j.ejmech.2019.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/22/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
Nalbuphine, a partial agonist/antagonist opioid analgesic, is structurally related to morphine. It is equipotent to morphine and has no serious side effects. In the past few decades, studies focusing on morphine metabolism have indicated that one of its sugar-conjugated metabolites, morphine-6-glucuronide, exerts a higher analgesic effect than its parent drug. Considering that nalbuphine is a morphine analog that follows a similar metabolic scheme, nalbuphine glucuronides were synthesized in this study and their potential analgesic effects were assessed. Nalbuphine-3-glucuronide (N3G) and nalbuphine-6-glucuronide (N6G) were synthesized based on Schmidt's glycosylation with OPiv protections on the glycosyl donor. In a pharmacodynamic study, paw pressure and cold-ethanol tail-flick tests were conducted in rats to evaluate the analgesic response after intracisternal and intraperitoneal administrations of nalbuphine, N3G, or N6G. The antinociceptive response was evaluated for each compound by calculating the area under the curve and the duration spent at greater than 50% maximum possible analgesia. In conclusion, intracisternal administration of N6G exhibited a stronger analgesic response than nalbuphine in the pain tests after both cold and mechanical stimuli, but N3G had no obvious effect. Similar to that of morphine, the glucuronide metabolite of nalbuphine at the 6-O-position exerted at least three-fold higher antinociceptive potency and five-fold longer analgesic duration than nalbuphine.
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Affiliation(s)
- Ren-Jong Liang
- Medical Supplies and Maintenance, Hualien Armed Forces General Hospital, Hualien, Taiwan, ROC
| | - Yen-Hsun Lai
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Yu-Ting Kao
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ting-Hsuan Yang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yen-Lun Chen
- Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Hong-Jaan Wang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC; Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan, ROC.
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16
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Nedahl M, Johansen SS, Linnet K. Brain-blood ratio of morphine in heroin and morphine autopsy cases. Forensic Sci Int 2019; 301:388-393. [DOI: 10.1016/j.forsciint.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/23/2019] [Accepted: 06/05/2019] [Indexed: 11/16/2022]
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17
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Mazák K, Noszál B, Hosztafi S. Advances in the Physicochemical Profiling of Opioid Compounds of Therapeutic Interest. ChemistryOpen 2019; 8:879-887. [PMID: 31312587 PMCID: PMC6610444 DOI: 10.1002/open.201900115] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/24/2019] [Indexed: 01/27/2023] Open
Abstract
This review focuses on recent developments in the physicochemical profiling of morphine and other opioids. The acid-base properties and lipophilicity of these compounds is discussed at the microscopic, species-specific level. Examples are provided where this type of information can reveal the mechanism of pharmacokinetic processes at the submolecular level. The role of lipophilicity in quantitative structure-activity relationship (QSAR) studies of opioids is reviewed. The physicochemical properties and pharmacology of the main metabolites of morphine are also discussed. Recent studies indicate that the active metabolite morphine-6-glucuronide (M6G) can contribute to the analgesic activity of systemically administered morphine. The unexpectedly high lipophilicity of M6G partly accounts for its analgesic activity. When administered parenterally, another suspected minor metabolite, morphine-6-sulfate (M6S) has superior antinociceptive effects to those of morphine. However, because sulfate esters of morphine derivatives cannot cross the blood-brain barrier these esters may be good candidates to develop peripheral analgesic drugs.
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Affiliation(s)
- Károly Mazák
- Semmelweis University Department of Pharmaceutical Chemistry, Research Group of Drugs of Abuse and Doping Agents, Hungarian Academy of Sciences Hőgyes E. u. 9. H-1092 Budapest Hungary
| | - Béla Noszál
- Semmelweis University Department of Pharmaceutical Chemistry, Research Group of Drugs of Abuse and Doping Agents, Hungarian Academy of Sciences Hőgyes E. u. 9. H-1092 Budapest Hungary
| | - Sándor Hosztafi
- Semmelweis University Department of Pharmaceutical Chemistry, Research Group of Drugs of Abuse and Doping Agents, Hungarian Academy of Sciences Hőgyes E. u. 9. H-1092 Budapest Hungary
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18
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Ghanem CI, Manautou JE. Modulation of Hepatic MRP3/ABCC3 by Xenobiotics and Pathophysiological Conditions: Role in Drug Pharmacokinetics. Curr Med Chem 2019; 26:1185-1223. [PMID: 29473496 DOI: 10.2174/0929867325666180221142315] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/17/2018] [Accepted: 02/05/2018] [Indexed: 12/13/2022]
Abstract
Liver transporters play an important role in the pharmacokinetics and disposition of pharmaceuticals, environmental contaminants, and endogenous compounds. Among them, the family of ATP-Binding Cassette (ABC) transporters is the most important due to its role in the transport of endo- and xenobiotics. The ABCC sub-family is the largest one, consisting of 13 members that include the cystic fibrosis conductance regulator (CFTR/ABCC7); the sulfonylurea receptors (SUR1/ABCC8 and SUR2/ABCC9) and the multidrug resistanceassociated proteins (MRPs). The MRP-related proteins can collectively confer resistance to natural, synthetic drugs and their conjugated metabolites, including platinum-containing compounds, folate anti-metabolites, nucleoside and nucleotide analogs, among others. MRPs can be also catalogued into "long" (MRP1/ABCC1, -2/C2, -3/C3, -6/C6, and -7/C10) and "short" (MRP4/C4, -5/C5, -8/C11, -9/C12, and -10/C13) categories. While MRP2/ABCC2 is expressed in the canalicular pole of hepatocytes, all others are located in the basolateral membrane. In this review, we summarize information from studies examining the changes in expression and regulation of the basolateral hepatic transporter MPR3/ABCC3 by xenobiotics and during various pathophysiological conditions. We also focus, primarily, on the consequences of such changes in the pharmacokinetic, pharmacodynamic and/or toxicity of different drugs of clinical use transported by MRP3.
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Affiliation(s)
- Carolina I Ghanem
- Instituto de Investigaciones Farmacologicas (ININFA), Facultad de Farmacia y Bioquimica. CONICET. Universidad de Buenos Aires, Buenos Aires, Argentina.,Catedra de Fisiopatologia. Facultad de Farmacia y Bioquimica. Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Jose E Manautou
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, CT, United States
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19
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The combination of opioid and neurotensin receptor agonists improves their analgesic/adverse effect ratio. Eur J Pharmacol 2019; 848:80-87. [DOI: 10.1016/j.ejphar.2019.01.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 01/30/2023]
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20
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Zhang T, Guo L, Yu F, Chen M, Wu B. The nuclear receptor Rev-erbα participates in circadian regulation of Ugt2b enzymes in mice. Biochem Pharmacol 2019; 161:89-97. [PMID: 30639455 DOI: 10.1016/j.bcp.2019.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 01/09/2019] [Indexed: 11/29/2022]
Abstract
Circadian clock is known to modulate phase I metabolism, however whether and how the phase II enzymes UDP-glucuronosyltransferases (UGTs) are regulated by circadian clock are largely unknown. In this study, we aimed to investigate a potential role of the clock gene Rev-erbα in regulation of Ugt2b enzymes. Ugt2b mRNA and protein expression in mouse livers were determined at a 4-h interval around the clock. Ugt2b activity was probed using morphine as a specific substrate. Regulation of Ugt2b by Rev-erbα was investigated using mouse hepatoma Hepa-1c1c7 cells and Rev-erbα knock-out (Rev-erbα-/-) mice. Luciferase reporter, mobility shift and chromatin immunoprecipitation (ChIP) assays were performed to identify the Rev-erbα binding site in Ugt2b36 promoter. Circadian variations in hepatic mRNA expression were observed for six Ugt2b genes (Ugt2b1, Ugt2b5, Ugt2b35, Ugt2b36, Ugt2b37, and Ugt2b38) in mice. Likewise, the total Ugt2b protein showed a circadian fluctuation. Glucuronidation of morphine (an Ugt2b substrate) both in vitro and in vivo was dosing-time dependent. Morphine glucuronidation was more extensive at the dosing time of ZT2 than at ZT14 consistent with the Ugt2b protein levels. Furthermore, Rev-erbα knockdown significantly increased Ugt2b mRNA and protein in Hepa-1c1c7 cells, whereas Rev-erbα overexpression or activation down-regulated Ugt2b expression. Moreover, Rev-erbα ablation in mice up-regulated the mRNA and protein expression of Ugt2b and blunted Ugt2b rhythmicity in the liver. In addition, Rev-erbα repressed the transcription of Ugt2b36 through specific binding to the -30 to -18 bp of promoter region based on a combination of luciferase reporter, mobility shift and ChIP assays. In summary, the clock gene Rev-erbα negatively regulates the expressions of Ugt2b genes, contributing to their circadian variations.
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Affiliation(s)
- Tianpeng Zhang
- Research Center for Biopharmaceutics and Pharmacokinetics, College of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou, China
| | - Lianxia Guo
- Research Center for Biopharmaceutics and Pharmacokinetics, College of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou, China
| | - Fangjun Yu
- Research Center for Biopharmaceutics and Pharmacokinetics, College of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou, China
| | - Min Chen
- Research Center for Biopharmaceutics and Pharmacokinetics, College of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou, China
| | - Baojian Wu
- Research Center for Biopharmaceutics and Pharmacokinetics, College of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou, China.
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21
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Averitt DL, Eidson LN, Doyle HH, Murphy AZ. Neuronal and glial factors contributing to sex differences in opioid modulation of pain. Neuropsychopharmacology 2019; 44:155-165. [PMID: 29973654 PMCID: PMC6235988 DOI: 10.1038/s41386-018-0127-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/21/2018] [Accepted: 05/27/2018] [Indexed: 12/12/2022]
Abstract
Morphine remains one of the most widely prescribed opioids for alleviation of persistent and/or severe pain; however, multiple preclinical and clinical studies report that morphine is less efficacious in females compared to males. Morphine primarily binds to the mu opioid receptor, a prototypical G-protein coupled receptor densely localized in the midbrain periaqueductal gray. Anatomical and physiological studies conducted in the 1960s identified the periaqueductal gray, and its descending projections to the rostral ventromedial medulla and spinal cord, as an essential descending inhibitory circuit mediating opioid-based analgesia. Remarkably, the majority of studies published over the following 30 years were conducted in males with the implicit assumption that the anatomical and physiological characteristics of this descending inhibitory circuit were comparable in females; not surprisingly, this is not the case. Several factors have since been identified as contributing to the dimorphic effects of opioids, including sex differences in the neuroanatomical and neurophysiological characteristics of the descending inhibitory circuit and its modulation by gonadal steroids. Recent data also implicate sex differences in opioid metabolism and neuroimmune signaling as additional contributing factors. Here we cohesively present these lines of evidence demonstrating a neural basis for sex differences in opioid modulation of pain, with a focus on the PAG as a sexually dimorphic core of descending opioid-induced inhibition and argue for the development of sex-specific pain therapeutics.
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Affiliation(s)
- Dayna L. Averitt
- 0000 0001 0016 8186grid.264797.9Department of Biology, Texas Woman’s University, Denton, TX 76204 USA
| | - Lori N. Eidson
- 0000 0001 0941 6502grid.189967.8Emory University School of Medicine, Atlanta, GA 30322 USA
| | - Hillary H. Doyle
- 0000 0004 1936 7400grid.256304.6Neuroscience Institute, Georgia State University, Atlanta, GA 30303 USA
| | - Anne Z. Murphy
- 0000 0004 1936 7400grid.256304.6Neuroscience Institute, Georgia State University, Atlanta, GA 30303 USA
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22
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Maskell PD, Wilson NE, Seetohul LN, Crichton ML, Beer LJ, Drummond G, De Paoli G. Postmortem tissue distribution of morphine and its metabolites in a series of heroin-related deaths. Drug Test Anal 2018; 11:292-304. [DOI: 10.1002/dta.2492] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Peter D. Maskell
- School of Science, Engineering and Technology; Abertay University; Dundee DD11HG UK
| | | | - L. Nitin Seetohul
- School of Science and Technology; Nottingham Trent University; Nottingham UK
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23
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Ryder TF, Calabrese MF, Walker GS, Cameron KO, Reyes AR, Borzilleri KA, Delmore J, Miller R, Kurumbail RG, Ward J, Kung DW, Brown JA, Edmonds DJ, Eng H, Wolford AC, Kalgutkar AS. Acyl Glucuronide Metabolites of 6-Chloro-5-[4-(1-hydroxycyclobutyl)phenyl]-1 H-indole-3-carboxylic Acid (PF-06409577) and Related Indole-3-carboxylic Acid Derivatives are Direct Activators of Adenosine Monophosphate-Activated Protein Kinase (AMPK). J Med Chem 2018; 61:7273-7288. [PMID: 30036059 DOI: 10.1021/acs.jmedchem.8b00807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Studies on indole-3-carboxylic acid derivatives as direct activators of human adenosine monophosphate-activated protein kinase (AMPK) α1β1γ1 isoform have culminated in the identification of PF-06409577 (1), PF-06885249 (2), and PF-06679142 (3) as potential clinical candidates. Compounds 1-3 are primarily cleared in animals and humans via glucuronidation. Herein, we describe the biosynthetic preparation, purification, and structural characterization of the glucuronide conjugates of 1-3. Spectral characterization of the purified glucuronides M1, M2, and M3 indicated that they were acyl glucuronide derivatives. In vitro pharmacological evaluation revealed that all three acyl glucuronides retained selective activation of β1-containing AMPK isoforms. Inhibition of de novo lipogenesis with representative parent carboxylic acids and their respective acyl glucuronide conjugates in human hepatocytes demonstrated their propensity to activate cellular AMPK. Cocrystallization of the AMPK α1β1γ1 isoform with 1-3 and M1-M3 provided molecular insights into the structural basis for AMPK activation by the glucuronide conjugates.
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Affiliation(s)
- Tim F Ryder
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Matthew F Calabrese
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Gregory S Walker
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | | | - Kris A Borzilleri
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | | | - Ravi G Kurumbail
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | - Daniel W Kung
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Janice A Brown
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | | | - Heather Eng
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
| | - Angela C Wolford
- Medicine Design , Pfizer Worldwide Research & Development , Groton , Connecticut 06340 , United States
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24
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Wang F, Meng J, Zhang L, Johnson T, Chen C, Roy S. Morphine induces changes in the gut microbiome and metabolome in a morphine dependence model. Sci Rep 2018; 8:3596. [PMID: 29483538 PMCID: PMC5827657 DOI: 10.1038/s41598-018-21915-8] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 02/13/2018] [Indexed: 12/29/2022] Open
Abstract
Opioid analgesics are frequently prescribed in the United States and worldwide. However, serious comorbidities, such as dependence, tolerance, immunosuppression and gastrointestinal disorders limit their long-term use. In the current study, a morphine-murine model was used to investigate the role of the gut microbiome and metabolome as a potential mechanism contributing to the negative consequences associated with opioid use. Results reveal a significant shift in the gut microbiome and metabolome within one day following morphine treatment compared to that observed after placebo. Morphine-induced gut microbial dysbiosis exhibited distinct characteristic signatures, including significant increase in communities associated with pathogenic function, decrease in communities associated with stress tolerance and significant impairment in bile acids and morphine-3-glucuronide/morphine biotransformation in the gut. Moreover, expansion of Enterococcus faecalis was strongly correlated with gut dysbiosis following morphine treatment, and alterations in deoxycholic acid (DCA) and phosphatidylethanolamines (PEs) were associated with opioid-induced metabolomic changes. Collectively, these results indicate that morphine induced distinct alterations in the gut microbiome and metabolome, contributing to negative consequences associated with opioid use. Therapeutics directed at maintaining microbiome homeostasis during opioid use may reduce the comorbidities associated with opioid use for pain management.
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Affiliation(s)
- Fuyuan Wang
- Department of Veterinary Population Medicine, University of Minnesota, 225 VMC 1365 Gortner Ave., St Paul, MN, 55108, USA
| | - Jingjing Meng
- Department of Surgery and Sylvester Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, 33101, USA
| | - Li Zhang
- Department of Pharmacology, University of Minnesota, 515 Delaware St SE, Moos 11-204, Minneapolis, MN, 55455, USA
| | - Timothy Johnson
- Department of Veterinary and Biomedical Sciences, University of Minnesota, 225 VMC 1365 Gortner Ave., St Paul, MN, 55108, USA
| | - Chi Chen
- Department of Food Science and Nutrition, University of Minnesota, 1334 Eckles Ave, St Paul, MN, 55108, USA
| | - Sabita Roy
- Department of Veterinary Population Medicine, University of Minnesota, 225 VMC 1365 Gortner Ave., St Paul, MN, 55108, USA. .,Department of Surgery and Sylvester Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, 33101, USA. .,Department of Pharmacology, University of Minnesota, 515 Delaware St SE, Moos 11-204, Minneapolis, MN, 55455, USA.
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25
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Doyle HH, Murphy AZ. Sex-dependent influences of morphine and its metabolites on pain sensitivity in the rat. Physiol Behav 2017; 187:32-41. [PMID: 29199028 DOI: 10.1016/j.physbeh.2017.11.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 12/21/2022]
Abstract
Preclinical studies report that the effective dose for morphine is approximately 2-fold higher in females than males. Following systemic administration, morphine is metabolized via Phase II glucuronidation in the liver and brain into two active metabolites: morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), each possessing distinct pharmacological profiles. M6G binds to μ opioid receptors and acts as a potent analgesic. In contrast, M3G binds to toll-like receptor 4 (TLR4), initiating a neuroinflammatory response that directly opposes the analgesic effects of morphine and M6G. M3G serum concentrations are 2-fold higher in females than males, however, sex-specific effects of morphine metabolites on analgesia and glial activation in vivo remain unknown. The present studies test the hypothesis that increased M3G, and subsequent TLR4-mediated activation of glia, is a primary mechanism driving the attenuated response to morphine in females. We demonstrate that intra-PAG M6G results in a greater analgesic response in females than morphine alone. M6G analgesia was reversed with co-administration of (-)-naloxone, but not (+)-naloxone, suggesting that this effect is μ opioid receptor mediated. In contrast, intra-PAG administration of M3G significantly attenuated the analgesic effects of systemic morphine in males only, increasing the 50% effective dose of morphine two-fold (5.0 vs 10.3mg/kg) and eliminating the previously observed sex difference. An increase in IL-1β, IL-6 and TNF was observed in females following intra-PAG morphine or M6G. In males, only IL-1β levels increased following morphine. Changes in cytokine levels following M3G were limited to TNF in females. Together, these data implicate sex differences in morphine metabolism, specifically M3G, as a contributing factor in the attenuated response to morphine observed in females.
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Affiliation(s)
- H H Doyle
- Neuroscience Institute, Georgia State University, Atlanta, GA 30303, United States
| | - A Z Murphy
- Neuroscience Institute, Georgia State University, Atlanta, GA 30303, United States.
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Minkowitz HS, Leiman D, Melson T, Singla N, DiDonato KP, Palmer PP. Sufentanil Sublingual Tablet 30 mcg for the Management of Pain Following Abdominal Surgery: A Randomized, Placebo-Controlled, Phase-3 Study. Pain Pract 2017; 17:848-858. [DOI: 10.1111/papr.12531] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/04/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Harold S. Minkowitz
- Department of Anesthesiology; Memorial Hermann Memorial City Medical Center; Houston Texas U.S.A
| | - David Leiman
- Research Department; Hermann Drive Surgical Hospital; Houston Texas U.S.A
| | - Timothy Melson
- Department of Anesthesiology; Shoals Medical Trials, Inc; Sheffield Alabama U.S.A
| | - Neil Singla
- Lotus Clinical Research; Pasadena California U.S.A
| | - Karen P. DiDonato
- Medical and Clinical Affairs; AcelRx Pharmaceuticals; Redwood City California U.S.A
| | - Pamela P. Palmer
- Medical and Clinical Affairs; AcelRx Pharmaceuticals; Redwood City California U.S.A
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Ehieli E, Yalamuri S, Brudney CS, Pyati S. Analgesia in the surgical intensive care unit. Postgrad Med J 2016; 93:38-45. [PMID: 27777355 DOI: 10.1136/postgradmedj-2016-134047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 07/10/2016] [Accepted: 08/27/2016] [Indexed: 01/30/2023]
Abstract
Critically ill patients are a heterogeneous group with diverse comorbidities and physiological derangements. The management of pain in the critically ill population is emerging as a standard of care in the intensive care unit (ICU). Pain control of critically ill patients in the ICU presents numerous challenges to intensivists. Inconsistencies in pain assessment, analgesic prescription and variation in monitoring sedation and analgesia result in suboptimal pain management. Inadequate pain control can have deleterious effects on several organ systems in critically ill patients. Therefore, it becomes incumbent on physicians and nurses caring for these patients to carefully evaluate their practice on pain management and adopt an optimal pain management strategy that includes a reduction in noxious stimuli, adequate analgesia and promoting education regarding sedation and analgesia to the ICU staff. Mechanistic approaches and multimodal analgesic techniques have been clearly demonstrated to be the most effective pain management strategy to improve outcomes. For example, recent evidence suggests that the use of short acting analgesics and analgesic adjuncts for sedation is superior to hypnotic based sedation in intubated patients. This review will address analgesia in the ICU, including opioid therapy, adjuncts, regional anaesthesia and non-pharmacological options that can provide a multimodal approach to treating pain.
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Affiliation(s)
- Eric Ehieli
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Suraj Yalamuri
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Charles S Brudney
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Surgical Intensive Care Unit, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Lam LH, Pirrello RD, Ma JD. A Case-Based Approach to Integrating Opioid Pharmacokinetic and Pharmacodynamic Concepts in Cancer Pain Management. J Clin Pharmacol 2015; 56:785-93. [DOI: 10.1002/jcph.676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/04/2015] [Indexed: 01/03/2023]
Affiliation(s)
- Lisa H. Lam
- University of California; San Diego; Skaggs School of Pharmacy & Pharmaceutical Sciences; La Jolla CA USA
| | - Rosene D. Pirrello
- University of California; San Diego; Skaggs School of Pharmacy & Pharmaceutical Sciences; La Jolla CA USA
- University of California; Irvine Health; Orange CA USA
| | - Joseph D. Ma
- University of California; San Diego; Skaggs School of Pharmacy & Pharmaceutical Sciences; La Jolla CA USA
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A review of morphine and morphine-6-glucuronide’s pharmacokinetic–pharmacodynamic relationships in experimental and clinical pain. Eur J Pharm Sci 2015; 74:45-62. [DOI: 10.1016/j.ejps.2015.03.020] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 01/31/2015] [Accepted: 03/23/2015] [Indexed: 01/10/2023]
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Ochiai W, Sugiyama K. [Altered expression of transporter and analgesic of morphine in neuropathic pain mice]. YAKUGAKU ZASSHI 2015; 135:703-8. [PMID: 25948305 DOI: 10.1248/yakushi.14-00234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
It is known that morphine is less effective for patients with neuropathic pain, accounting for approximately 70% of cancer patients with severe pain. One of the causes of the decline is reported as a decreased function of the μ-opioid receptor, which binds to the active metabolites of morphine in the mesencephalic ventral tegmental area. However, the details of this mechanism are not understood. We hypothesized that a decrease in the concentration of morphine in the brain reduces its analgesic effect on neuropathic pain, and found that the analgesic effect of morphine was correlated with its concentration in the brain. We examined the reason for the decreased concentration of morphine in the brain in case of neuropathic pain. We discovered increased P-glycoprotein (P-gp) expression in the small intestine, increased expression and activity of UGT2B in the liver, and increased P-gp expression in the brain under conditions of neuropathic pain. In this symposium, we argue that low brain morphine concentration is considered one of the causes of lower sensitivity to morphine in neuropathic pain patients.
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Affiliation(s)
- Wataru Ochiai
- Department of Clinical Pharmacokinetics, School of Pharmacy and Pharmaceutical Sciences, Hoshi University
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Tóth A, Brózik A, Szakács G, Sarkadi B, Hegedüs T. A novel mathematical model describing adaptive cellular drug metabolism and toxicity in the chemoimmune system. PLoS One 2015; 10:e0115533. [PMID: 25699998 PMCID: PMC4338831 DOI: 10.1371/journal.pone.0115533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/25/2014] [Indexed: 02/01/2023] Open
Abstract
Cells cope with the threat of xenobiotic stress by activating a complex molecular network that recognizes and eliminates chemically diverse toxic compounds. This "chemoimmune system" consists of cellular Phase I and Phase II metabolic enzymes, Phase 0 and Phase III ATP Binding Cassette (ABC) membrane transporters, and nuclear receptors regulating these components. In order to provide a systems biology characterization of the chemoimmune network, we designed a reaction kinetic model based on differential equations describing Phase 0-III participants and regulatory elements, and characterized cellular fitness to evaluate toxicity. In spite of the simplifications, the model recapitulates changes associated with acquired drug resistance and allows toxicity predictions under variable protein expression and xenobiotic exposure conditions. Our simulations suggest that multidrug ABC transporters at Phase 0 significantly facilitate the defense function of successive network members by lowering intracellular drug concentrations. The model was extended with a novel toxicity framework which opened the possibility of performing in silico cytotoxicity assays. The alterations of the in silico cytotoxicity curves show good agreement with in vitro cell killing experiments. The behavior of the simplified kinetic model suggests that it can serve as a basis for more complex models to efficiently predict xenobiotic and drug metabolism for human medical applications.
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Affiliation(s)
- Attila Tóth
- MTA-SE Molecular Biophysics Research Group, Hungarian Academy of Sciences, Budapest, 1094, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, 1094, Hungary
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, 1113, Hungary
| | - Anna Brózik
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, 1113, Hungary
| | - Gergely Szakács
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, 1113, Hungary
| | - Balázs Sarkadi
- MTA-SE Molecular Biophysics Research Group, Hungarian Academy of Sciences, Budapest, 1094, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, 1094, Hungary
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, 1113, Hungary
| | - Tamás Hegedüs
- MTA-SE Molecular Biophysics Research Group, Hungarian Academy of Sciences, Budapest, 1094, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, 1094, Hungary
- * E-mail:
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Fridlender M, Kapulnik Y, Koltai H. Plant derived substances with anti-cancer activity: from folklore to practice. FRONTIERS IN PLANT SCIENCE 2015; 6:799. [PMID: 26483815 PMCID: PMC4589652 DOI: 10.3389/fpls.2015.00799] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/14/2015] [Indexed: 05/20/2023]
Abstract
Plants have had an essential role in the folklore of ancient cultures. In addition to the use as food and spices, plants have also been utilized as medicines for over 5000 years. It is estimated that 70-95% of the population in developing countries continues to use traditional medicines even today. A new trend, that involved the isolation of plant active compounds begun during the early nineteenth century. This trend led to the discovery of different active compounds that are derived from plants. In the last decades, more and more new materials derived from plants have been authorized and subscribed as medicines, including those with anti-cancer activity. Cancer is among the leading causes of morbidity and mortality worldwide. The number of new cases is expected to rise by about 70% over the next two decades. Thus, there is a real need for new efficient anti-cancer drugs with reduced side effects, and plants are a promising source for such entities. Here we focus on some plant-derived substances exhibiting anti-cancer and chemoprevention activity, their mode of action and bioavailability. These include paclitaxel, curcumin, and cannabinoids. In addition, development and use of their synthetic analogs, and those of strigolactones, are discussed. Also discussed are commercial considerations and future prospects for development of plant derived substances with anti-cancer activity.
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Affiliation(s)
| | | | - Hinanit Koltai
- *Correspondence: Hinanit Koltai, Institute of Plant Sciences, Agricultural Research Organization, Volcani Center, POB6, Bet Dagan 50250, Israel,
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Klimas R, Mikus G. Morphine-6-glucuronide is responsible for the analgesic effect after morphine administration: a quantitative review of morphine, morphine-6-glucuronide, and morphine-3-glucuronide. Br J Anaesth 2014; 113:935-44. [DOI: 10.1093/bja/aeu186] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Higashi E, Ando A, Iwano S, Murayama N, Yamazaki H, Miyamoto Y. Hepatic microsomal UDP-glucuronosyltransferase (UGT) activities in the microminipig. Biopharm Drug Dispos 2014; 35:313-20. [DOI: 10.1002/bdd.1898] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 03/21/2014] [Accepted: 03/25/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Eriko Higashi
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories; Toray Industries, Inc.; 6-10-1 Tebiro Kamakura Kanagawa 248-8555 Japan
| | - Akihiro Ando
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories; Toray Industries, Inc.; 6-10-1 Tebiro Kamakura Kanagawa 248-8555 Japan
| | - Shunsuke Iwano
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories; Toray Industries, Inc.; 6-10-1 Tebiro Kamakura Kanagawa 248-8555 Japan
| | - Norie Murayama
- Laboratory of Drug Metabolism and Pharmacokinetics; Showa Pharmaceutical University; 3-3165 Higashi-tamagawa Gakuen Machida Tokyo 194-8543 Japan
| | - Hiroshi Yamazaki
- Laboratory of Drug Metabolism and Pharmacokinetics; Showa Pharmaceutical University; 3-3165 Higashi-tamagawa Gakuen Machida Tokyo 194-8543 Japan
| | - Yohei Miyamoto
- Toxicology and Pharmacokinetics Laboratories, Pharmaceutical Research Laboratories; Toray Industries, Inc.; 6-10-1 Tebiro Kamakura Kanagawa 248-8555 Japan
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Knych HK, Steffey EP, McKemie DS. Preliminary pharmacokinetics of morphine and its major metabolites following intravenous administration of four doses to horses. J Vet Pharmacol Ther 2014; 37:374-81. [DOI: 10.1111/jvp.12098] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 11/14/2013] [Indexed: 11/26/2022]
Affiliation(s)
- H. K. Knych
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis CA USA
- Department of Veterinary Molecular Biosciences; School of Veterinary Medicine; University of California; Davis CA USA
| | - E. P. Steffey
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis CA USA
- Department of Veterinary Surgery and Radiology; School of Veterinary Medicine; University of California; Davis CA USA
| | - D. S. McKemie
- K.L. Maddy Equine Analytical Chemistry Laboratory; School of Veterinary Medicine; University of California; Davis CA USA
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Laux-Biehlmann A, Chung H, Mouheiche J, Vérièpe J, Delalande F, Lamshöft M, Welters ID, Soldevila S, Bazin H, Lamarque L, Van Dorsselaer A, Poisbeau P, Schneider F, Goumon Y, Garnero P. Endogenous morphine-6-glucuronide (M6G) is present in the plasma of patients: validation of a specific anti-M6G antibody for clinical and basic research. Biofactors 2014; 40:113-20. [PMID: 23861301 DOI: 10.1002/biof.1107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 04/03/2013] [Indexed: 11/10/2022]
Abstract
Endogenous morphine and its derivatives (morphine-6-glucuronide [M6G]; morphine-3-glucuronide [M3G]) are formed by mammalian cells from dopamine. Changes in the concentrations of endogenous morphine have been demonstrated in several pathologies (sepsis, Parkinson's disease, etc.), and they might be relevant as pathological markers. While endogenous morphine levels are detectable using enzyme-linked immunosorbant assay (ELISA), mass spectrometry (MS) analysis was, so far, the only approach to detect and quantify M6G. This study describes the preparation of a specific anti-M6G rabbit polyclonal antibody and its validation. The specificity of this antibody was assessed against 30 morphine-related compounds. Then, a M6G-specific ELISA-assay was tested to quantify M6G in the plasma of healthy donors, morphine-treated, and critically ill patients. The antibody raised against M6G displays a strong affinity for M6G, codeine-6-glucuronide, and morphine-3-6-glucuronide, whereas only weak cross-reactivities were observed for the other compounds. Both M6G-ELISA and LC-MS/MS approaches revealed the absence of M6G in the plasma of healthy donors (controls, n = 8). In all positive donors treated with morphine-patch (n = 5), M6G was detected using both M6G-ELISA and LC-MS/MS analysis. Finally, in a study on critically ill patients with circulating endogenous morphine (n = 26), LC-MS/MS analysis revealed that 73% of the positive-patients (19 of 26), corresponding to high M6G-levels in M6G-ELISA, contained M6G. In conclusion, we show that endogenous M6G can be found at higher levels than morphine in the blood of morphine-naive patients. With respect to the interest of measuring endogenous M6G in pathologies, we provide evidences that our ELISA procedure represents a powerful tool as it can easily and specifically detect endogenous M6G levels.
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Affiliation(s)
- Alexis Laux-Biehlmann
- CNRS UPR3212, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique and University of Strasbourg, Strasbourg, France
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Kobori T, Harada S, Nakamoto K, Tokuyama S. Mechanisms of P-Glycoprotein Alteration During Anticancer Treatment: Role in the Pharmacokinetic and Pharmacological Effects of Various Substrate Drugs. J Pharmacol Sci 2014; 125:242-54. [DOI: 10.1254/jphs.14r01cr] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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De Gregori M, Garbin G, De Gregori S, Minella CE, Bugada D, Lisa A, Govoni S, Regazzi M, Allegri M, Ranzani GN. Genetic variability at COMT but not at OPRM1 and UGT2B7 loci modulates morphine analgesic response in acute postoperative pain. Eur J Clin Pharmacol 2013; 69:1651-8. [DOI: 10.1007/s00228-013-1523-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
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Laux-Biehlmann A, Mouheiche J, Vérièpe J, Goumon Y. Endogenous morphine and its metabolites in mammals: History, synthesis, localization and perspectives. Neuroscience 2013; 233:95-117. [DOI: 10.1016/j.neuroscience.2012.12.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/07/2012] [Indexed: 10/27/2022]
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Li Y, Paxton JW. The effects of flavonoids on the ABC transporters: consequences for the pharmacokinetics of substrate drugs. Expert Opin Drug Metab Toxicol 2013; 9:267-85. [PMID: 23289831 DOI: 10.1517/17425255.2013.749858] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The flavonoids are a large group of dietary plant compounds with suggested health benefits. There is accumulating evidence that many of these flavonoids can interact with the major drug transporters (and metabolizing enzymes) in the body, leading to alterations in the pharmacokinetics of substrate drugs, and thus their efficacy and toxicity. AREAS COVERED This review summarizes and updates the reported in vitro and in vivo interactions between common dietary flavonoids and the major drug-effluxing ABC transporters; these include P-glycoprotein, breast cancer resistance protein and multidrug resistance proteins 1 and 2. In contrast to previous reviews, the ADME of flavonoids are considered, along with their glycosides and Phase II conjugates. The authors also consider their possible interactions with the ABC transporters in the oral absorption, distribution into pharmacological sanctuaries and excretion of substrate drugs. Electronic databases, including PubMed, Scopus and Google Scholar were searched to identify appropriate in vitro and in vivo ABC transporter-flavonoid interactions, particularly within the last 10 years. EXPERT OPINION Caution is advised when taking flavonoid-containing supplements or herbal remedies concurrently with drugs. Further clinical studies are warranted to explore the impact of flavonoids and their metabolites on the pharmacokinetics, efficacy and toxicity of drugs.
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Affiliation(s)
- Yan Li
- Auckland University of Technology, Faculty of Health and Environmental Sciences, Department of Interdisciplinary Studies, Auckland, New Zealand
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41
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Knych HK, Corado CR, McKemie DS, Steffey EP. Pharmacokinetics and selected pharmacodynamic effects of tramadol following intravenous administration to the horse. Equine Vet J 2012; 45:490-6. [PMID: 23145962 DOI: 10.1111/j.2042-3306.2012.00688.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 09/21/2012] [Indexed: 11/30/2022]
Abstract
REASONS FOR PERFORMING STUDY Both the potential analgesic effect and the conflicting reports describing tramadol disposition in the horse warrant further study of the pharmacokinetics of tramadol in this species. OBJECTIVES To describe the pharmacokinetics of tramadol and its metabolites, O-desmethyltramadol and N-desmethyltramadol, following i.v. administration of 3 doses to the horse. METHODS Nine adult horses received a single i.v. dose of 0.5, 1.5 and 3 mg/kg bwt tramadol. Blood samples were collected prior to and at various times up to 72 h post administration. Plasma samples were analysed using liquid chromatography-mass spectrometry and data analysed using noncompartmental analysis. Chin-to-ground distance, heart rate and rhythm, step count and gastrointestinal activity were also assessed. RESULTS Maximal measured plasma tramadol concentrations were 454 ± 101.6, 1086.7 ± 330.7 and 1697.9 ± 406.1 ng/ml for 0.5, 1.5 and 3 mg/kg bwt, respectively. Depending on the dose administered, the tramadol clearance, volume of distribution and half-life ranged from 24.6 to 25.0 ml/min/kg, 2.66 to 3.33 l/kg and 2.17 to 3.05 h, respectively. Following administration of 0.5, 1.5 and 3 mg/kg bwt tramadol, the maximal measured plasma concentrations of the active metabolite, O-desmethyltramadol, were 3.9 ± 1.9, 9.6 ± 4.8 and 12.9 ± 5.2 ng/ml, respectively. Muscle fasiculations and tremors were seen following administration of the 2 high doses. No significant changes in chin-to-ground distance, heart rate and rhythm, step count and gastrointestinal activity were observed. CONCLUSIONS AND POTENTIAL RELEVANCE This study confirms and extends previous studies describing the pharmacokinetics of tramadol following i.v. administration to the horse. Plasma tramadol concentrations exceeded those necessary for analgesia in human patients; however, further studies are necessary to determine plasma concentrations of tramadol necessary for analgesic efficacy in the horse. These results support further investigation of the analgesic efficacy of tramadol in the horse.
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Affiliation(s)
- H K Knych
- Department of Veterinary Molecular Biosciences, School of Veterinary Medicine, University of California, USA.
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Li AC, Chovan JP, Yu E, Zamora I. Update on hydrocodone metabolites in rats and dogs aided with a semi-automatic software for metabolite identification Mass-MetaSite. Xenobiotica 2012; 43:390-8. [DOI: 10.3109/00498254.2012.715697] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Smith T, Binning AR, Dahan A. Efficacy and safety of morphine-6-glucuronide (M6G) for postoperative pain relief: A randomized, double-blind study. Eur J Pain 2012; 13:293-9. [DOI: 10.1016/j.ejpain.2008.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 04/10/2008] [Accepted: 04/27/2008] [Indexed: 10/22/2022]
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Laux A, Muller AH, Miehe M, Dirrig-Grosch S, Deloulme JC, Delalande F, Stuber D, Sage D, Van Dorsselaer A, Poisbeau P, Aunis D, Goumon Y. Mapping of endogenous morphine-like compounds in the adult mouse brain: Evidence of their localization in astrocytes and GABAergic cells. J Comp Neurol 2011; 519:2390-416. [PMID: 21456021 DOI: 10.1002/cne.22633] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Endogenous morphine, morphine-6-glucuronide, and codeine, which are structurally identical to vegetal alkaloids, can be synthesized by mammalian cells from dopamine. However, the role of brain endogenous morphine and its derivative compounds is a matter of debate, and knowledge about its distribution is lacking. In this study, by using a validated antibody, we describe a precise mapping of endogenous morphine-like compounds (morphine and/or its glucuronides and/or codeine) in the mouse brain. First, a mass spectrometry approach confirmed the presence of morphine and codeine in mouse brain, but also, of morphine-6-glucuronide and morphine-3-glucuronide representing two metabolites of morphine. Second, light microscopy allowed us to observe immunopositive cell somas and cytoplasmic processes throughout the mouse brain. Morphine-like immunoreactivity was present in various structures including the hippocampus, olfactory bulb, band of Broca, basal ganglia, and cerebellum. Third, by using confocal microscopy and immunofluroscence co-localization, we characterized cell types containing endogenous opiates. Interestingly, we observed that morphine-like immunoreactivity throughout the encephalon is mainly present in γ-aminobutyric acid (GABA)ergic neurons. Astrocytes were also labeled throughout the entire brain, in the cell body, in the cytoplasmic processes, and in astrocytic feet surrounding blood vessels. Finally, ultrastructural localization of morphine-like immunoreactivity was determined by electron microscopy and showed the presence of morphine-like label in presynaptic terminals in the cerebellum and postsynaptic terminals in the rest of the mouse brain. In conclusion, the presence of endogenous morphine-like compounds in brain regions not usually involved in pain modulation opens the exciting opportunity to extend the role and function of endogenous alkaloids far beyond their analgesic functions.
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Affiliation(s)
- Alexis Laux
- Nociception and Pain Department, Institut des Neurosciences Cellulaires et Intégratives, CNRS UPR 3212 and Université de Strasbourg, F-67084 Strasbourg, France
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McLachlan AJ, Bath S, Naganathan V, Hilmer SN, Le Couteur DG, Gibson SJ, Blyth FM. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Br J Clin Pharmacol 2011; 71:351-64. [PMID: 21284694 DOI: 10.1111/j.1365-2125.2010.03847.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Pain is highly prevalent in frail older people who often have multiple co-morbidities and multiple medicines. Rational prescribing of analgesics in frail older people is complex due to heterogeneity in drug disposition, comorbid medical conditions, polypharmacy and variability in analgesic response in this population. A critical issue in managing older people with pain is the need for judicious choice of analgesics based on a comprehensive medical and medication history. Care is needed in the selection of analgesic medicine to avoid drug-drug or drug-disease interactions. People living with dementia and cognitive impairment have suboptimal pain relief which in part may be related to altered pharmacodynamics of analgesics and challenges in the systematic assessment of pain intensity in this patient group. In the absence of rigorously controlled trials in frail older people and those with cognitive impairment a pharmacologically-guided approach can be used to optimize pain management which requires a systematic understanding of the pharmacokinetics and pharmacodynamics of analgesics in frail older people with or without changes in cognition.
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Affiliation(s)
- Andrew J McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia.
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Charlet A, Muller AH, Laux A, Kemmel V, Schweitzer A, Deloulme JC, Stuber D, Delalande F, Bianchi E, Van Dorsselaer A, Aunis D, Andrieux A, Poisbeau P, Goumon Y. Abnormal nociception and opiate sensitivity of STOP null mice exhibiting elevated levels of the endogenous alkaloid morphine. Mol Pain 2010; 6:96. [PMID: 21172011 PMCID: PMC3017033 DOI: 10.1186/1744-8069-6-96] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 12/20/2010] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Mice deficient for the stable tubule only peptide (STOP) display altered dopaminergic neurotransmission associated with severe behavioural defects including disorganized locomotor activity. Endogenous morphine, which is present in nervous tissues and synthesized from dopamine, may contribute to these behavioral alterations since it is thought to play a role in normal and pathological neurotransmission. RESULTS In this study, we showed that STOP null brain structures, including cortex, hippocampus, cerebellum and spinal cord, contain high endogenous morphine amounts. The presence of elevated levels of morphine was associated with the presence of a higher density of mu opioid receptor with a higher affinity for morphine in STOP null brains. Interestingly, STOP null mice exhibited significantly lower nociceptive thresholds to thermal and mechanical stimulations. They also had abnormal behavioural responses to the administration of exogenous morphine and naloxone. Low dose of morphine (1 mg/kg, i.p.) produced a significant mechanical antinociception in STOP null mice whereas it has no effect on wild-type mice. High concentration of naloxone (1 mg/kg) was pronociceptive for both mice strain, a lower concentration (0.1 mg/kg) was found to increase the mean mechanical nociceptive threshold only in the case of STOP null mice. CONCLUSIONS Together, our data show that STOP null mice displayed elevated levels of endogenous morphine, as well as an increase of morphine receptor affinity and density in brain. This was correlated with hypernociception and impaired pharmacological sensitivity to mu opioid receptor ligands.
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Affiliation(s)
- Alexandre Charlet
- Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique et Université de Strasbourg, Strasbourg, F-67084, France
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Balch RJ, Trescot A. Extended-release morphine sulfate in treatment of severe acute and chronic pain. J Pain Res 2010; 3:191-200. [PMID: 21197323 PMCID: PMC3004644 DOI: 10.2147/jpr.s6529] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Indexed: 11/26/2022] Open
Abstract
Morphine is the archetypal opioid analgesic. Because it is a short-acting opioid, its use has been limited to the management of acute pain. The development of extended-release formulations have resulted in the increased utilization of morphine in chronic pain conditions. This review documents the history of morphine use in pain treatment, and describes the metabolism, pharmacodynamics, formulations, and efficacy of the currently available extended-release morphine medications.
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Affiliation(s)
- Robert J Balch
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA USA
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Endogenous morphine levels are increased in sepsis: a partial implication of neutrophils. PLoS One 2010; 5:e8791. [PMID: 20098709 PMCID: PMC2808358 DOI: 10.1371/journal.pone.0008791] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Accepted: 12/26/2009] [Indexed: 11/19/2022] Open
Abstract
Background Mammalian cells synthesize morphine and the respective biosynthetic pathway has been elucidated. Human neutrophils release this alkaloid into the media after exposure to morphine precursors. However, the exact role of endogenous morphine in inflammatory processes remains unclear. We postulate that morphine is released during infection and can be determined in the serum of patients with severe infection such as sepsis. Methodology The presence and subcellular immunolocalization of endogenous morphine was investigated by ELISA, mass spectrometry analysis and laser confocal microscopy. Neutrophils were activated with Interleukin-8 (IL-8) or lipopolysaccharide (LPS). Morphine secretion was determined by a morphine-specific ELISA. μ opioid receptor expression was assessed with flow cytometry. Serum morphine concentrations of septic patients were determined with a morphine-specific ELISA and morphine identity was confirmed in human neutrophils and serum of septic patients by mass spectrometry analysis. The effects of the concentration of morphine found in serum of septic patients on LPS-induced release of IL-8 by human neutrophils were tested. Principal Findings We confirmed the presence of morphine in human neutrophil extracts and showed its colocalisation with lactoferrin within the secondary granules of neutrophils. Morphine secretion was quantified in the supernatant of activated human polymorphonuclear neutrophils in the presence and absence of Ca2+. LPS and IL-8 were able to induce a significant release of morphine only in presence of Ca2+. LPS treatment increased μ opioid receptor expression on neutrophils. Low concentration of morphine (8 nM) significantly inhibited the release of IL-8 from neutrophils when coincubated with LPS. This effect was reversed by naloxone. Patients with sepsis, severe sepsis and septic shock had significant higher circulating morphine levels compared to patients with systemic inflammatory response syndrome and healthy controls. Mass spectrometry analysis showed that endogenous morphine from serum of patient with sepsis was identical to poppy-derived morphine. Conclusions Our results indicate that morphine concentrations are increased significantly in the serum of patients with systemic infection and that morphine is, at least in part, secreted from neutrophils during sepsis. Morphine concentrations equivalent to those found in the serum of septic patients significantly inhibited LPS-induced IL-8 secretion in neutrophils.
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Lötsch J, Geisslinger G, Tegeder I. Genetic modulation of the pharmacological treatment of pain. Pharmacol Ther 2009; 124:168-84. [DOI: 10.1016/j.pharmthera.2009.06.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 06/22/2009] [Indexed: 12/15/2022]
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